ABA insurance and Medicaid coverage in Maine

Autism insurance mandate

State mandate for autism coverage

Yes, the research found a state autism coverage law.

Statute

24-A M.R.S. §2768 (individual policies and contracts), §2847-T (group policies, contracts, and certificates), and §4259 (individual and group HMO contracts). 24 M.R.S. §2317-B(12-H) makes those three sections applicable to nonprofit hospital and medical service organizations and health care plans licensed under Title 24. Enacted by P.L. 2009, c. 635 (LD 1198), signed April 12, 2010; age limit amended by P.L. 2013, c. 597 (LD 347). Revisor text extracted 10/05/2026; section histories end at P.L. 2013, c. 597.

Age limits

A covered individual who is 10 years of age or under (§2768(2), §2847-T(2), §4259(2)). Original mandate was 5 years of age or under, applying to policies, contracts, and certificates executed, delivered, issued for delivery, continued, or renewed in Maine on or after January 1, 2011 (P.L. 2009, c. 635; Bureau reprint states the Act was effective July 12, 2010, with that January 1, 2011 application date). P.L. 2013, c. 597, §4 applies the age-10 requirement to policies, contracts, and certificates executed, delivered, issued for delivery, continued, or renewed on or after January 1, 2015. The Bureau of Insurance mandate chart lists the same dates: effective 1/2011 (age 5 or under) and effective 1/2015 (expanded to age 10).

Annual cap

Permissive $36,000 per year on applied behavior analysis only; the statute does not require carriers to impose it. No limit on the number of visits (§2768(2)(C), §2847-T(2)(C), §4259(2)(C)). Payments for coverage unrelated to autism spectrum disorders may not be counted toward the ABA maximum. Diagnosis, counseling, and speech, occupational, and physical therapy are outside that dollar cap. Group policies: the cap is allowed only 'notwithstanding section 2843 and to the extent allowed by federal law' (§2847-T(2)(D)). HMO contracts: the cap is allowed only 'notwithstanding section 4234-A and to the extent allowed by federal law for group contracts' (§4259(2)(D)). Individual policies (§2768(2)(D)) contain the $36,000 permission with no federal-law qualifier. The Bureau's May 2015 review states the ACA eliminated annual dollar limits such as the $36,000 ABA cap for individual and small-group plans; carriers substituted hour limits in 2014 and, the Bureau reported, removed limits for 2015 to meet mental-health parity, with carrier-reported exceptions for grandfathered plans and some ACA transitional small groups. The Bureau's 2023 EHB benchmark chart (revised 06/01/2022) still tells filers the policy may limit ABA to the actuarial equivalent of at least $36,000 worth of visits/services per year.

Excludes self-funded employer plans

Yes, self-funded employer plans are generally outside state mandates.

Notes

The Bureau of Insurance states that Maine mandated benefits apply only to the fully insured market and do not apply to self-funded plans, MaineCare, or Medicare. The autism statutes regulate insurance policies, contracts, certificates, and HMO contracts and do not mention self-funded or ERISA plans. The mandate chart marks autism extra-territorial (ET) = Y, meaning it applies to certificates issued in Maine under group policies issued outside Maine. Treatment must be determined medically necessary by a licensed physician or licensed psychologist under 24-A M.R.S. §4301-A(10-A); ongoing medical necessity may be required at least annually. Covered treatment is habilitative or rehabilitative care, including ABA, plus counseling by a licensed psychiatrist, psychologist, clinical professional counselor, or clinical social worker, and therapy by a licensed or certified speech, occupational, or physical therapist. ABA is eligible only if provided by a person professionally certified by a national board of behavior analysts or performed under that person's supervision. 'Autism spectrum disorders' is still defined by DSM-IV pervasive developmental disorders (autistic disorder, Asperger's disorder, and PDD-NOS). Prescription drugs are required only if the policy otherwise covers drugs, and then on the same terms as other conditions. The mandate does not affect IEP or IFSP obligations. Coinsurance, deductibles, and exclusions are allowed if not inconsistent with the section. The May 2015 Bureau narrative says the age-10 expansion started January 1, 2014; the enacted application clause in that report's appendix and P.L. 2013, c. 597, §4, and the current Bureau chart, all say January 1, 2015.

Medicaid ABA coverage

Medicaid covers ABA

Yes, per the sources below.

Program

MaineCare Benefits Manual, Chapter II, Section 28 - now titled 'Adaptive Behavior Services for Children' (replacement rule effective April 29, 2026; formerly Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations). Includes Applied Behavior Analysis (ABA).

Agency

Maine DHHS, Office of MaineCare Services (OMS)

Provider enrollment

https://www.maine.gov/dhhs/oms/providers/provider-enrollment-revalidation

Payers named in our research

Names come from the research behind this page. Appearing here does not mean a payer is accepting new providers or that networks are open. Always confirm directly with the payer.