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The denial-letter kit: appeal it, in order
An insurance denial is a starting position, and most denials for autism services can be appealed. This kit gives you the printable call log, a fill-in appeal letter skeleton, and the deadlines that bind your insurer. Start with the denial letter itself: the reason code printed on it decides which template you use.
First, read the denial letter: find the reason code
The plan must tell you, in writing, why it denied and how to appeal. Denials fall into two types, and they route differently:
- Medical-necessity denial (“this treatment is not needed,” “too many hours,” “wrong setting”). These go through internal appeal and then, if needed, to an independent external review by a medical expert.
- Administrative denial (“not a covered service,” “network issue,” “you failed to pre-authorize,” an underpaid claim). These may need your state regulator if the plan is fully insured, or the Department of Labor and your employer if it is self-funded.
If the denial says “not medically necessary,” the plan must give you the clinical guidelines it used, on request. Request them. You cannot rebut criteria you have not seen.
Is your plan self-funded? Answer these 3 questions first
Whether your health plan is “self-funded” decides which autism coverage laws protect your family. State mandates cover fully insured plans; self-funded employer plans follow federal ERISA rules instead, and the state mandate does not bind them. Three questions tell you which one you have. Answer them below, then follow the branch that matches.
Why this one fact decides everything else
Federal law (ERISA) preempts state insurance regulation for self-funded employer plans, so no state autism mandate applies to them. Most large companies (500+ employees) self-fund, and the insurance card usually looks identical either way.
VerifiedSource: U.S. Department of Labor (EBSA); Autism Speaks, Self-Funded Health Benefit Plans · How we verify
Question 1: who pays the claims, your employer or the insurer?
In a fully insured plan, the employer buys a policy and the insurance company pays claims with its own money, so the state regulates it. In a self-funded plan, your employer pays the claims and hires an insurer only to administer the plan, so the card can say Aetna or Cigna and still be a self-funded plan. Level-funded plans count as self-funded for mandate purposes.
Question 2: what does your SPD say?
Every self-funded ERISA plan must give you a Summary Plan Description. Ask HR for a copy, then search it for “self-funded,” “self-insured,” and the name of the plan sponsor. If your employer is named as the plan sponsor and administrator, that is a strong self-funded tell.
Question 3: what does HR say when you ask this exact sentence?
“Is our health plan self-funded or fully insured?” It is a routine benefits question and HR should know. While you are there, ask what coverage exists for autism screening, diagnosis, and treatment, whether ABA is a covered benefit, and for the SPD. Get the answers in writing.
Branch A: you have a fully insured plan (your state-mandate path)
Florida’s autism mandate
Florida’s Steven A. Geller Autism Coverage Act requires covered plans to pay for screening and for treatment of autism spectrum disorder through speech therapy, occupational therapy, physical therapy, and ABA. It applies to group health plans and the state employee program, and explicitly does not apply to individual-market plans, individually underwritten plans, or small-employer plans.
VerifiedSource: Sections 627.6686 and 641.31098, Florida Statutes · How we verify
The Florida caps
Under the statute, ABA and the related therapies are capped at $36,000 per year and $200,000 in lifetime benefits, and the annual cap is adjusted upward every January 1 for medical inflation.
VerifiedSource: Section 627.6686(4)(b) and (8), Florida Statutes · How we verify
The exact current-year inflation-adjusted annual cap is not printed in the statute, and we have not yet verified the current figure. Confirm the current number with your plan before budgeting around it.
Not yet verified as of . Treat this as unconfirmed. What this meansSource: Section 627.6686(8), Florida Statutes · How we verify
One more rule worth knowing: a fully insured plan follows the law of the state where the policy was issued (usually the employer’s headquarters state), not the state where you live. Check the card or ask HR which state that is.
Branch B: you have a self-funded plan (your ERISA path, and what still works)
Self-funded is not the end of the road
As of 2018, about 45% of companies with 500 or more employees covered ABA or other intensive behavioral therapy voluntarily, and most companies that size self-fund. Check the SPD and ask before assuming you are uncovered.
VerifiedSource: Mercer National Survey of Employer-Sponsored Health Plans (2018), via Autism Speaks · How we verify
The federal parity lever
Self-funded plans that offer mental health benefits must follow the federal Mental Health Parity and Addiction Equity Act: they cannot make mental health care, including ABA, harder to get than comparable medical care. Since 2021, plans must produce their written parity comparative analysis on request to a participant or to the Department of Labor.
VerifiedSource: U.S. Department of Labor, EBSA, Mental Health and Substance Use Disorder Parity · How we verify
Your other levers: ask the employer to add the benefit (the employer, not the insurer, is the decision-maker in a self-funded plan), and check whether one of your employer’s plan options is fully insured. For enforcement, the state regulator cannot help with a self-funded plan; the U.S. Department of Labor (EBSA) is your door.
The call log (print this before your first phone call)
Plans frequently claim they never received documents. From your first call onward, write down every contact, get a reference number every time, and send documents in ways you can prove (certified mail, or fax with confirmation, then a follow-up call a week later).
| Date | Who I spoke to | Reference number | What they said | What I sent, and how | Follow up by |
|---|---|---|---|---|---|
The appeal letter skeleton, with brackets to fill in
This skeleton follows the packet structure recommended by the Mental Health and Autism Insurance Project. Attach the denial letter, the diagnosis, the BCBA assessment and treatment plan, and letters from treating providers.
Re: Appeal of denial, [member name], member ID [number], claim/reference [number from the denial letter]
To the Appeals Department of [plan name]:
I am appealing your denial dated [date] of [service denied, for example ABA therapy at N hours per week] for my child, [name].
[The story: what is going on that makes this treatment necessary. Describe your child’s diagnosis, current needs, and any serious behaviors. If treatment already happened, describe what occurred.]
[Why the denial is wrong: respond to the reason code on the letter. If the denial says “not medically necessary,” state that you requested the clinical criteria and respond to them directly. Attach the treating provider’s letter.]
[Any rule you believe the plan broke: for example a dollar or visit cap on ABA that does not apply to comparable medical care, which is a federal parity concern, or missing notice before cutting previously approved care.]
I request that this denial be overturned. [If care is ongoing: I also request continued coverage of the current course of treatment pending the outcome of this appeal.] [If urgent: I request an expedited appeal.]
Enclosed: [list every document]. Please confirm receipt in writing.
[Name, address, phone, email, date]
Deadlines: yours and theirs
| Appeal level | Your deadline | Their deadline |
|---|---|---|
| Internal appeal | Printed on the denial letter. Calendar it the day the letter arrives; never miss it. | Stated in the plan documents; ask for it in writing on your first call and log the answer. |
| Expedited appeal (urgent, or approved care being cut) | Request it explicitly, in writing if possible. | Generally 72 hours. See the receipt below. |
| External review | Instructions and the deadline come with the final internal denial letter. | Set by the external review process named in that letter. |
The 72-hour rule and continued coverage
When previously approved care is being cut, the plan generally must respond to an expedited appeal within 72 hours, and under the ACA appeal rules (45 CFR 147.136) it cannot reduce or terminate an ongoing course of treatment without advance notice and a chance to appeal first. You can request continued coverage pending the outcome of the appeal; ask for it explicitly.
VerifiedSource: ACA appeal rules (45 CFR 147.136); U.S. Department of Labor, EBSA · How we verify
Florida routes external reviews for state-regulated plans through a process overseen by state regulators. We have not yet verified the current Florida external review filing steps and time limits from the primary source, so follow the instructions printed on your final denial letter.
Not yet verified as of . Treat this as unconfirmed. What this meansSource: Florida Department of Financial Services · How we verify
Internal appeal, external review, and when each applies
You almost always must appeal internally first, unless it is an expedited case. Plans typically allow one or two levels of internal appeal. If the internal appeal fails on a medical-necessity dispute, you have the right to an independent external review: a medical expert outside the plan reviews the documents and decides. Reuse the same packet, add anything new about your child’s status, and directly refute the plan’s response to your internal appeal.
In parallel: a fully insured plan answers to your state insurance regulator, and a self-funded plan answers to the U.S. Department of Labor (EBSA) and to your employer. Knowing which plan you have (the checker above) tells you which door to knock on.
If the payer is Medicaid
EPSDT: the floor for children under 21
For a child under 21 enrolled in Medicaid, the EPSDT mandate requires the state to cover any medically necessary service that corrects or improves the child’s condition, and states cannot use rigid dollar caps or visit limits to deny it. A flat “we don’t cover ABA” answer is usually not lawful for a child under 21.
VerifiedSource: Medicaid.gov, EPSDT; CMS State Health Official letter SHO #24-005 (2024) · How we verify
Medicaid denials have their own appeal track with their own deadlines, and the EPSDT standard above is your central argument. The federal page explains EPSDT in plain words.
Common questions
Does the Florida autism mandate apply to my plan?
Only if your plan is a fully insured group plan or the state employee program. The mandate explicitly does not apply to individual-market plans, individually underwritten plans, or small-employer plans, and self-funded plans follow federal ERISA law instead.
Section 627.6686, Florida Statutes. Verified .
My employer’s plan is self-funded. Is ABA just not covered?
Not necessarily. Many self-funded plans cover ABA voluntarily, federal parity still applies if the plan offers mental health benefits, and the employer itself can add the benefit. Check the SPD before assuming anything.
Autism Speaks; U.S. Department of Labor (EBSA). Verified .
How fast must the plan decide an urgent appeal?
When previously approved care is being cut, the plan generally must respond within 72 hours, and it cannot end an ongoing course of treatment without advance notice and a chance to appeal first. Ask explicitly for continued coverage pending the appeal.
ACA appeal rules (45 CFR 147.136); DOL. Verified .
Can Medicaid deny ABA for my child?
For a child under 21 on Medicaid, EPSDT requires coverage of medically necessary care that corrects or improves the child’s condition, without rigid caps. Denials can be appealed, and the EPSDT standard is your central argument.
Medicaid.gov; CMS SHO #24-005. Verified .