Ava’s Law in Georgia, codified at O.C.G.A. § 33-24-59.10, requires certain state-regulated health insurance plans to cover the diagnosis and treatment of autism spectrum disorder, including applied behavior analysis (ABA) therapy. Coverage for ABA is capped at $30,000 per year, and the mandate reaches only some plan types, so whether it protects your family depends heavily on how your insurance is structured.
What the Law Requires Insurers to Cover
Covered plans must provide benefits for diagnostic assessments, ABA therapy, and other therapeutic interventions a treating provider determines are medically necessary. Insurers cannot single out autism treatments for higher deductibles, co-payments, or coinsurance than they apply to comparable medical conditions.
Diagnosis has to come from a licensed physician or psychologist using criteria from the current edition of the Diagnostic and Statistical Manual of Mental Disorders. As originally enacted in 2015, the law applied to children aged six and under, reflecting an emphasis on early intervention. The statute has been amended since then, so families should check the current text of O.C.G.A. § 33-24-59.10 for the age and benefit thresholds that apply today.
The law does not require coverage for therapies an insurer classifies as experimental or investigational. If your insurer denies a specific therapy on those grounds, you have the right to appeal through the insurer’s internal process and then through the state.
Which Health Plans Ava’s Law Actually Reaches
This is where many Georgia families run into trouble. The mandate applies to state-regulated, fully insured health benefit plans. That includes individual grandfathered plans, fully insured large group plans, and fully insured small group grandfathered plans. If your employer buys a policy from a carrier regulated by the Georgia Office of the Commissioner of Insurance, the law likely applies to you.
The largest exclusion is self-funded employer plans. When an employer pays claims directly out of its own funds rather than buying insurance from a carrier, the arrangement falls under the federal Employee Retirement Income Security Act (ERISA). ERISA preempts state insurance mandates, meaning Georgia cannot force those plans to cover autism treatment. Most large employers self-fund, so this gap is significant. The Georgia Office of the Commissioner of Insurance has confirmed it lacks jurisdiction over self-insured employers and their health and welfare benefit plans.
Non-grandfathered individual and small group plans also sit outside the state mandate. Those plans must comply with the Affordable Care Act’s essential health benefit requirements, which typically include behavioral health services, but families on these plans should check the specific benefit schedule rather than relying on Ava’s Law.
The $30,000 Cap in Practice
The annual cap on ABA therapy coverage is the part of the law families feel most sharply. Intensive ABA programs commonly run $60,000 to $250,000 per year depending on the number of weekly hours prescribed. A child receiving 20 to 40 hours of therapy per week will exhaust a $30,000 benefit within a few months. Comprehensive autism evaluations alone can cost $500 to $6,000 before treatment begins.
Practically, a child receiving 25 hours of ABA per week at typical rates will use up a $30,000 benefit in roughly four to six months, leaving the family responsible for the balance of the year out of pocket.
Options When Ava’s Law Doesn’t Apply
Federal Parity Protections for Self-Funded Plans
Families on self-funded ERISA plans still have some protection. The federal Mental Health Parity and Addiction Equity Act requires group health plans that offer both medical/surgical benefits and mental health benefits to apply the same financial requirements and treatment limitations to both categories. In practice, a self-funded plan cannot impose co-pays, visit limits, or annual caps on autism treatment that are more restrictive than what applies to medical and surgical benefits generally.
An important distinction: a self-funded plan is permitted to exclude autism entirely. But if it chooses to cover autism, it cannot carve out specific treatments like ABA therapy for exclusion or apply limitations only to that condition. Courts have found that singling out behavioral therapies for autism while covering the underlying diagnosis violates the Parity Act’s prohibition on treatment limitations that apply only to mental health benefits.
Financial requirements under the Parity Act include deductibles, copayments, coinsurance, and out-of-pocket limits. Treatment limitations include caps on the frequency of treatment, number of visits, and days of coverage. If your self-funded plan covers autism but restricts any of these more tightly than for comparable medical conditions, that is a potential parity violation to raise with your plan administrator or the U.S. Department of Labor.
Georgia Medicaid
Families who qualify for Medicaid have a separate pathway. Since January 2018, Georgia Medicaid has covered autism spectrum disorder assessment and treatment for individuals under age 21. Coverage is based on medical necessity and follows Early and Periodic Screening, Diagnostic, and Treatment standards. A member needs a documented diagnosis from a licensed physician, psychologist, or other designated licensed professional using DSM-5 criteria to qualify for Adaptive Behavior Services.
Georgia Medicaid enrolls board-certified behavior analysts to deliver these services directly, which can eliminate the out-of-pocket exposure families on private plans face when they hit the annual cap. For families with private insurance who find the $30,000 ceiling inadequate, checking whether the child qualifies for Medicaid as a secondary coverage source is worth the effort.
Filing a Complaint When Coverage Is Denied
The Georgia Office of the Commissioner of Insurance and Safety Fire oversees compliance with Ava’s Law for state-regulated plans. Its Consumer Services Division investigates complaints about how insurers handle claims, including autism coverage denials.
Before filing, contact your insurance company directly and ask them to resolve the issue. If that does not work, you can file through the OCI’s online Consumer Complaint Portal, which is faster than the paper form. You will need your policy and claim numbers, the date of the denial, the exact name of the insurance company and any agent or adjuster involved, copies of denial letters, invoices and correspondence with the insurer, both sides of your insurance card, and a concise written summary of the dispute.
The Consumer Services Division cannot help with self-insured employer plans, federal employee health insurance, Medicare, Medicaid, or the State of Georgia Employee’s Health Plan. If your plan is self-funded, complaints about parity violations go to the U.S. Department of Labor’s Employee Benefits Security Administration instead.