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News Autism Insurance Resource Center FAQs

FAQs en Español , bằng tiếng Việt at www.disabilityinfo.org/arica/
10/20/2017
  • Massachusetts Developmental Disabilities Council
  • Department of Developmental Services
  • Department of Public Health
  • Department of Elementary and Secondary Education
  • Nancy Lurie Marks Family Foundation
  • Doug Flutie Jr. Foundation for Autism

What is ARICA and what does it do?

ARICA (An Act Relative to Insurance Coverage for Autism), is a law passed in 2010, requiring private health insurers in Massachusetts to provide coverage for the diagnosis and treatment of Autism Spectrum Disorder.

What types of policies does ARICA cover?

The legislation affects only 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. Many employers have “self-funded” plans, which are regulated under a federal law and not subject to ARICA. However, a majority of “self-funded” plans in Massachusetts are covering autism treatments.

How can I find out if I have coverage for autism therapies?

Contact your employer or insurer 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.

What if my employer’s self-funded plan won’t cover the autism therapies I need?

If your plan doesn’t provide coverage for therapies, there are options for obtaining insurance through MassHealth and/or the Health Connector to access coverage. Important: 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, as some of the alternatives can be accessed only during specific enrollment periods.


If your employer doesn’t provide coverage for autism treatment, our Center can help you advocate with your employer and advise you on alternative ways to access coverage.

Is MassHealth subject to ARICA?

ARICA applies only to state regulated private insurance, but MassHealth covers many of the same treatments:

  • MassHealth covers Applied Behavior Analysis (ABA) therapy for children under age 21 with MassHealth Standard and MassHealth CommonHealth; and under age 19 with MassHealth Family Assistance. Prior authorization is required.
  • MassHealth may cover co-pays and deductibles for ARICA mandated treatments 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 the Massachusetts Department of Developmental Services (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 Children’s Behavioral Health Initiative (CBHI) program.

 

Are there age, service, or dollar limitations to the amount of the coverage under ARICA?

No. There are no age limits. Per ARICA “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, subject to medical necessity criteria.

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, schools may not require parents to access private insurance for services that a child is entitled to receive through school. Additional information can be found here.

For further information, contact an information specialist at 774-455-4056 or e-mail us at info@disabilityinfo.org,

Footnote

Last updated October 13, 2015

For the most current version, please check our website http://www.disabilityinfo.org/arica/
The Autism Insurance Resource Center is a division of INDEX/UMass Medical School Shriver Center. Partial funding for the Center is provided through grants from the Massachusetts Developmental Disabilities Council (MDDC), Massachusetts Department of Developmental Services (DDS), Massachusetts Department of Public Health (DPH), and the Massachusetts Department of Elementary and Secondary Education (DESE). The Nancy Lurie Marks Family Foundation, and the Doug Flutie Jr. Foundation for Autism. INDEX is a state-wide information and referral service for people with disabilities. Online access to comprehensive resources is available at http://disabilityinfo.org/.

EK Shriver Center /UMass Medical School, 55 Lake Avenue N., S3-301, Worcester, MA 01655
Copyright ©2014 Autism Insurance Resource Center – All Rights Reserved

Massachusetts Developmental Disabilities Council 

The MDDC is an independent agency dedicated to empowering people with developmental disabilities.

Department of Public Health 

DPH promotes the health and well-being of all residents by ensuring access to high-quality public health and healthcare services, and by focusing on prevention, wellness and health equity in all people.

Department of Elementary and Secondary Education 

ESE oversees the education of children grades pre-k through 12 in Massachusetts, striving to ensure that all students across the Commonwealth succeed.

Nancy Lurie Marks Family Foundation

The primary mission of the Nancy Lurie Marks (NLM) Family Foundation is to help people with autism lead fulfilling and rewarding lives. The Foundation is committed to understanding autism from a scientific perspective, increasing opportunities and services available to the autism community and educating the public about autism.

Doug Flutie Jr. Foundation for Autism

The goal of the Flutie Foundation is to help families affected by autism live life to the fullest.

Through our programs and partnerships, we help people with autism get access to care; lead more active lifestyles; and grow toward adult independence.

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