District of Columbia State-Regulated Insurance Coverage

District of Columbia provides meaningful coverage for autism under district-regulated plans.

District of Columbia’s autism insurance bill, B20-0302, was enacted on in 2013. The law became effective January 1, 2014.

To which plan types does the STATE autism insurance law apply?

  • Individual Plans, subject to ACA - YES
  • Individual Plans, specifically exempt from the ACA (often called Grandfathered Plans) - NO
  • Fully Insured Large Group Plans - NO
  • Fully Insured Small Group Grandfathered Plans - NO
  • Fully Insured Small Group Non-Grandfathered Plans - YES

What services are covered by the law?

  • Habilitative services for the treatment of autism spectrum disorder, including applied behavior analysis

Does the District of Columbia have caps on ABA coverage?

No. There are no age or dollar limits on coverage.

  • Whether or not caps are included in a health insurance plan is specific to each type of plan, and such limitations are required to be disclosed in the plan document. Most often, there is a specific section of the plan that describes the plan’s autism/ABA benefit. A consumer can contact plan representatives to learn where to find autism-related information in the plan document.
  • There are now laws that challenge the validity of the age and dollar cap limitations. These are known as “mental health parity” laws, and they generally apply to services used to treat autism.
  • Mental health parity laws prevent group health plans [and health insurance issuers] that provide mental health or substance-use disorder (MH/SUD) benefits from imposing less favorable limitations on MH/SUD benefits than on medical/surgical benefits. This means that quantitative treatment limits like age and dollar caps are not permitted in most cases. 
    • To learn about the federal mental health parity law, The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), visit here.
    • To learn about state mental health parity laws, the nonprofit Kennedy Forum sponsors a web-based tool, Parity Track, that provides further details on individual state laws, regulations, pending bills and implementation. (Autism Speaks is not responsible for the contents or opinions contained on third-party websites.)

Other comments about the law.

For purposes of the essential health benefits benchmark plan, Council Bill B20-0302 (The Better Prices, Better Quality, Better Choices for Health Coverage Temporary Amendment Act of 2013) defined “habilitative services” to include “health care services that help a person keep, learn, or improve skills and functioning for daily living, including applied behavioral analysis for the treatment of autism spectrum disorder.”

As such, small group and individual plans sold through the D.C. Exchange must provide coverage for ABA for individuals with autism. This requirement does not apply to grandfathered plans (i.e. plans issued prior to March 23, 2010).

If you have additional questions, please email advocacy@autismspeaks.org