Autism insurance mandates: checking the therapy benefit

For OT, PT and speech practices treating autistic children or adults: a state autism mandate binds only the state-regulated, insured plans its text names, not self-funded employer plans, and its list of services may leave therapy out.⁠^1,2 Before the evaluation, identify who funds the plan, which benefit pays for your discipline, and its limits, in writing.

Which health plans does a state autism mandate actually reach?

A state autism mandate reaches the insured plans the state regulates and its text names; self-funded private employer plans, Medicare Advantage plans and federal employee plans answer to federal law instead, and Medicaid’s coverage for children rests on its federal EPSDT benefit. The line comes from ERISA’s preemption section. It "shall supersede any and all State laws insofar as they may now or hereafter relate to any employee benefit plan", then saves "any law of any State which regulates insurance", then says no employee benefit plan shall be "deemed to be an insurance company or other insurer" for a state law that regulates insurers.⁠¹ A state can require an insurer to cover autism treatment in the policies it sells to employers. It cannot reach an employer’s own self-funded plan by calling it an insurer.

ERISA’s reach has an edge too. The Department of Labor describes it as setting minimum standards for most voluntarily established health plans "in private industry", and says it generally does not cover group health plans of governmental entities or of churches for their employees.⁠³ For a family covered through a city, a school district or a church, ask the plan which law governs its benefits.

The mandate’s own definitions narrow it further. Florida’s autism coverage law applies to a group policy or group benefit plan offered by an insurer, including the state employees’ group program, and states that the term "does not include any health insurance plan offered in the individual market, any health insurance plan that is individually underwritten, or any health insurance plan provided to a small employer".⁠⁴ A Florida family’s individual policy or a small employer’s plan is outside it, whatever the insurer.

Four programs run on federal rules of their own:

• Medicaid. Children under 21 enrolled in Medicaid are covered by EPSDT, which requires states to provide medically necessary services that are coverable under federal Medicaid, "regardless of whether the service is covered in a state’s Medicaid plan".⁠¹⁴ Whether a state’s private mandate also reaches Medicaid plans depends on its text; California’s excludes Medi-Cal plan contracts.⁠¹⁵ The EPSDT guide covers EPSDT for OT, PT and speech.
• Medicare Advantage. Federal standards for these plans "supersede any State law or regulation (other than State licensing laws or State laws relating to plan solvency)".⁠¹⁶
• Federal employees’ plans. The terms of a Federal Employees Health Benefits contract that relate to the nature, provision or extent of coverage "supersede and preempt any State or local law" relating to health insurance or plans.⁠¹⁷
• TRICARE. The military program runs its own autism coverage, through its Autism Care Demonstration and its medical benefit.⁠¹⁸ The TRICARE participation guide covers working with it.

Why is a self-funded employer plan outside the state mandate?

Because the employer, not an insurer, pays the claims, and ERISA says such a plan is not deemed an insurer.⁠¹ HealthCare.gov describes a self-insured plan as one where the employer "takes on the responsibility of paying employees’ and dependents’ medical claims" and may contract out enrollment, claims processing and provider networks to a third party administrator.⁠¹² So a card can carry a well-known insurer’s name for a plan the insurer only administers, while the employer’s plan document decides what autism treatment it covers, within federal rules such as the ERISA claims procedure.⁠¹⁹

Where does OT, PT or speech fit when a mandate names only ABA?

In the plan’s own therapy benefits, not inside an applied behavior analysis benefit: rehabilitative or habilitative care, a mental health benefit if the plan classifies them that way, or an autism benefit only when the mandate or plan names them. ASHA calls ABA "one method of treatment for children with autism spectrum disorder", and its state issue brief reports that in some states with mandated coverage for ABA services, other medically necessary services, speech-language pathology among them, "are not covered under the mandate and are being denied by insurers". ASHA’s own position is that insurers should cover all medically necessary services for children with autism.⁠²

Keep the two apart in every request and every conversation. A behavior analyst’s program is not an occupational therapy, physical therapy or speech-language plan of care, and an approval for one does not authorize the other; the ABA partnerships guide sets out which questions belong to the SLP, the OT, the PT and the behavior analyst. TRICARE draws the same line in its own program: its Autism Care Demonstration covers applied behavior analysis, while occupational, physical and speech therapy are covered under the TRICARE medical benefit.⁠¹⁸

The federal essential health benefit list separates them too, with "mental health and substance use disorder services, including behavioral health treatment" as one category and "rehabilitative and habilitative services and devices" as another.⁠²⁰ HealthCare.gov’s glossary describes rehabilitative services as helping a person keep, get back or improve skills "lost or impaired because you were sick, hurt, or disabled", and habilitative services as helping a person keep, learn or improve skills, with "therapy for a child who isn’t walking or talking at the expected age" as its example.⁠^21,22 For a young autistic child learning a skill for the first time, habilitative is the benefit name to ask about.

How does Florida’s autism mandate treat speech, OT and PT?

It names them. Florida’s statute, which defines autism spectrum disorder by the most recent edition of the DSM, requires covered plans to cover "treatment of autism spectrum disorder and Down syndrome through speech therapy, occupational therapy, physical therapy, and applied behavior analysis" for an eligible individual: someone under 18, or someone 18 or older who is in high school and was diagnosed with a developmental disability at 8 or younger.⁠⁴ Coverage is limited to treatment "prescribed by the insured’s treating physician in accordance with a treatment plan", may not be denied because the services are habilitative, and stays subject to the plan’s general exclusions, participating-provider rules and utilization review, including medical necessity review.⁠⁴ The statute also states annual and lifetime dollar limits, which the caps section below sets beside the federal rule.

What does California’s autism mandate cover for a therapy practice?

It covers behavioral health treatment, which it defines around ABA, and it does not name OT, PT or speech. Section 1374.73 of the Health and Safety Code requires every health care service plan contract that provides hospital, medical or surgical coverage to also cover behavioral health treatment for pervasive developmental disorder or autism, defined as professional services and treatment programs "including applied behavior analysis and evidence-based behavior intervention programs", delivered under a treatment plan prescribed by a qualified autism service provider.⁠¹⁵ It does not apply to Medi-Cal plan contracts, and it does not limit section 1374.72, which requires plan contracts to cover medically necessary treatment of mental health and substance use disorders, defined by the ICD and the DSM, on the same terms as other medical conditions.⁠^15,23 For a California SLP or OT, the speech or OT visit is therefore checked under the plan’s other benefits, including how it applies section 1374.72.

What do the essential health benefit rules add for autism therapy?

For individual and small-group plans, they require a habilitative benefit that may include PT, OT and speech-language pathology, and they limit how that benefit can be capped. Insurers selling in "the individual or small group market must ensure that such coverage includes the essential health benefits package".⁠⁶ A plan that claims grandfathered status from before the Affordable Care Act must say so in any summary of benefits it provides, and may lack some of the law’s protections.⁠²⁴

Within that package, three habilitative rules matter for an autistic child’s therapy:

• Coverage. The plan must cover habilitative services, which help a person "keep, learn, or improve skills and functioning for daily living" and may include physical and occupational therapy and speech-language pathology.⁠⁵
• Limits. It may not impose habilitative limits "less favorable than any such limits imposed on coverage of rehabilitative services and devices".⁠⁵
• No shared pool. For plan years beginning on or after January 1, 2017, it may not impose combined limits on habilitative and rehabilitative services.⁠⁵

Where a state’s base benchmark plan had no habilitative coverage, the state decides which services the category includes.⁠²⁰ And the mental health services in the package, including behavioral health treatment, must comply with the federal parity law.⁠⁵

For a Marketplace qualified health plan, a state’s autism mandate can sit inside or outside that package. For plan years beginning before January 1, 2028, a benefit required by state action on or before December 31, 2011, or "a benefit covered in the State’s EHB-benchmark plan", counts as an essential health benefit, while a later state requirement that is not in the benchmark plan counts as "in addition to the essential health benefits"; the state must defray the cost of those additional benefits and identifies which they are, and a new definition applies from 2028.⁠^5,25 The difference matters to a practice because the federal bar on dollar limits attaches to essential health benefits, so ask the state, through its insurance department, how it classifies its autism mandate.

Large employers’ plans, insured or self-funded, sit outside that requirement, which is addressed to the individual and small-group markets; their therapy benefit is what the plan document provides, within state law for an insured plan and federal rules such as parity and the dollar-limit bar.⁠⁶

Does mental health parity cover autism-related OT, PT and speech?

It can, when the plan treats those services as mental health benefits; parity then limits how far the plan’s visit caps, cost sharing and prior authorization for them can exceed what it applies to medical and surgical care. The federal rule defines mental health benefits as "benefits with respect to items or services for mental health conditions, as defined under the terms of the group health plan", and requires a plan’s definition of mental health conditions to be consistent with generally recognized independent standards of current medical practice, which the current text ties to the ICD’s mental, behavioral and neurodevelopmental disorders chapter and the DSM.⁠^8,26 The regulation’s own examples call autism spectrum disorder "a mental health condition".⁠⁸

Whether a speech or OT visit for an autistic child counts as a mental health benefit turns on the plan’s terms, so ask; the answer decides which comparison applies:

• The general rule. A plan may not apply a financial requirement or treatment limitation to mental health benefits that is more restrictive than the predominant one applied to substantially all medical and surgical benefits in the same classification, and outpatient in-network and outpatient out-of-network are separate classifications.⁠⁸
• Visit caps. Quantitative treatment limitations include "annual, episode, and lifetime day and visit limits".⁠⁸ The Labor Department’s summary says that for a majority of health plans, visit limits on mental health benefits cannot be more restrictive than those on medical or surgical visits.⁠²⁷
• Prior authorization and medical necessity. Nonquantitative limitations include "medical management standards (such as prior authorization) limiting or excluding benefits based on medical necessity".⁠⁸

Parity has limits of its own. It does not require a group plan to provide any mental health benefits at all; it does not apply to a group plan of a small employer, defined as an average of at least two and not more than 50 employees in the preceding calendar year; and its individual-market counterpart applies the same provisions to individual policies, in its current form for policy years beginning on or after January 1, 2026, grandfathered or not.⁠^8,26,28 Small-group plans that must cover the essential health benefits still owe parity for their mental health services through that requirement.⁠⁵

Can a therapy practice get a plan’s medical necessity criteria?

Yes, for mental health benefits, if the practice is a contracting provider. The parity statute requires the criteria for medical necessity determinations for mental health benefits to be made available "to any current or potential participant, beneficiary, or contracting provider upon request", and the regulations repeat it.⁠^8,9 Ask in writing, name the diagnosis and the service, and keep the reply with the authorization file. An out-of-network practice can ask the family to request the criteria as a participant or beneficiary.

Is the 2024 federal parity rule being enforced in 2026?

Not its new parts, under the departments’ statement of May 15, 2025, which on October 25, 2026 is still the newest item on the Department of Labor’s parity news page.⁠¹¹ The statement says the 2024 Final Rule took effect on November 22, 2024, with applicability for plan years starting on or after January 1, 2025 and January 1, 2026; that the departments would not enforce it, or otherwise pursue enforcement actions, for a failure to comply that occurs before a final decision in the lawsuit the ERISA Industry Committee filed in January 2025 challenging parts of it, plus an additional 18 months; that this relief covers only the portions that are new in relation to the 2013 final rule; and that the parity law’s "statutory obligations, as amended by the CAA, 2021, continue to have effect". The departments are reconsidering the rule, including whether to rescind or modify it, and HHS encourages states, the primary enforcers of parity for insurers, to take a similar approach.⁠¹⁰

The regulation’s current text still prints the 2024 amendments, including an example in which a plan covers autism but, out of network, pays only for developmental screenings and excludes other outpatient treatment such as ABA, and so "fails to provide meaningful benefits for treatment of ASD in the classification"; that example illustrates a paragraph whose applicability date is the first plan year beginning on or after January 1, 2026.⁠⁸ In a request or appeal, lead with the statute, such as the right to the criteria, and ask the state insurance department how it is enforcing parity for insured plans.⁠^9,10

Can a plan cap autism therapy by dollars, age or visits?

Dollar caps on essential health benefits are barred; age and visit caps are not barred by that rule and come from the mandate or the plan, within the parity and habilitative rules. A group health plan or insurer "may not establish any lifetime limit on the dollar amount of essential health benefits for any individual", and the same words bar annual dollar limits, in network or out.⁠⁷ Plans that are not required to provide the essential health benefits must still define them, for this rule, consistently with a state’s benchmark plan.⁠⁷ The lifetime bar reaches grandfathered plans too, and the annual bar reaches grandfathered group plans.⁠²⁴

Two exceptions shape what a practice sees. Dollar limits remain possible on specific covered benefits that are not essential health benefits, where other law allows them, and the rule does not prevent a plan from "excluding all benefits for a condition", though once a plan covers any benefits for a condition, the rule applies.⁠⁷

Florida’s statute shows why the plan document, not the statute, is the source for the number. It still states that coverage for the mandated services "shall be limited to $36,000 annually and may not exceed $200,000 in total lifetime benefits", adjusted each January 1 for the change in the medical component of the Consumer Price Index.⁠⁴ That cap sits beside the federal bar, so read what the plan actually applies, and raise any dollar cap on a therapy the plan counts as an essential health benefit with the plan and the state insurance department, which takes complaints about insurers.⁠^7,29

Age and visit caps work differently:

• Age. The mandate sets its own, as Florida’s eligibility rule does, while California’s section 1374.73 states no age limit in its text.⁠^4,15
• Visits in plans covering essential health benefits. Habilitative visit limits can be no less favorable than rehabilitative ones and cannot be combined with them.⁠⁵
• Visits for mental health benefits. Where the plan files autism therapy as a mental health benefit, its visit limit faces the parity comparison.⁠⁸

How can a practice tell a fully insured plan from a self-funded one?

Not from the card, which may carry the name of a company that only administers a self-funded plan, but from the plan’s own documents and the employer’s benefits office.⁠¹² Three documents settle it:

• The summary plan description. When an insurer is responsible in whole or part for financing or administering a group health plan, the summary plan description must give its name and address, say whether and to what extent the plan’s benefits are backed by a contract or policy of insurance it issued, and describe any administrative services it provides, such as paying claims.⁠¹³
• The plan document. For plans subject to ERISA, the instruments under which the plan is operated must generally be furnished to participants within 30 days of request.⁠⁸
• The summary of benefits and coverage. A plan or insurer must give it to a participant or beneficiary who asks, within seven business days, and it lists "the exceptions, reductions, and limitations of the coverage".⁠³⁰

These requests come from the family, as the participant or beneficiary, so give them the questions in writing. The regulator follows the answer: a state insurance department takes complaints about insurance companies, while the Employee Benefits Security Administration oversees job-based benefit plans.⁠^29,31

What order of questions identifies the plan type?

Work down this list; each yes points to the rules that govern that coverage, and a child with two coverages, such as an employer plan and Medicaid, gets an answer for each.

What should a benefit check for autism-related therapy ask?

Ask about your discipline’s benefit for this diagnosis and these codes, not about "autism coverage", because the mandate’s benefit and the therapy benefit can be different lines in the same plan.⁠^2,15 Confirm whether prior authorization applies and what it covers. HealthCare.gov defines preauthorization as a plan’s decision that a service "is medically necessary", and adds that it is not a promise that the plan covers the cost.⁠³²

Record the answers before the evaluation, and if they contradict the summary of benefits, ask the family to request the plan document. The intake call script covers the first call with the family, the credentialing guide covers getting in network, and the guide to out-of-network benefits covers families whose plan has the clinic out of network.

What paperwork do plans ask for on an autism therapy request?

Whatever the governing law and the plan’s own criteria name, so get the criteria before writing the request. Two statutes show how different the paperwork can be:

• Florida’s mandate limits coverage to treatment prescribed by the treating physician under a treatment plan, and lists what the treatment plan includes: a diagnosis, the proposed treatment by type, its frequency and duration, the anticipated outcomes stated as goals, how often the treatment plan is updated, and the treating physician’s signature.⁠⁴ That reaches OT, PT and speech under the mandate, so the physician’s signature belongs on the therapy plan, not only on an ABA plan.
• California’s mandate asks for a treatment plan "prescribed by a qualified autism service provider" for behavioral health treatment, and lets plans use case management, utilization review and prior authorization.⁠¹⁵ That paperwork is for the ABA benefit; an OT or speech request goes by the plan’s own requirements.

Beyond the statute, the plan’s medical necessity criteria set the test: a contracting provider can request them for mental health benefits, and after a denial an ERISA plan must give the claimant relevant documents free.⁠^9,19 HealthCare.gov’s general definition of medically necessary is care "needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine", but the plan’s own definition is the one it applies.⁠³³

Each discipline documents its own evaluation and plan. An occupational therapist’s letter does not argue for speech-language visits, and none should borrow ABA hours, goals or codes to make a therapy request fit.

What should a letter of medical necessity for autism therapy include?

It should answer the plan’s criteria for this patient and this discipline, signed by the treating therapist, with the evaluation and plan of care attached.

Where does a denied autism therapy claim go for review?

It goes by plan type: an insured plan’s denial runs through the plan’s internal appeal and then a qualifying state external review, a self-funded plan’s through the ERISA claims procedure and the federal external review, and a Medicaid denial to a state fair hearing. The federal rule requires an internal appeals process; an insurer covered by a qualifying state external review process follows it, while the federal process applies to plans and insurers "not subject to an applicable State external review process", which is where a self-insured plan lands unless a state process binds it; grandfathered plans are generally outside the rule.⁠³⁴

For an ERISA plan, insured or self-funded, the Labor Department’s claims procedure applies:

• Time to appeal. At least 180 days after the family receives the denial.⁠¹⁹
• The file. Free copies of "all documents, records, and other information relevant to the claimant’s claim for benefits", on request.⁠¹⁹
• Urgent claims. A health care professional with knowledge of the patient’s condition may act as the authorized representative.⁠¹⁹

For a child under 21 on Medicaid, the state must offer a hearing to anyone who believes a claim for covered services was wrongly denied, and a prior authorization decision is among the actions listed.⁠³⁵ The EPSDT guide covers the managed care appeal steps and the correct-or-ameliorate standard.

A complaint about an insured plan can also go to the state insurance department.⁠²⁹ The family’s side, with each plan type’s deadlines and an appeal letter, is in what to do when insurance denies therapy.

What changes when the autistic patient is an adult?

Mostly the reach of the mandate, which may stop at an age its statute sets. Florida’s mandate covers people under 18, and people 18 or older who are in high school and were diagnosed with a developmental disability at 8 or younger, while California’s behavioral health section states no age limit in its text.⁠^4,15 The habilitative rule for plans covering the essential health benefits and the parity rule state no age limit in their text, so an autistic adult’s therapy is checked against them in the same way.⁠^5,8

Public programs change more:

• Medicaid. EPSDT covers enrollees under 21; for adults, physical therapy, occupational therapy and speech, hearing and language services are optional benefits a state may add.⁠^14,36 The EPSDT guide covers planning for the 21st birthday.
• Medicare Advantage. Federal standards supersede state law, so a state autism mandate does not set the benefit.⁠¹⁶ The Medicare therapy coverage guide covers Medicare’s own therapy rules.

With an adult, ask the patient what they want help with first, and discuss the benefit with the patient unless they ask you to include someone else; the adult referrals guide covers adult referral routes.

Which rules and appeal route apply to each type of plan?

Match the plan type to its regulator, the rules that reach an autistic patient’s therapy, and the review route.

How should a practice explain an autism mandate to a family?

Explain the plan’s benefit, not the mandate: say which plan type you found, which benefit pays for your discipline, what limits apply, and what is still open. When a family has heard that their state requires autism coverage, the honest answer is that the requirement reaches some plans and some services, and that an authorization is a medical-necessity decision, not a promise to pay.⁠^1,32 The guide to explaining insurance, fees and payment covers the wider conversation; the family guide to insurance and therapy for children explains plan types for parents.

What should a clinic’s DrSensory listing say about autism and insurance?

It should say which plans the clinic is in network with and how it checks autism-related therapy benefits, because the insurance boxes alone cannot. Families search DrSensory free for occupational therapy, physical therapy and speech therapy clinics; it lists clinics rather than individual therapists, every clinic keeps a basic listing at no cost, and claiming is free.⁠³⁸ A paid listing adds a description in the clinic’s own words, the ages and conditions treated, and a Clinic details box that shows the insurance boxes the clinic ticks.⁠^39,40 A ticked box names no plan and no benefit, so use the description for the specifics, such as which plans the clinic contracts with and how it verifies each family’s benefit before the evaluation, and update both when a contract changes; the profile guide covers each field. DrSensory does not verify clinical quality, and a listing is not an endorsement.⁠^38,39

How do two autism therapy requests play out on different plans?

The two cases share one insurer’s name on the card and differ in everything that decides the benefit; the facts are invented to show the method, not likely results.

Sources

1. U.S. Government Publishing Office, govinfo. 29 U.S.C. 1144, Other laws (United States Code, 2023 edition; ERISA section 514; subsection (a), the preemption clause, and subsection (b)(2)(A) and (B), the savings and deemer clauses). Checked October 25, 2026.
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   “shall supersede any and all State laws insofar as they may now or hereafter relate to any employee benefit plan described in section 1003(a) of this title and not exempt under section 1003(b) of this title”; “nothing in this subchapter shall be construed to exempt or relieve any person from any law of any State which regulates insurance, banking, or securities”; “shall be deemed to be an insurance company or other insurer, bank, trust company, or investment company or to be engaged in the business of insurance or banking for purposes of any law of any State purporting to regulate insurance companies, insurance contracts”.
2. American Speech-Language-Hearing Association. Applied Behavior Analysis Issues in the States (ASHA state advocacy issue brief, one page, undated; ASHA’s own position). Checked October 25, 2026.
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   “Applied behavior analysis (ABA) therapy is one method of treatment for children with autism spectrum disorder (ASD).”; “In some states with mandated insurance coverage for ABA services, other medically necessary services”; “are not covered under the mandate and are being denied by insurers for services provided”; “ASHA maintains that insurers should cover all medically necessary services for children with ASD.”.
3. U.S. Department of Labor. ERISA (Health Plans and Benefits topic page). Checked October 25, 2026.
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   “is a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans”; “requires plans to establish a grievance and appeals process for participants to get benefits from their plans”; “In general, ERISA does not cover group health plans established or maintained by governmental entities, churches for their employees, or plans which are maintained solely to comply with applicable workers compensation, unemployment, or disability laws.”.
4. The Florida Legislature, Online Sunshine. The 2026 Florida Statutes, section 627.6686, Coverage for individuals with autism spectrum disorder required; exception (the Steven A. Geller Autism Coverage Act; history note: s. 1, ch. 2016-222 is the latest amendment listed). Checked October 25, 2026.
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   “means a group health insurance policy or group health benefit plan offered by an insurer which includes the state group insurance program provided under s. 110.123”; “The term does not include any health insurance plan offered in the individual market, any health insurance plan that is individually underwritten, or any health insurance plan provided to a small employer.”; “means any of the following disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association”; “‘Eligible individual’ means an individual under 18 years of age or an individual 18 years of age or older who is in high school who has been diagnosed as having a developmental disability at 8 years of age or younger.”; “Treatment of autism spectrum disorder and Down syndrome through speech therapy, occupational therapy, physical therapy, and applied behavior analysis.”; “Coverage shall be limited to treatment that is prescribed by the insured’s treating physician in accordance with a treatment plan.”; “Coverage for the services described in subsection (3) shall be limited to $36,000 annually and may not exceed $200,000 in total lifetime benefits.”; “Coverage may not be denied on the basis that provided services are habilitative in nature.”; “Coverage may be subject to other general exclusions and limitations of the insurer’s policy or plan, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, and utilization review of health care services, including the review of medical necessity, case management, and other managed care provisions.”; “These elements include, but are not limited to, a diagnosis, the proposed treatment by type, the frequency and duration of treatment, the anticipated outcomes stated as goals, the frequency with which the treatment plan will be updated, and the signature of the treating physician.”; “shall be adjusted annually on January 1 of each calendar year to reflect any change from the previous year in the medical component of the then current Consumer Price Index”.
5. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 156.115, Provision of EHB (current text; eCFR up to date as of October 22, 2026; paragraphs (a)(2), (a)(4) and (a)(6)). Checked October 25, 2026.
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   “Are required by a State action taking place on or before December 31, 2011.”; “With respect to the mental health and substance use disorder services, including behavioral health treatment services, required under § 156.110(a)(5), comply with the requirements under section 2726 of the Public Health Service Act and its implementing regulations.”; “Cover health care services and devices that help a person keep, learn, or improve skills and functioning for daily living (habilitative services). Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings”; “Do not impose limits on coverage of habilitative services and devices that are less favorable than any such limits imposed on coverage of rehabilitative services and devices”; “For plan years beginning on or after January 1, 2017, do not impose combined limits on habilitative and rehabilitative services and devices.”.
6. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 147.150, Coverage of essential health benefits (current text; eCFR up to date as of October 22, 2026; paragraph (a)). Checked October 25, 2026.
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   “in the individual or small group market must ensure that such coverage includes the essential health benefits package as defined in section 1302(a) of the Affordable Care Act”.
7. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 147.126, No lifetime or annual limits (current text; eCFR up to date as of October 22, 2026; paragraphs (a), (b) and (c)). Checked October 25, 2026.
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   “may not establish any lifetime limit on the dollar amount of essential health benefits for any individual, whether provided in-network or out-of-network”; “may not establish any annual limit on the dollar amount of essential health benefits for any individual, whether provided in-network or out-of-network”; “from placing annual or lifetime dollar limits with respect to any individual on specific covered benefits that are not essential health benefits to the extent that such limits are otherwise permitted under applicable Federal or State law”; “from excluding all benefits for a condition. However, if any benefits are provided for a condition, then the requirements of this section apply. Other requirements of Federal or State law may require coverage of certain benefits.”; “a group health plan or a health insurance issuer that is not required to provide essential health benefits under section 1302(b) must define “essential health benefits” in a manner that is consistent with the following:”; “an EHB-benchmark plan selected by a State in accordance with the available options and requirements for EHB-benchmark plan selection at § 156.111 of this subchapter”.
8. Office of the Federal Register, Electronic Code of Federal Regulations. 29 CFR 2590.712, Parity in mental health and substance use disorder benefits (Department of Labor, ERISA plans) (current text; eCFR up to date as of October 22, 2026, which includes the 2024 amendments; paragraphs (a), (c), (d), (e), (f) and (i)). Checked October 25, 2026.
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   “Mental health benefits means benefits with respect to items or services for mental health conditions, as defined under the terms of the group health plan”; “any condition defined by the plan or coverage as being or as not being a mental health condition must be defined consistent with generally recognized independent standards of current medical practice”; “the definition must include all conditions covered under the plan or coverage, except for substance use disorders, that fall under any of the diagnostic categories listed in the mental, behavioral, and neurodevelopmental disorders chapter (or equivalent chapter) of the most current version of the ICD or that are listed in the most current version of the DSM”; “may not apply any financial requirement or treatment limitation to mental health or substance use disorder benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation of that type applied to substantially all medical/surgical benefits in the same classification”; “(3) Outpatient, in-network.”; “(4) Outpatient, out-of-network.”; “Different types of quantitative treatment limitations include annual, episode, and lifetime day and visit limits.”; “Medical management standards (such as prior authorization) limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative”; “A plan covers treatment for autism spectrum disorder (ASD), a mental health condition, and covers outpatient, out-of-network developmental screenings for ASD but excludes all other benefits for outpatient treatment for ASD, including applied behavior analysis (ABA) therapy, when provided on an out-of-network basis.”; “it fails to provide meaningful benefits for treatment of ASD in the classification”; “The criteria for medical necessity determinations made under a group health plan with respect to mental health or substance use disorder benefits”; “must be made available by the plan administrator (or the health insurance issuer offering such coverage) to any current or potential participant, beneficiary, or contracting provider upon request”; “for plans subject to ERISA, instruments under which the plan is established or operated must generally be furnished to plan participants within 30 days of request”; “Require a group health plan (or health insurance issuer offering coverage in connection with a group health plan) to provide any mental health benefits or substance use disorder benefits”; “The requirements of this section do not apply to a group health plan (or health insurance issuer offering coverage in connection with a group health plan) for a plan year of a small employer.”; “an employer who employed an average of at least two (or one in the case of an employer residing in a State that permits small groups to include a single individual) but not more than 50 employees on business days during the preceding calendar year”; “on the first day of the first plan year beginning on or after January 1, 2025, except that the requirements of paragraphs (c)(2)(ii)(A), (c)(4)(i)(B), and (c)(4)(iii) of this section apply on the first day of the first plan year beginning on or after January 1, 2026”.
9. U.S. Government Publishing Office, govinfo. 29 U.S.C. 1185a, Parity in mental health and substance use disorder benefits (United States Code, 2023 edition; ERISA section 712; subsection (a)(4), availability of plan information). Checked October 25, 2026.
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   “The criteria for medical necessity determinations made under the plan with respect to mental health or substance use disorder benefits”; “shall be made available by the plan administrator (or the health insurance issuer offering such coverage) in accordance with regulations to any current or potential participant, beneficiary, or contracting provider upon request”.
10. U.S. Department of Labor, Employee Benefits Security Administration. Statement of U.S. Departments of Labor, Health and Human Services, and the Treasury regarding enforcement of the final rule on requirements related to the Mental Health Parity and Addiction Equity Act (statement dated May 15, 2025). Checked October 25, 2026.
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    “The 2024 Final Rule, which became effective on November 22, 2024, has staggered applicability dates of plan years starting on or after January 1, 2025, and plan years (in the individual market, policy years) starting on or after January 1, 2026.”; “On January 17, 2025, the ERISA Industry Committee (ERIC) filed suit in the U.S. District Court for the District of Columbia challenging certain provisions of the 2024 Final Rule”; “The Departments have requested that the ERIC litigation be held in abeyance while the Departments reconsider the 2024 Final Rule, including whether to issue a notice of proposed rulemaking rescinding or modifying the regulation through notice and comment rulemaking.”; “The Departments will not enforce the 2024 Final Rule or otherwise pursue enforcement actions, based on a failure to comply that occurs prior to a final decision in the litigation, plus an additional 18 months.”; “This enforcement relief applies only with respect to those portions of the 2024 Final Rule that are new in relation to the 2013 final rule.”; “The Departments note that MHPAEA’s statutory obligations, as amended by the CAA, 2021, continue to have effect.”; “HHS encourages states that are the primary enforcers of MHPAEA with respect to issuers to adopt a similar approach to enforcement.”.
11. U.S. Department of Labor, Employee Benefits Security Administration. News and Updates: Mental Health and Substance Use Disorder Parity (the parity news page; under “What’s New” its first item is the statement dated 05/15/2025). “Explore recent updates about MHPAEA implementation and enforcement.”; “Statement regarding enforcement of the MHPAEA 2024 Final Rule”. Checked October 25, 2026.
12. Centers for Medicare & Medicaid Services, HealthCare.gov. Self-insured plan (glossary). Checked October 25, 2026.
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    “Type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims.”; “These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third party administrator, or they can be self-administered.”.
13. Office of the Federal Register, Electronic Code of Federal Regulations. 29 CFR 2520.102-3, Contents of summary plan description (current text; eCFR up to date as of October 22, 2026; paragraph (q)). Checked October 25, 2026.
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    “If a health insurance issuer, within the meaning of section 733(b)(2) of the Act, is responsible, in whole or in part, for the financing or administration of a group health plan, the summary plan description shall indicate the name and address of the issuer, whether and to what extent benefits under the plan are guaranteed under a contract or policy of insurance issued by the issuer, and the nature of any administrative services (e.g., payment of claims) provided by the issuer.”.
14. Centers for Medicare & Medicaid Services, Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment (benefit page, undated). Checked October 25, 2026.
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    “The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.”; “States are required to provide any additional 1905(a) services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan.”; “It is the responsibility of states to determine medical necessity on a case-by-case basis.”.
15. California Legislative Information. California Health and Safety Code section 1374.73 (as amended by Stats. 2025, Ch. 413, effective January 1, 2026). Checked October 25, 2026.
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    “Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012.”; “‘Behavioral health treatment’ means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism”; “The treatment is provided under a treatment plan prescribed by a qualified autism service provider”; “A health care service plan contract in the Medi-Cal program”; “This section does not limit the obligation to provide services under Section 1374.72.”; “a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing”.
16. U.S. Government Publishing Office, govinfo. 42 U.S.C. 1395w-26, Establishment of standards (Medicare Advantage) (United States Code, 2023 edition; subsection (b)(3), relation to State laws). Checked October 25, 2026.
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    “The standards established under this part shall supersede any State law or regulation (other than State licensing laws or State laws relating to plan solvency) with respect to MA plans which are offered by MA organizations under this part.”.
17. U.S. Government Publishing Office, govinfo. 5 U.S.C. 8902, Contracting authority (Federal Employees Health Benefits Program) (United States Code, 2023 edition; subsection (m)(1)). Checked October 25, 2026.
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    “The terms of any contract under this chapter which relate to the nature, provision, or extent of coverage or benefits (including payments with respect to benefits) shall supersede and preempt any State or local law, or any regulation issued thereunder, which relates to health insurance or plans.”.
18. Defense Health Agency, TRICARE. Autism Care Demonstration (beneficiary page, last updated September 21, 2026). “The TRICARE Comprehensive Autism Care Demonstration covers applied behavior analysis services.”; “TRICARE covered services must be clinically necessary and appropriate. These include occupational therapy, physical therapy, speech therapy, psychological services, psychological testing, and prescription drugs. The TRICARE medical benefit covers these services.”. Checked October 25, 2026.
19. Office of the Federal Register, Electronic Code of Federal Regulations. 29 CFR 2560.503-1, Claims procedure (current text; eCFR up to date as of October 22, 2026; paragraphs (a), (b)(4) and (h)). Checked October 25, 2026.
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    “these requirements apply to every employee benefit plan described in section 4(a) and not exempted under section 4(b) of the Act”; “in the case of a claim involving urgent care, within the meaning of paragraph (m)(1) of this section, a health care professional, within the meaning of paragraph (m)(7) of this section, with knowledge of a claimant’s medical condition shall be permitted to act as the authorized representative of the claimant”; “at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination”; “upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits”.
20. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 156.110, EHB-benchmark plan standards (current text; eCFR up to date as of October 22, 2026; paragraphs (a)(5), (a)(7) and (f)). Checked October 25, 2026.
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    “Provide coverage of at least the following categories of benefits:”; “(5) Mental health and substance use disorder services, including behavioral health treatment.”; “(7) Rehabilitative and habilitative services and devices.”; “If the base-benchmark plan does not include coverage for habilitative services, the State may determine which services are included in that category.”.
21. Centers for Medicare & Medicaid Services, HealthCare.gov. Rehabilitative/Rehabilitation services (glossary). Checked October 25, 2026.
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    “Health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled.”; “These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.”.
22. Centers for Medicare & Medicaid Services, HealthCare.gov. Habilitative/Habilitation services (glossary). “Health care services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age.”. Checked October 25, 2026.
23. California Legislative Information. California Health and Safety Code section 1374.72 (paragraphs (a)(1) and (a)(2)). Checked October 25, 2026.
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    “Every health care service plan contract issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions”; “a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders”.
24. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 147.140, Preservation of right to maintain existing coverage (grandfathered plans) (current text; eCFR up to date as of October 22, 2026; paragraphs (a)(2), (d) and (e)(1)). Checked October 25, 2026.
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    “must include a statement that the plan or coverage believes it is a grandfathered health plan within the meaning of section 1251 of the Patient Protection and Affordable Care Act, and must provide contact information for questions and complaints, in any summary of benefits provided under the plan”; “Being a grandfathered health plan means that your [plan or policy] may not include certain consumer protections of the Affordable Care Act that apply to other plans”; “The provisions of PHS Act section 2711 insofar as it relates to lifetime dollar limits, and the provisions of PHS Act sections 2712, 2714, 2715, and 2718, apply to grandfathered health plans”; “the provisions of PHS Act section 2711 insofar as it relates to annual dollar limits, apply to grandfathered health plans that are group health plans”.
25. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 155.170, Additional required benefits (current text; eCFR up to date as of October 22, 2026, as amended May 20, 2026; paragraph (a)). Checked October 25, 2026.
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    “A State may require a QHP to offer benefits in addition to the essential health benefits.”; “For plan years beginning before January 1, 2028, a benefit required by State action taking place on or before December 31, 2011, a benefit required by State action for purposes of compliance with Federal requirements, or a benefit covered in the State’s EHB-benchmark plan is considered an EHB.”; “A benefit required by State action taking place on or after January 1, 2012, other than for purposes of compliance with Federal requirements, that is not a benefit covered in the State’s EHB-benchmark plan is considered in addition to the essential health benefits.”; “For plan years beginning on or after January 1, 2028, a State may require a QHP to cover benefits in addition to the essential health benefits”; “A State must make payments in accordance with paragraph (b) of this section to defray the cost of any State-required benefits in addition to the EHB.”; “The State will identify which State-required benefits are in addition to the EHB.”.
26. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 146.136, Parity in mental health and substance use disorder benefits (Department of Health and Human Services) (current text; eCFR up to date as of October 22, 2026, which includes the 2024 amendments; paragraphs (a), (d) and (f)). Checked October 25, 2026.
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    “Mental health benefits means benefits with respect to items or services for mental health conditions, as defined under the terms of the group health plan”; “must be made available by the plan administrator (or the health insurance issuer offering such coverage) to any current or potential participant, beneficiary, or contracting provider upon request”; “for a plan year of a small employer (as defined in section 2791 of the PHS Act)”.
27. U.S. Department of Labor, Employee Benefits Security Administration. Mental Health and Substance Use Disorder Parity (consumer page). Checked October 25, 2026.
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    “MHPAEA makes sure yearly visit limits, needs for prior authorization and proof of medical necessity are comparable.”; “Visit limits on mental health benefits can’t be more restrictive than those applied to medical or surgical visits for a majority of health plans.”.
28. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 147.160, Parity in mental health and substance use disorder benefits (individual market) (current text; eCFR up to date as of October 22, 2026). Checked October 25, 2026.
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    “The provisions of §§ 146.136 and 146.137 of this subchapter apply to individual”; “The provisions of this section apply for policy years beginning on or after January 1, 2026.”; “This section applies to non-grandfathered and grandfathered health plans as defined in § 147.140.”.
29. National Association of Insurance Commissioners. Insurance Departments (directory of state insurance departments). “Having a problem with an insurance company or agent? Find your state insurance department and file a complaint.”. Checked October 25, 2026.
30. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 147.200, Summary of benefits and coverage and uniform glossary (current text; eCFR up to date as of October 22, 2026; paragraphs (a)(1)(ii)(F) and (a)(2)(i)(C)). Checked October 25, 2026.
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    “A plan or issuer must provide the SBC to participants or beneficiaries upon request for an SBC or summary information about the health coverage, as soon as practicable, but in no event later than seven business days following receipt of the request.”; “The exceptions, reductions, and limitations of the coverage”.
31. U.S. Department of Labor, Employee Benefits Security Administration. About EBSA (agency page). Checked October 25, 2026.
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    “EBSA commits to educating and assisting more than 155 million workers, retirees, and their families covered by the benefit plans we oversee.”; “EBSA’s mission is to ensure the security of the retirement, health, and other job-based benefits of America’s workers and their families.”; “We accomplish this mission by developing effective regulations; assisting and educating workers, plan sponsors, fiduciaries, and service providers; and vigorously enforcing the law.”.
32. Centers for Medicare & Medicaid Services, HealthCare.gov. Preauthorization (glossary). “A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.”; “Sometimes called prior authorization, prior approval or precertification.”; “Preauthorization isn’t a promise your health insurance or plan will cover the cost.”. Checked October 25, 2026.
33. Centers for Medicare & Medicaid Services, HealthCare.gov. Medically necessary (glossary). “Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.”. Checked October 25, 2026.
34. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 147.136, Internal claims and appeals and external review processes (current text; eCFR up to date as of October 22, 2026; paragraphs (a), (b), (c) and (d)). Checked October 25, 2026.
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    “Paragraph (d) of this section sets forth a Federal external review process for plans and issuers not subject to an applicable State external review process.”; “The provisions of this section generally do not apply to coverage offered by health insurance issuers and group health plans that are grandfathered health plans”; “must implement an effective internal claims and appeals process”; “then the issuer must comply with the applicable State external review process”; “(that is, the plan is self-insured) and is subject to a State external review process that applies to and is binding on the plan (for example, is not preempted by ERISA)”.
35. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 431.220, When a hearing is required (Medicaid fair hearings) (current text; eCFR up to date as of October 22, 2026; paragraph (a)(1)). Checked October 25, 2026.
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    “The State agency must grant an opportunity for a hearing to the following:”; “denied his or her claim for eligibility or for covered benefits or services”; “A prior authorization decision.”.
36. Centers for Medicare & Medicaid Services, Medicaid.gov. Mandatory & Optional Medicaid Benefits (benefit list, undated; EPSDT appears under “Mandatory Benefits”, the three therapies under “Optional Benefits”). Checked October 25, 2026.
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    “States are required to provide all mandatory benefits under federal law. States may provide optional benefits if they choose to add them through the state plan process.”; “Physical therapy (1905(a)(11), 42 CFR 440.110(a))”; “Occupational therapy (1905(a)(11), 42 CFR 440.110(b))”; “Speech, hearing and language disorder services (1905(a)(11), 42 CFR 440.110(c))”.
37. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR part 438, subpart F: sections 438.408 and 438.410, resolution and expedited appeals (current text). Checked October 24, 2026.
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    “the State must establish a timeframe that is no longer than 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal”; “the State must establish a timeframe that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal”; “may extend the timeframes from paragraph (b) of this section by up to 14 calendar days”; “the enrollee is deemed to have exhausted the MCO’s, PIHP’s, or PAHP’s appeals process. The enrollee may initiate a State fair hearing”; “An enrollee may request a State fair hearing only after receiving notice that the MCO, PIHP, or PAHP is upholding the adverse benefit determination”; “The review must be at the enrollee’s option and must not be required before or used as a deterrent to proceeding to the State fair hearing”; “The enrollee must have no less than 90 calendar days and no more than 120 calendar days from the date of the MCO’s, PIHP’s, or PAHP’s notice of resolution to request a State fair hearing”; “taking the time for a standard resolution could seriously jeopardize the enrollee’s life, physical or mental health, or ability to attain, maintain, or regain maximum function”; “The MCO, PIHP, or PAHP must ensure that punitive action is not taken against a provider who requests an expedited resolution or supports an enrollee’s appeal”.
38. DrSensory. DrSensory for therapists (the For Therapists hub). Checked October 25, 2026.
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    “DrSensory is a directory families use free to find occupational therapy, physical therapy and speech therapy clinics”; “Every clinic keeps a basic listing at no cost.”; “The directory lists clinics rather than individual therapists, so one listing covers a whole practice at one address.”; “Claiming is free and has three steps: find your listing, confirm your email with a six-digit code, choose a password.”; “DrSensory does not guarantee rankings, sell your leads or vouch for clinical quality”.
39. DrSensory. Therapy Clinic Directory Pricing (the pricing page and its comparison table). “A description in your own words”; “Ages and conditions treated”; “We do not verify clinical quality.”; “Listing is not an endorsement, and we say so publicly on every results page.”. Checked October 25, 2026.
40. DrSensory. Claim and optimize your DrSensory profile (the guide for clinics). “The languages you speak and the insurance you take appear in a paid profile’s Clinic details box once you fill them in”; “The Clinic details box shows the boxes you tick; the description is where you name the plans.”. Checked October 25, 2026.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. State mandates, plan documents and federal enforcement positions change, so confirm each rule with the plan, the state insurance department or the Department of Labor; its examples are hypothetical, not DrSensory data or benchmarks.