Autism Advocacy & Insurance

The letter says “not medically necessary,” or “experimental,” or simply that the hours your child’s therapist prescribed won’t be covered. After a diagnosis, after the waitlists, after you’ve already started paying out of pocket — it lands hard. But a denial letter is the opening move in a process that exists precisely because insurers get these calls wrong, and that process regularly reverses them.

What follows is how that process works: what your plan likely owes, why ABA gets denied, how to appeal, and the one question — who actually regulates your plan — that decides which set of rules you’re playing by.

Overview

Health plans have a long history of denying claims related to autism — and behavioral health generally. That history is exactly why specific statutes came along and mandated coverage: all states require many health plans to cover medically necessary autism care, including ABA. Federal law adds a second layer of protection on top of that. Just because an insurer denies or limits a claim on a first pass doesn’t mean there aren’t options for the insured — insurers deny claims that they later pay all the time, often for reasons that have more to do with paperwork and internal cost criteria than with whether your child needs the therapy.

You are not late. The harder truth is that which rules protect you depends on a distinction most parents have never heard of: is your health plan governed by state law, or by a federal law called ERISA? Almost everything else on this page branches from that single question.

Autism coverage under state law

Each of the three states has a law on the books requiring certain health plans to cover autism treatment, ABA included. The catch — and it’s a big one — is that these state laws reach only state-regulated plans. They do not reach self-funded employer plans, which the next section covers. With that caveat front of mind, here is what each state requires of the plans it does govern.

Tennessee. Tennessee requires state-regulated plans to cover medically necessary autism care — including ABA supervised by a qualified behavior analyst — with no age cutoff: coverage turns on medical necessity, not a birthday. The requirement comes from insurance-regulator guidance layered on top of an older, narrower statute, so if you read only the statute you’ll come away with a narrower picture than the one that actually governs.

Georgia — “Ava’s Law.” Georgia’s mandate, known as Ava’s Law, requires covered plans to provide autism treatment including ABA, along with speech, occupational, and physical therapy and licensed psychological care, for individuals 20 years of age or under.

Alabama. Alabama’s autism-coverage act (HB 284, Act 2017-337) requires covered plans to provide screening, diagnosis, and treatment of autism, ABA included, along with related medical and therapy services, for individuals 18 years of age or under. Michael served as lead lobbyist for that act — so the Alabama mandate on this page is law he helped pass.

A word about the dollar and age caps you may have read about — annual ABA maximums, “covered only through a certain age.” Those numbers appear in the statutes, but they are open to challenge, and that matters. A hard dollar cap on autism therapy, when the plan puts no comparable cap on medical or surgical care, runs afoul of a federal parity law (explained below). Age caps are a less direct target — parity puts real pressure on them too, but the argument is narrower. The clearest example is in Alabama, where the major Blue Cross plan acknowledged as much and said it would not enforce the statutory caps. So if an insurer quotes you a flat annual maximum on ABA as the reason it’s cutting off coverage, treat that as a number to challenge.

When your plan is self-funded (ERISA)

This is where the state-versus-ERISA question gets decided, and it’s the part parents most often get wrong.

If you get insurance through a large employer, there’s a good chance the plan is self-funded — meaning the employer pays claims out of its own money and simply hires an insurance company (Blue Cross, Aetna, Cigna, UnitedHealthcare) to administer it. The insurer’s name is on your card, so the plan looks like ordinary insurance — but a self-funded plan answers to a federal law called ERISA, and the state autism mandates above generally don’t apply to it at all. Ava’s Law, the Tennessee coverage rule, the Alabama act: a self-funded family can’t lean on any of them.

That sounds like bad news, and it’s certainly a curveball. But self-funded does not mean no coverage. Many large employers cover ABA voluntarily and well. And a separate federal law — mental-health parity, covered below — does reach most self-funded plans. So even with no state mandate behind you, you still have a real federal argument. What changes is the process you’ll use and the clock you’re on, and those differences are significant enough that knowing which kind of plan you have should be your first move.

How to tell, in plain steps:

1. Ask your employer’s HR or benefits office directly: “Is our health plan fully insured or self-funded? Is it an ERISA plan?” They will know, and they’re allowed to tell you.
2. Read the Summary Plan Description (the long benefits booklet). A self-funded plan usually says “self-funded” or “self-insured,” references ERISA, and names the insurance company as a claims administrator rather than the entity actually paying.
3. Call member services at the number on your card and ask the same question.
4. Use this rule of thumb as a hint, not proof: very large or national employers are frequently self-funded; small employers and plans you bought yourself on the marketplace are usually fully insured. Government, church, and federal-employee plans follow their own separate rules.

Once you know the answer: a fully insured plan puts state law, independent external review, and your state insurance department on your side. A self-funded plan puts you on the ERISA track — the plan’s own appeal process, then federal court if it comes to that — where, as the next sections explain, the appeal itself carries unusual weight.

Why ABA gets denied

Denials tend to arrive in a handful of recognizable shapes, and knowing the label helps, because each one has a known answer.

• “Not medically necessary.” The most common, and among the most appealable: ABA is the standard, evidence-based treatment for autism, and a current diagnosis plus a detailed treatment plan speaks directly to necessity.
• “Experimental” or “investigational.” For ABA this label is essentially outdated; seeing it is often a sign the denial is weak or was issued by reflex.
• Hour and visit caps. The plan approves, say, ten hours when your child’s clinician prescribed twenty-five. That’s frequently a parity problem in disguise rather than a clinical judgment.
• Age-based cutoffs. Coverage that stops at a birthday — another limit that parity puts under pressure.
• “Lack of progress” or “maintenance, not active treatment.” Usually surfaces at a re-authorization rather than at the start, and is answered with the clinician’s data and goals.

There’s also a denial that hides as a network problem rather than a coverage one: the plan says ABA is covered, but there’s no in-network provider who can actually deliver the prescribed level of care, or the only option is hours away with a months-long waitlist. When a plan’s network can’t furnish a covered, medically necessary service, many plans owe an in-network exception or a single-case agreement that lets your child see an out-of-network provider at in-network cost. A network that exists on paper but not in reach is itself an argument.

None of these is self-executing. Each is a position the plan took, in writing, that you’re entitled to test — and the next section is how you test it.

Appealing a denial

An appeal is your formal request that the plan reconsider, backed by evidence. The denial letter itself will name your deadline to appeal, and those windows are short, so the first practical step is to read that letter for the date and calendar it.

The second step is to make the plan show its work. Before you answer the denial, request the plan’s own file in writing: the specific written reason for the denial, the exact plan language it relied on, the clinical or medical-necessity criteria it applied, and the name and credentials of the reviewer who made the call. You’re entitled to this, and it changes the appeal from guesswork into a direct response — you can’t rebut a rule you haven’t seen, and once you’ve seen it, the mismatch between the rule and your child’s documentation often becomes the whole case.

From there the path forks based on the state-versus-ERISA question above. Whichever path you’re on, the evidence is largely the same, and building it well is most of the work:

• A current, qualified autism diagnosis from a physician or psychologist.
• A comprehensive ABA assessment and individualized treatment plan from a licensed or certified behavior analyst (a BCBA), stating the prescribed hours and the clinical reasoning behind them.
• A letter of medical necessity — which often must come from the treating physician or pediatrician, not the billing office, and is separate from the BCBA’s plan.
• Where hours or dollars were capped, a parity comparison showing the plan treats ABA more strictly than it treats comparable medical care — built against the plan’s own criteria, which you requested above.

If your plan is state-regulated (fully insured): you’ll file an internal appeal with the insurer, usually one or two levels. If that’s denied and the denial turns on medical judgment — medical necessity, or an “experimental” label — you can generally take it to an independent external review by a neutral medical reviewer outside the insurance company: in Tennessee through the state’s insurance department, in Georgia and Alabama through a federally administered process (your denial letter names the right forum and says whether your denial qualifies). A denial that rests on plan terms instead — a flat exclusion, an exhausted dollar cap — may not be eligible for external review; those are the ones to raise with your state insurance department as a complaint, and, where the cap itself is the problem, to challenge on parity grounds — especially in Alabama, where the major carrier has already acknowledged the statutory caps don’t hold up under federal parity.

If your plan is self-funded (ERISA): you’ll go through the plan’s internal appeal first — and this is the step to take with real care, because of a rule that catches families off guard. If your case later reaches federal court, the judge will generally look only at the record that existed when the plan made its final decision. New evidence and new arguments are usually shut out at the lawsuit stage. In plain terms: the internal appeal is the moment that counts. Every diagnosis, every clinician letter, every parity comparison has to go in then, not later. It’s a reason to be thorough now, while the door is open. Only after you’ve exhausted the plan’s appeals can a suit be filed in federal court to recover the benefit.

If your child is on TennCare or Medicaid, those programs have their own appeal process, with its own deadlines, and the same evidence applies.

Mental-health parity

There’s a federal law that does a lot of quiet work in autism cases, and you can apply its core idea yourself. The Mental Health Parity and Addiction Equity Act says, in essence, that a plan can’t treat mental-health care — and autism therapy counts — more harshly than it treats physical, medical, and surgical care.

You don’t need the acronym to use the test. Ask yourself: is my plan applying stricter rules to ABA, speech, or OT than it applies to something like physical therapy or diabetes care? A hard annual dollar cap on ABA with no equivalent cap on medical treatment is the classic example — and it’s exactly why the statutory caps discussed earlier so often fall. The same logic reaches the non-numerical rules too: tighter medical-necessity criteria, heavier prior-authorization or step-therapy requirements, more aggressive ongoing review applied to ABA than to comparable care. A plan must, on request, hand over a written analysis justifying limits like these.

Parity is also the reason a self-funded family isn’t out of options: state mandates may not reach a self-funded plan, but federal parity generally does.

Where insurance and school overlap

Insurance is one source of services; your child’s school is another — and they’re separate, parallel duties. A public school can owe autism-related services under special-education law even when your insurer pays nothing, and a health plan can owe ABA even when the school provides nothing. One “no” doesn’t control the other, and pursuing both is normal.

If your child is on Medicaid and under 21, there’s an additional route: a federal Medicaid benefit (often abbreviated EPSDT) requires coverage of medically necessary services for eligible children, and that has been understood to include ABA. When private coverage falls through, Medicaid is sometimes the path that works.

This page handles the insurance and coverage fight. For the school side — IEPs, evaluations, the IDEA, Section 504 — see the special education page.

Across Tennessee, Georgia & Alabama

Michael is admitted in Tennessee, Georgia, and Alabama, and before the U.S. Courts of Appeals for the Sixth, Ninth, and Eleventh Circuits, where he has litigated special education and civil-rights appeals at the federal level. Because the state autism mandates differ from one another, and because self-funded plans answer to federal law instead, full admission across all three states means a coverage matter in Tennessee, Georgia, or Alabama can be handled without handing it to out-of-state counsel.

His record includes representing the student-plaintiff in Sophie G. v. Wilson County Schools, a Section 504 disability-discrimination appeal decided by the Sixth Circuit in 2018 on behalf of a student with autism — a school matter rather than an insurance one, but squarely autism-related. Prior results do not guarantee a similar outcome.

In 2025, the Autism Law Summit named Michael its Lawyer of the Year, in recognition of advocacy on behalf of individuals with autism.

Autism advocacy and insurance is one of seven practice areas at the firm.

When a lawyer helps

Plenty of families win an appeal on their own, and you should know that before anything else. Many internal and external appeals succeed without a lawyer in the picture, and there is free, non-firm help available before you ever pay anyone: your state’s insurance department, along with autism advocacy organizations, can help you assemble an appeal at no cost.

A lawyer tends to matter most in a few specific situations: when your plan is self-funded (ERISA) and the record you build in the internal appeal is about to become the only thing a court will ever see; when there’s a likely parity violation or a flat ABA exclusion to challenge; when the plan keeps denying despite a solid medical-necessity letter; or when you’re weighing whether the dispute is headed toward federal court at all. Suing an insurer is generally the last step, not the first — for a self-funded plan you usually have to finish the internal appeals before a court will hear you — and most denials are resolved well before litigation. The value of having a lawyer ready for that step is often that it makes the step unnecessary.

On cost, one general point: in an ERISA benefits case, a court has discretion to order the plan to reimburse a family’s reasonable attorney’s fees when the family prevails. That mechanism exists so that cost isn’t the thing that stops a meritorious appeal.

When you’re ready to talk it through

If an insurer denied your child’s ABA therapy — or cut the hours, or called it experimental — in Tennessee, Georgia, or Alabama, the next step is smaller than it looks: find out who governs your plan, and the rest of the path follows from there. That’s a conversation we can have whenever you’re ready.

This page is general information about insurance and autism-coverage law, not legal advice, and reading it doesn’t create an attorney-client relationship.

Common questions

Is ABA therapy covered by insurance in Tennessee, Georgia, or Alabama?

Usually yes for qualifying state-regulated plans: Tennessee by a 2019 insurance-department bulletin applying mental-health parity (no age cutoff), Georgia under Ava's Law (through age 20), and Alabama under its autism-coverage act (through age 18). Each mandate has carve-outs — Alabama's reaches only employers with 51 or more employees, and Georgia's excludes the smallest employers and some individual plans — and a self-funded employer plan follows different, federal rules.

What if my health plan is self-funded?

If your plan is self-funded (common with large employers), it's governed by federal ERISA, and state autism mandates generally don't apply. But you're not out of options: federal mental-health parity still usually applies, so a self-funded plan can't impose limits on ABA that it wouldn't impose on comparable medical care. Ask HR whether your plan is fully insured or self-funded.

How do I appeal an ABA therapy denial?

Start with the insurer's internal appeal — submit your child's autism diagnosis, the BCBA's treatment plan and prescribed hours, and a letter of medical necessity, and request the plan's own denial reasons and clinical criteria in writing. If that's denied, a state-regulated plan can often go to independent external review — your denial letter says whether yours qualifies; with a self-funded (ERISA) plan, the internal appeal is the process — after it, the remedy is a lawsuit in federal court. Deadlines are short and set in your denial letter, so act quickly.

What does "not medically necessary" mean on an ABA denial?

It's the insurer's most common reason for denying ABA — a claim that the prescribed therapy isn't clinically required. It's also one of the most appealable. ABA is the standard, evidence-based treatment for autism, so this denial is rebutted with a current diagnosis, a detailed treatment plan, and documentation tying the prescribed hours to accepted clinical standards.

Do I need a lawyer to appeal an ABA denial?

Often, no — many families win the internal or external appeal on their own, and your state insurance department and autism advocacy groups offer free help. A lawyer matters most when the plan is self-funded (ERISA), when there's a likely parity violation or a flat ABA exclusion, when the denial repeats despite a solid medical-necessity letter, or when the ERISA record is about to close.

Can I sue my insurance company for denying my child's autism therapy?

Sometimes — but a lawsuit is usually the last step, not the first. For a self-funded (ERISA) plan, you generally must finish the plan's internal appeals before filing in federal court, and the court mostly reviews the record you built during that appeal. Most denials are resolved through the appeal process without litigation.

Does my state's autism mandate apply to my plan?

Only if your plan is state-regulated (fully insured). State mandates like Ava's Law don't reach self-funded employer plans governed by federal ERISA. To find out which you have, ask HR or member services whether the plan is "fully insured or self-funded," or check your Summary Plan Description — self-funded plans say so and name the insurer only as administrator.

Wherever your matter stands, the next step is a conversation. Call (615) 378-8942 or email mfb@braun-law.com.