Improving Systems, Practices and Outcomes

Use of Private Insurance for Early Intervention Services

Under 34 CFR §303.520(3)(b), a state may use the private insurance of a parent to pay for services under this part only if the parent provides consent to do so in accordance with 34 CFR § 303.7 (parental consent), 303.420(a)(3) (consent prior to provision of services) and 303.420(a)(4) (use of private insurance).

It is important to remember that under 34 CFR §303.521(c) if a State has in effect a State law requiring the provision of a free appropriate public education (FAPE) to children with disabilities from birth, the State may not charge parents for any services (e.g., physical or occupational therapy) that are part of FAPE for that infant or toddler and family.

State Policies

  • PDF: Colorado requires coverage of Part C services by public medical assistance and private health insurance up to $6,067, including case management costs, per calendar or policy year.
  • DOC: Connecticut (effective 7/1/2012) requires coverage of Part C services up to $6,400 per child per year and an aggregate benefit of $19,200 per child over the total three-year period. Group insurance policies have an exemption to the expense limit for children with autism spectrum disorder, who have a maximum benefit available through early intervention providers of $50,000 per child per year and an aggregate benefit of $150,000 per child over the total three-year period. These costs are exempt from (1) being applied against or result in a loss of benefits due to any maximum lifetime or annual limits specified in the policy, (2) adversely affecting the availability of health insurance to the child, the child's parent or the child's family members insured under any such policy, or (3) being a reason to rescind or cancel such policy.
  • WWW: Indiana also requires insurers to reimburse early intervention services if they are otherwise covered under a policy and exempts these payments from counting against any lifetime caps.
  • Massachusetts mandates that both indemnity and managed care plans cover early intervention.
  • doc: New Hampshire requires coverage for Children's Early Intervention Therapy Services up to $3,200 per child per year not to exceed $9,600 by the child's third birthday.
  • WWW: New Mexico requires coverage for children, from birth through three years of age, for or under the family, infant, toddler program administered by the department of health, provided eligibility criteria are met, for a maximum benefit $3,500 annually for medically necessary early intervention services. The services are provided as part of an individualized family service plan and delivered by certified and licensed personnel working in early intervention programs that are approved by the department of health. No payment shall be applied against any maximum lifetime or annual limits specified in the policy, health benefits plan or contract.
  • WWW: New York requires local early intervention program administrators to seek commercial insurance reimbursement for early intervention services delivered to children whose commercial insurance policies are subject to New York State law. State law subrogates municipalities to covered children's insurance policies for reimbursement of services delivered through the Early Intervention Program, and provides the following protections for family insurance policies when used for early intervention services:
    • Payment for early intervention services cannot be applied to the lifetime and annual monetary caps on the child/family's insurance policy.
    • Parents cannot be asked to pay co-payments and deductibles (these costs are covered by the county and state).
    • The visit limitations for covered services may apply to early intervention services; however, use of covered services cannot reduce the number of visits otherwise available under the plan (e.g., if the policy covers 10 visits of physical therapy, and the county is reimbursed for 10 visits of physical therapy used for the purposes of early intervention, the child/family will continue to have 10 visits available for health care purposes - such as services required after surgery or an accident).
    For more information see: WWW: https://www.health.ny.gov/community/infants_children/early_intervention/memo03-2.htm#_toc42408102
  • WWW: Rhode Island requires coverage of Part C services up to $5,000 annually per dependent child and exempts these costs from counting against any lifetime cap in a family's policy.
  • WWW: Virginia also requires coverage of Part C services up to $5,000 annually and exempt these costs from counting against any lifetime caps in a family's policy. The state also applies these provisions in a separate act to the insurance program for state employees.

Health Insurance Legislation for Autism Spectrum Disorders (ASD)

Several states have enacted insurance legislation specific to autism spectrum disorders or have modified existing legislation to further define neurological disorders to include ASD for the purpose of covering needed services for eligible children. The following resources describe state health insurance legislation for ASD:

PDF: State Health Insurance for Autism Spectrum Disorders (ASD)(February 2009). Also available in Excel format. Information compiled by Anne Taylor Karasek formerly of NECTAC.

WWW: Easter Seals State Autism Profiles include: state insurance coverage for autism if available; the number of children with autism who have received the state's special education services; Medicaid services specific for individuals with autism; educational programs provided to students with autism or training that focused on autism; special education criteria; other state-led resources; and, sponsors of autism legislation.

WWW NCSL searchable database of state legislation tracks autism legislation from the 2008 session to present. You may search by state, topic, status, primary sponsor, bill number or keyword. In addition, the site WWW summarizes current state insurance legislative approaches to meet the needs of children and adults with autism.

  • IDEAs that Work: Office of Special Education Programs, U.S. Department of Education

The ECTA Center is a program of the FPG Child Development Institute of the University of North Carolina at Chapel Hill, funded through cooperative agreement number H326P170001 from the Office of Special Education Programs, U.S. Department of Education. Opinions expressed herein do not necessarily represent the Department of Education's position or policy.

Project Officer: Julia Martin Eile     © 2012-2018 ECTA Center

  • UNC Frank Porter Graham Child Development Institute