An Act Relative to Insurance Coverage for Autism (ARICA) - Frequently Asked Questions

What we know about the recently enacted autism insurance legislation - H4935

What does ARICA do?

What types of policies does ARICA cover?

How can I find out if I have coverage under ARICA?

Are individuals or family members covered for services under MassHealth or CommonHealth?

Is there a limit to the amount of the coverage?

Is there an age limit to this coverage?

What treatments are covered under ARICA?

Are Social Skills Groups covered?

Are Communication Devices covered?

How are education services affected?


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 110 individuals. Text of ARICA Law.

What types of policies does ARICA cover?

Massachusetts legislation can only affect certain types of health care policies, so coverage under ARICA will depend on the type of policy you have. Private insurers, employees and retirees under the state plan, hospital service plans and HMOs would all be 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?

Contact your employer to verify that your policy is subject to the new law, and if so, what annual date your group policy renews. Even if your company is regulated by ERISA, they may as practice comply with State laws. In addition, there is language in the recently enacted federal health care reform that will eventually cover autism treatment. If you are covered by an ERISA plan, please contact us for additional information and assistance in advocating for coverage with your company.

Are individuals or family members covered for services under MassHealth or CommonHealth?

These programs are not subject to the new law, but consumers should know the following:

  • MassHealth will cover co-pays and deductibles for ARICA mandated treatment covered by private insurance.
  • The Premium Assistance Program can help subsidize purchase of private insurance policies and policies through Commonwealth Choice that will cover ARICA. Note- Commonwealth Choice has an enrollment window of July 1-August 15, 2011.
  • Families covered by MassHealth or CommonHealth 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.
  • In certain cases, consumers may be able to access some treatments through EPSDT.

Is there a limit to the amount of the coverage?

No. The diagnosis and treatment of Autism Spectrum Disorders will not be 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.

Is there an age limit to this coverage?

There is no age limit.

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.

Are Communication Devices covered?

ARICA does not require coverage for devices, but will cover the therapy required to program and use the device. For more information, refer to our Fact Sheet on Augmentative and Alternative Communication

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 .