The Massachusetts Autism Insurance Law (aka ARICA)
Frequently Asked Questions
What does ARICA do?
ARICA requires health insurers in Massachusetts to provide coverage for the diagnosis and treatment of Autism Spectrum Disorder, which currently affects 1 in every 68 individuals. Text of ARICA Law.
What types of policies does ARICA cover?
Massachusetts legislation only affects certain types of health care policies, so coverage under ARICA depends on the type of policy you have. Private insurers, employees and retirees under the state plan, hospital service plans and HMOs are all required to comply with the mandate. Self‐funded plans are regulated by ERISA – which is federal law. This includes many of the State’s largest employers. ERISA plans are not subject to State laws and not required to provide coverage under ARICA.
How can I find out if I have coverage under ARICA, and what if I don’t have coverage?
Contact your employer to ask if your policy is self‐funded or not. Even if your plan is self‐funded, your company may provide coverage under ARICA, and/or cover autism therapies. If your plan doesn’t provide coverage for therapies, there are options for obtaining insurance through the Health Connector that includes ARICA coverage.
Alternate coverage can only be obtained from the Health Connector during Open Enrollment periods. If a child is transitioning out of Early Intervention and will need alternate coverage, it’s important to plan this well before the child turns 3.
Are individuals or family members covered for services under MassHealth or CommonHealth?
These programs are not subject to the law, but consumers should know the following:
- MassHealth covers Applied Behavior Analysis (ABA) therapy for children under age 21 through a special process of prior authorization. Providers should contact MassHealth customer service (1‐ 800‐841‐2900) to request prior authorization for ABA.
- MassHealth may cover co‐pays and deductibles for ARICA mandated treatments, including ABA therapy, covered by private insurance.
- The Premium Assistance Program can help subsidize purchase of private insurance policies and policies through the Connector that will cover ARICA.
- Families covered by MassHealth with children under age 9, can also apply for the Massachusetts Children’s Autism Medicaid Waiver through DDS. Note – this is a limited program with specific application windows, check with DDS for more information.
- Consumers can access other services for emotional and behavioral issues through the Consumer Behavioral Health Initiative (CBHI), program.
Are there age, service, or dollar limitations to the amount of the coverage?
No. There are no age limits. The diagnosis and treatment of Autism Spectrum Disorders is not subject to any annual or lifetime dollar or unit of service limitation on coverage which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions.
What treatments are covered under ARICA?
The law covers the following care prescribed, provided, or ordered for an individual diagnosed with one of the Autism Spectrum Disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary:
- Habilitative or Rehabilitative Care – this includes professional, counseling and guidance services and treatment programs, including but not limited to, applied behavior analysis supervised by a board certified behavior analyst, that are necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of an individual.
- Pharmacy care – medications prescribed by a licensed physician and health‐related services deemed medically necessary to determine the need or effectiveness of the medications, to the same extent that pharmacy care is provided by the insurance policy for other medical conditions.
- Psychiatric care – direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
- Psychological care – direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.
- Therapeutic care ‐ services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers.
Are Social Skills Groups covered?
Yes, per the parameters of covered treatments described above.
How are education services affected?
ARICA does not affect educational services provided under an IFSP, IEP or ISP. Insurers are not required to pay for in-school services. Conversely, under IDEA, schools may not require parents to access private insurance for services that are part of FAPE.