Q&A About Autism Insurance in Massachusetts

The new autism legislation in Massachusetts is called ARICA — An Act Relative to Insurance Coverage for Autism. It is very good news for individuals with autism spectrum disorder (ASD) and their families. It gives them increased access to treatments that offer the greatest likelihood of positive life outcomes: ABA and other evidence-based therapies.

What is ARICA?

ARICA is “An Act Relative to Insurance Coverage for Autism.” It went into effect in Massachusetts on January 1, 2011. Massachusetts is one of 24 states that have recently enacted such legislation. This new law requires that insured health plans cover “medically necessary” services for the diagnosis and treatment of autism spectrum disorders (ASD) as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR).

Who can obtain services?

Children or adults of any age with a diagnosis of Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorders Not Otherwise Specified (PPD-NOS) who have a medical need for services.

What services are covered by the ARICA law?

According to the Massachusetts Division of Insurance (DOI), insured health plans must now cover evidence-based, medically necessary autism services that are prescribed, provided, or ordered by a licensed physician or licensed psychologist. These services include:

• Pharmacy
• Psychiatric
• Psychological
• Therapeutic Habilitative or Rehabilitative Care

What is “habilitative or rehabilitative care”?

“Habilitative or rehabilitative care” is defined by the DOI as professional, counseling, and guidance services as well as evidence-based treatment programs such as applied behavior analysis (ABA).

What are ABA services? Are they effective?

ABA services focus on positive reinforcement, teaching in small steps, prompting, and repeated practice. These services can be provided in home, school, or health settings. ABA has been endorsed by the National Institutes of Health and has been identified by the Surgeon General of the United States as the most effective way to treat ASD. According to the National Autism Center’s National Standards Report (2009), data collected through hundreds of studies indicate that ABA is a highly effective method to teach children and adolescents with ASD.

How soon will I be able to get autism services for my child?

How soon you will be able to access services depends upon the date your health plan is issued and/or renewed. For example, if your insurance plan’s open enrollment does not take place until next November, you will not be able to access services until then.

Which insurers are not impacted by this legislation?

• Companies with self-funded insurance plans are not required to provide this coverage. You may, however, ask your company to provide this coverage.
• Mass Health is not covered under the ARICA law; however, Massachusetts has a premium assistance program that allows Mass Health families to access private insurance.

Which insured health plans are covered by the new law?

Participating health plans include Blue Cross, United Behavioral Health (UBH), Celtic Care, and Tufts.

Are there limitations on services covered by this new legislation?

The new law requires insured health plans to cover the diagnosis and treatment of ASD in exactly the same way they cover the diagnosis and treatment of physical conditions. This includes any annual or lifetime limitations imposed on dollars spent or visits covered. The law also makes it clear that there are no age restrictions for individuals in need of services.

How do I access services?

This varies by insurance company. For assistance in obtaining services, call Ashley McLeod at 781.437.1382, or e-mail amcleod@mayinstitute.org.

May Institute offers free informational sessions – Accessing Autism Services: The New ARICA Law – on the new legislation. We are also available to offer this session to interested groups. Please contact us for more information.