Maryland's Autism Insurance Mandate: Does Your Plan Have to Cover ABA?

If your family has private health insurance, the most useful question to ask about ABA therapy is often not does my insurance cover autism treatment? It’s is my plan subject to Maryland law? Maryland has a strong rule requiring coverage of habilitative services for children, including ABA for children with autism. But it applies only to some kinds of plans.

This guide explains what the law requires, which plans it covers, the exact age limit, and what to do if your plan says no. For a broader overview of the steps to starting ABA, see our guide to getting started with ABA therapy in Maryland.

What the law says

Maryland’s rule is Insurance Article §15-835, often called the habilitative services mandate. It defines habilitative services as services and devices, including occupational, physical and speech therapy, that help a child keep, learn, or improve skills and functioning for daily living.

The law doesn’t name autism in that definition, but the state has made clear how it applies:

• The Maryland Insurance Administration (MIA)‘s Parents’ Guide to Habilitative Services says that for children with autism or autism spectrum disorders, habilitative services include applied behavior analysis, behavioral health treatment, psychological care and therapeutic care.
• The law requires the Insurance Commissioner to issue regulations on how medical necessity is decided for autism. Those regulations are in COMAR 31.10.39, and they bar a plan from denying payment for ABA on the grounds that it is experimental or investigational.

The MIA also says plans subject to Maryland law may not limit coverage of medically necessary habilitative services. That’s different from rehabilitative therapy, which plans often cap at a set number of visits a year.

The age limit, worded precisely

Under §15-835, covered plans must provide habilitative services to children until at least the end of the month in which the child turns 19.

So if your child turns 19 in March, the law requires coverage through the end of that March. The words “at least” matter: a plan may choose to cover habilitative services beyond that point, and the MIA suggests checking your policy to see whether yours does.

Which plans the mandate covers

The law applies to insurers, nonprofit health service plans and HMOs that provide hospital, medical or surgical benefits under policies or contracts issued or delivered in Maryland. The MIA’s parents’ guide puts it in everyday terms. Plans subject to Maryland insurance law include:

• A health plan you bought in Maryland from an insurance company or HMO
• A health plan your employer bought in Maryland from an insurance company or HMO

Plans that are often called “fully insured” fall in this group. So do individual plans bought in Maryland, including through Maryland Health Connection.

Which plans it doesn’t cover

According to the MIA, Maryland law does not require these plans to cover habilitative services:

• Employer self-funded or self-insured plans. The employer pays claims out of its own funds, even if a well-known insurance company processes them. The MIA explains that self-funded plans are exempt from state insurance regulation and not subject to Maryland’s mandated benefits. They fall under federal law instead, chiefly ERISA.
• Some group policies issued in another state. If your employer’s home office is outside Maryland, your policy may have been issued there.
• Federal employee health benefit plans.
• Medicare and Medicaid. Maryland Medicaid has its own ABA benefit for members under 21, covered in our guide to whether Maryland Medicaid covers ABA.

The MIA adds that a plan not bound by Maryland law can still include habilitative benefits. A plan falling outside the mandate doesn’t mean there’s no coverage. It means you have to check that plan’s own terms.

Military families: TRICARE covers ABA through its own program, the Autism Care Demonstration, which has its own rules. TRICARE requires a referral to the program and pre-authorization for all ABA services.

How to find out which kind of plan you have

The insurance card alone usually won’t tell you. Many self-funded plans use a familiar insurer’s name and network. Try these steps:

1. Ask your employer’s benefits or HR office whether the plan is fully insured or self-funded, and in which state the policy was issued.
2. Call member services (the number is on the card) and ask, “Does my plan cover applied behavior analysis, or ABA, for autism spectrum disorder? Is the plan subject to Maryland’s habilitative services law?”
3. Ask for it in writing. The MIA suggests asking for a copy of the pages that list habilitative services benefits.
4. Keep notes of who you spoke with, the date and any reference number.

If a customer service representative can’t help, the MIA suggests asking for a supervisor.

Medical necessity: what plans may ask for

Coverage under the mandate depends on medical necessity. COMAR 31.10.39 limits how strict a plan’s review rules for autism treatment can be. Under the regulation, a plan may require:

• A comprehensive evaluation by your child’s primary care provider or a specialty physician showing a need for habilitative services
• A prescription from that provider with specific treatment goals
• An annual review by the prescribing provider, together with the ABA provider, documenting benefit and updating goals and the treatment plan

The regulation also says a plan may not deny coverage based solely on the number of hours prescribed when the request is for:

• Up to 25 hours a week for a child who is at least 18 months old and hasn’t yet turned 6
• Up to 10 hours a week for a child who is at least 6 and hasn’t yet turned 19

Those numbers aren’t a cap. The regulation lets plans authorize more hours when they are medically necessary. The plan can still review medical necessity on other grounds, so these numbers aren’t a guaranteed amount of therapy.

Plans may also limit payment to services from properly licensed or authorized providers. In Maryland, the behavior analyst who designs and supervises your child’s program holds a state license.

School and early intervention services

Two rules affect families whose children also get services through Infants and Toddlers or school:

• Under §15-835, a plan doesn’t have to pay for habilitative services delivered through early intervention or school services. Those programs are funded separately, at no cost to families.
• Under COMAR 31.10.39, a plan may not deny payment just because a treatment goal names the child’s educational setting as the place the service happens. A plan also isn’t required to provide the services listed in a child’s IEP.

The MIA notes that some children need services for needs that don’t affect their education, such as social interaction, and that families can pursue those through their health plan. Our guide to IEP services vs. ABA therapy in Maryland explains how the two fit together.

If your plan denies or limits ABA

The MIA’s parents’ guide describes the general process when your provider says a service is needed and your plan disagrees:

1. Read the denial letter. It explains the decision, how to appeal and whether you can complain to the MIA. There are time limits, so note them.
2. Ask the plan to reconsider, following the instructions in the letter. Your provider, or someone else you authorize, can do this for you. The Health Education and Advocacy Unit in the Maryland Attorney General’s Office can help (877-261-8807 or 410-528-1840).
3. Ask for independent review. If the plan upholds its denial, you can have an independent medical expert decide whether the service is medically necessary.
4. File a complaint with the MIA if your plan is subject to Maryland insurance law. The MIA sends the case to an independent medical expert. Complaints must be in writing with a signed consent form. The MIA’s consumer line is 410-468-2000 or 800-492-6116.

If the plan isn’t subject to Maryland law, the MIA can’t process the complaint, but the guide says the plan will send your case to an independent medical expert. In some urgent situations, or if a plan doesn’t follow its own appeal process, you may be able to go to the MIA directly. The guide explains when.

Getting started with Climbing Star in Maryland

Climbing Star’s Maryland practice, Climbing Star MD, is based in Elkridge and provides in-home ABA across Howard County, Baltimore County, Baltimore City and Anne Arundel County. We verify your benefits before services start, including whether your plan covers ABA, and help with the prior-authorization paperwork. Treatment plans are designed and supervised by licensed behavior analysts, and trained behavior technicians deliver sessions under their supervision. The first step is a free consultation: call our Maryland line at (410) 670-5250 or start online.

Official sources

The rules in this article come from these official Maryland and federal sources (checked October 2026):

• Md. Code, Insurance §15-835
• COMAR 31.10.39.02 (definitions)
• COMAR 31.10.39.03 (UR criteria for autism)
• MIA, Parents’ Guide to Habilitative Services 2024
• TRICARE, Autism Care Demonstration

This article is for general informational purposes and is not medical or legal advice. Coverage rules change; please verify your specific plan and consult qualified professionals about your child’s needs.