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, up to an annual cap of $30,000 for qualifying children. Whether the law helps you depends almost entirely on what kind of plan you have, and the cap itself often runs out well before a year of intensive therapy does.
What the Law Covers
Covered plans must pay for diagnostic assessments, ABA therapy, and other therapeutic interventions a treating provider determines are medically necessary. Insurers cannot apply higher deductibles, co-payments, or coinsurance to autism treatment than they apply to comparable medical conditions.
The annual ABA benefit is capped at $30,000. Anything above that is the family’s responsibility, and the gap can be large: intensive ABA programs commonly run $60,000 to $250,000 per year depending on prescribed weekly hours. A child receiving 20 to 40 hours of therapy per week will exhaust the cap within a few months.
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. The law’s original eligibility covered children aged six and under, reflecting the emphasis on early intervention. Because the statute has been amended since its 2015 enactment, check the current text of O.C.G.A. § 33-24-59.10 for the most up-to-date age and benefit thresholds before relying on older summaries.
The law does not require coverage of therapies an insurer considers experimental or investigational. If your insurer denies a specific therapy on that basis, you can appeal through the insurer’s internal process and then through the state.
Which Plans Are Actually Covered
This is where many Georgia families run into trouble. The mandate applies to state-regulated, fully insured health benefit plans: individual grandfathered plans, fully insured large group plans, and fully insured small group grandfathered plans. If your employer buys a health insurance policy from a carrier regulated by the Georgia Office of the Commissioner of Insurance, the law likely applies to you.
Self-funded employer plans are the biggest exclusion. When an employer pays claims directly out of its own funds instead of buying insurance from a carrier, the plan is governed by the federal Employee Retirement Income Security Act (ERISA), which preempts state insurance mandates. Georgia cannot force those plans to cover autism treatment, and most large employers self-fund. 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, though they must comply with the Affordable Care Act’s essential health benefit requirements, which typically include behavioral health services. On those plans, check your specific benefit schedule rather than assuming Ava’s Law controls.
Not sure which type you have? Your summary plan description will say whether the plan is “fully insured” or “self-funded.” You can also call your HR department and ask directly.
What Happens When the $30,000 Cap Runs Out
Comprehensive autism evaluations alone can cost $500 to $6,000 before treatment begins. Once ABA starts, a child receiving 25 hours per week at typical rates will exhaust a $30,000 benefit in roughly four to six months. The family then covers the remainder of the year out of pocket, through Medicaid if the child qualifies, or by reducing therapy hours.
If You’re on a Self-Funded Plan: The Parity Act
Families on self-funded ERISA plans are not without options. The federal Mental Health Parity and Addiction Equity Act requires group health plans that offer both medical/surgical and mental health benefits to apply the same financial requirements and treatment limitations to both categories. A self-funded plan cannot impose co-pays, visit limits, or annual caps on autism treatment that are more restrictive than those it applies to medical and surgical benefits generally.
One important distinction: a self-funded plan is allowed to exclude autism coverage entirely. But if it chooses to cover autism as a condition, it cannot then carve out specific treatments like ABA therapy or impose limitations that apply only to that mental health 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 frequency of treatment, number of visits, and days of coverage. If your self-funded plan covers autism but applies any of these more tightly than it does for comparable medical conditions, raise it with your plan administrator or the U.S. Department of Labor’s Employee Benefits Security Administration.
Medicaid as a Second 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 directly, which can eliminate the out-of-pocket exposure families face after hitting a private plan’s cap. If your private insurance isn’t enough, it’s worth checking whether your child qualifies for Medicaid as a secondary coverage source.
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.
Contact your insurance company first and ask them to resolve the issue. If that doesn’t work, file through the OCI’s online Consumer Complaint Portal, which moves faster than the paper form. Have ready:
- Your policy number, claim number, and date of the denial
- The exact name of the insurance company and any agent or adjuster involved
- Copies of denial letters, invoices, correspondence with the insurer, and both sides of your insurance card
- 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. Parity complaints about self-funded plans go to the U.S. Department of Labor’s Employee Benefits Security Administration.
Tax Deductions and ABLE Accounts for Uncovered Costs
Out-of-pocket autism expenses above your insurance coverage may qualify as deductible medical expenses on your federal return. The IRS allows you to deduct the portion of qualifying medical and dental expenses that exceeds 7.5% of your adjusted gross income. Diagnostic evaluations, ABA sessions, speech therapy, occupational therapy, psychiatric care, and prescribed therapeutic equipment can all count.
ABLE accounts are tax-advantaged savings accounts for individuals with qualifying disabilities, including autism diagnosed before age 26. In 2026, up to $20,000 can be contributed annually. An account holder who works and does not participate in an employer-sponsored retirement plan can contribute an additional amount up to the lesser of their earned income or $15,650 (for residents of the continental United States). Contributions grow tax-free, and withdrawals used for qualifying disability-related expenses are not taxed.
ABLE funds do not count against the $2,000 asset limit for Supplemental Security Income eligibility up to $100,000, so families can save for disability-related costs without jeopardizing other benefits. Rollovers from 529 college savings plans into ABLE accounts are permitted on a tax-free basis, subject to the annual contribution limit.