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Benefits & legal support

What your child is entitled to, who pays for it, and where to get help pushing for it — without paying an advocate first.

Federal rules, state details. This covers the federal rules that apply everywhere in the US, and flags where your state fills in the details. Two things are the same in every state: your child's rights under IDEA, and the EPSDT rule that Medicaid must cover medically necessary treatment for enrolled children under 21. Almost everything else -- Medicaid income limits, which waivers exist and how long the wait is, how CHIP is run, what your state counts as a developmental delay -- is set state by state. Where that matters, we say so rather than giving you a national answer that might not be yours.

Medicaid and EPSDT -- the rule most parents are never told about

If your child is enrolled in Medicaid and under 21, EPSDT can require your state to cover treatment it doesn't otherwise cover for anyone else.

EPSDT stands for Early and Periodic Screening, Diagnostic and Treatment. It is the children's benefit inside Medicaid, and it covers every child under 21 who is enrolled in Medicaid. It has three parts: screening (regular check-ups including developmental screening), diagnostic (when a screening turns something up, the follow-up evaluation must happen -- CMS's own wording is that "necessary referrals should be made without delay"), and treatment.

The treatment part is the part worth knowing. States must cover any service that federal Medicaid law allows, where it is medically necessary to treat, correct or reduce a condition found by screening -- "regardless of whether the service is covered in a state's Medicaid plan". So "our state plan doesn't cover that" is not, by itself, a final answer for a child under 21.

This is the mechanism behind ABA and other autism therapies being covered by Medicaid in states that never listed them. CMS's guidance is careful about what it does and doesn't say: services for autism can be covered under existing federal benefit categories (Other Licensed Practitioner, Preventive Services, and Therapies), and states are "expected to adhere to long-standing EPSDT obligations for individuals from birth to age 21, including providing medically necessary services available for the treatment of ASD".

What CMS has NOT done is mandate ABA specifically. In its own words: "CMS is not endorsing or requiring any particular treatment modality for ASD", and "State Medicaid agencies are responsible for determining what services are medically necessary for eligible individuals." So the entitlement is to medically necessary treatment, decided by your state's process -- not to a named therapy. That distinction is exactly where appeals happen.
If you're told no

A denial is a decision your state made about medical necessity, and states have to give you a way to appeal it -- a fair hearing. The practical move is to get the denial in writing with the reason stated, and to have the treating clinician document why the service is necessary to "correct or ameliorate" your child's condition, which is the federal standard the state's decision has to answer to.

This is also exactly the kind of thing your state's Protection & Advocacy agency exists for -- see the last section on this page.

Children in Medicaid are broadly protected from out-of-pocket costs in a way CHIP children are not -- see the CHIP section below for why that difference can matter more than the coverage itself.
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Medicaid waivers, when your income is "too high"

Two different routes that can get a disabled child onto Medicaid without counting the parents' income. Both exist only if your state chose to offer them.

Ordinary Medicaid for a child counts the family's income. That rule is why a lot of families with a significantly disabled child are told they don't qualify, while also being told the therapy their child needs isn't covered by their employer plan. Federal law has two long-standing ways around this, and both turn on the same idea: if the child would qualify for Medicaid in an institution, they can be covered at home instead.

Both are OPTIONAL for states. The Katie Beckett group is an optional eligibility group -- many states use it, not all, and the ones that do call it different things (some run a TEFRA-like version under a section 1115 demonstration instead). Which 1915(c) waivers exist, and who they're for, is entirely your state's design.
Waiting lists are legal and they are the norm, not a sign something went wrong. Federal rules let states "choose the maximum number of people that will be served under a HCBS Waiver program" -- so a waiver can be full. In many states the wait is measured in years. The practical consequence: get on the list the moment you learn it exists, even if you're not sure you need it yet, and even while you pursue everything else on this page. Nothing about being on a waiver waiting list stops you using any other route here.
How to find out what your state actually offers

There is no single national list that is reliably current, because states add, close and rename these programs. The dependable route is your state Medicaid agency's own site, and your state's Protection & Advocacy agency (last section) -- they track this for a living and their help is free. Ask two specific questions: does this state have a Katie Beckett or TEFRA pathway for children, and which HCBS waivers serve children with developmental disabilities.

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CHIP -- for the gap above Medicaid

Covers children whose family earns too much for Medicaid but can't afford private insurance. Whether EPSDT comes with it depends on how your state built its program.

CHIP is the Children's Health Insurance Program. In Medicaid's own description, "children eligible for CHIP are in families with incomes too high to qualify for Medicaid, but too low to afford private coverage." It is jointly funded by the states and the federal government and run by states within federal rules, and income levels vary by state -- in a family of four, children earning up to $80,000 a year or more may qualify in some states. You apply the same way as for Medicaid, and applications are accepted year-round rather than in an open enrollment window.

The single most important thing to find out about your state's CHIP: is it a Medicaid expansion, or a separate program? States running CHIP as a Medicaid expansion "must provide the ... EPSDT benefit" -- so the entitlement in the first section of this page applies in full. Separate CHIP programs are not required to offer EPSDT. For an autistic child, that is the difference between "medically necessary treatment must be covered" and "whatever this benefit package happens to list".

Separate CHIP programs still have a federal floor. They must cover well-baby and well-child visits, dental, behavioral health and vaccines. Mental health parity applies: "limitations applied to covered benefits for mental health and substance use disorder conditions must be no more restrictive than limitations on benefits for medical and surgical conditions." Beyond that, states pick a benchmark to model coverage on -- the Federal Employees Health Benefit plan, a state employee plan, or the largest commercial HMO plan in the state -- so benefits genuinely do vary by state and by CHIP type.

CHIP can charge you; children's Medicaid largely can't. States may impose enrollment fees, premiums, deductibles, coinsurance and copayments in CHIP. There are limits: for families above 150% of the federal poverty level, "cumulative state cost sharing requirements can't exceed 5% of family income", states can't charge anything for well-baby and well-child care, and states running a Medicaid expansion CHIP "must follow the Medicaid cost sharing rules" instead. Worth budgeting for if your child needs frequent therapy visits.
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IDEA Part C -- early intervention, birth to 3

You can refer your own child. The clock is 45 days from referral to a written plan, and it doesn't wait for a diagnosis.

IDEA is the Individuals with Disabilities Education Act, the federal law behind special education in the US. It has two halves by age: "Infants and toddlers, birth through age 2, with disabilities and their families receive early intervention services under IDEA Part C. Children and youth ages 3 through 21 receive special education and related services under IDEA Part B." Part C is this section; Part B is the next one.

Part C runs on a hard federal clock. Screening, the initial evaluation, the initial assessments of child and family, and the first IFSP meeting "must be completed within 45 days from the date the lead agency or EIS provider receives the referral of the child." A parent can make that referral directly -- you do not need a doctor to do it for you, and you do not need an autism diagnosis first.

The plan Part C produces is an IFSP (Individualized Family Service Plan) rather than an IEP, and the difference is real: it covers the family, not only the child. The services it can include are broad -- speech-language pathology, occupational therapy, physical therapy, audiology, vision services, special instruction, psychological and social work services, nursing and nutrition, assistive technology, transportation, sign language and cued language services, and "family training, counseling, and home visits" -- plus service coordination, the person whose job is to stop you having to chase all of it yourself.

Eligibility for Part C is where state variation bites hardest. Federal law covers a child with a measurable developmental delay or with "a diagnosed physical or mental condition that has a high probability of resulting in developmental delay" -- but each state sets its own definition of what counts as a developmental delay, and covering at-risk infants and toddlers is an option states may take or leave. A child who qualifies in one state may not in the next one over.
Part C services "are provided at no cost, except ... where Federal or State law provides for a system of payments by families, including a schedule of sliding fees." So some states charge on a sliding scale and some don't. Certain core parts -- evaluation, assessment, service coordination, and the IFSP process itself -- have to be free everywhere. Ask your state's program what, if anything, it charges for before you assume either way.
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IDEA Part B -- Child Find, the IEP, and what the school owes you

The district has a legal duty to find and evaluate your child. You can start that in writing, today, without a diagnosis.

From age 3 to 21, Part B gives your child the right to a free appropriate public education (FAPE), and "under the IDEA, an individualized education program (IEP) is the primary vehicle for providing FAPE." It's not a small system: as of 2022-23 IDEA served more than 8 million infants, toddlers, children and youth with disabilities.

Child Find is the duty parents most often don't know they can lean on. States must ensure that "all children with disabilities residing in the State, including children with disabilities who are homeless children or are wards of the State, and children with disabilities attending private schools, regardless of the severity of their disability, and who are in need of special education and related services, are identified, located, and evaluated." It explicitly reaches children "who are suspected of being a child with a disability ... and in need of special education, even though they are advancing from grade to grade" -- so good grades are not a reason to refuse to evaluate. It reaches highly mobile and migrant children too.

IDEA also gives you a named set of procedural safeguards, and they are worth knowing by name because saying the name changes the conversation: independent educational evaluations, prior written notice, parental consent, access to education records, mediation, and "the opportunity to present and resolve complaints through the due process complaint and state complaint procedures."

Two different complaint routes, often confused

A STATE COMPLAINT alleges a public agency broke an IDEA rule, and "any individual or organization, including one from another state, may file" one. It is the cheaper, lighter route and it is decided by the state education agency.

A DUE PROCESS COMPLAINT is the adversarial route, heard by an impartial hearing officer, and it is what you use when the disagreement is about your child's identification, evaluation, placement or FAPE specifically. The next section covers it, because it's also the route to a funded out-of-district placement.

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When the public school can't do it: district-funded specialist placement

If the district can't provide an appropriate education, it can be required to pay for a school that can -- out of its own budget. This is the most expensive thing a parent can ask for, and the least advertised.

This is the part of the system almost nobody is told about. If the district cannot provide your child a free appropriate public education itself, the specialist school that can is not a private-school bill you pay. Federal regulation is blunt about it: where placement in a public or private residential program is necessary to provide special education and related services, "the program, including non-medical care and room and board, must be at no cost to the parents of the child." The same principle runs through the placement continuum -- "special schools" are one of the placements a district has to be able to reach.

The route runs through the process in the section above, not around it. You raise it at the IEP meeting, as an IEP decision about placement. If the team says no, your disagreement is about placement and FAPE -- which is exactly what a due process complaint covers. There is no separate application form for this, and no special-cases office to call. The IEP and due process system IS the mechanism.
If you place your child privately first and seek reimbursement afterwards, the rules tighten considerably. A hearing officer or court may order reimbursement where the district "had not made FAPE available to the child in a timely manner prior to that enrollment and that the private placement is appropriate" -- but reimbursement can be reduced or denied unless you told the IEP team you were rejecting their placement and intended to enrol privately at public expense, and gave the district written notice at least ten business days before removing your child. There are exceptions (the school prevented you giving notice, you were never told of the requirement, or notice would have risked physical harm to the child; courts may also waive it where a parent isn't literate in English or notice would cause serious emotional harm). Practical version: give the ten-day written notice, and give it early.
Where the money comes from, and why districts fight it

It is overwhelmingly local money, which is why these decisions feel so financially defensive from the district's side. Nationally in 2020-21, 44% of public school revenue was local and 46% state, with only 11% federal -- and "some 83 percent ($343 billion) of local revenues for public schools were derived from local property taxes". An out-of-district placement is paid out of the same district budget as everything else, meaning it competes directly with the district's other spending.

Massachusetts shows the mechanics concretely, and is used here only as a worked example -- every state funds this differently. Home districts carry the cost: "in general, special education costs are the responsibility of the district where the student resides or, if the student is living in a residential program, where his or her parents reside." Tuition prices for approved private special education programs aren't set by the schools; the state's Operational Services Division sets prices for more than 200 approved programs at roughly 100 private schools.

Massachusetts also softens the blow with a "circuit breaker" the district can claim: the state pays 75% of the cost above a per-student threshold. DESE's own worked example -- "in FY23, the per-student threshold was $49,494. If special education services provided to a student cost a district $75,000, reimbursement for that student would be the cost of $75,000 minus the threshold of $49,494 times 0.75, or $19,129.50." Two things follow for a parent: the district's real exposure is smaller than the sticker price, and any figure quoted at you should be checked against your own state's arrangements rather than assumed.

Cost is not a legal defence to FAPE, but it is unmistakably the reason this route is not advertised. Expect to have to name it yourself, in writing, at an IEP meeting -- and to be the one who keeps the record.
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Free help exists for exactly this, in every state

Before paying an advocate or a lawyer: two federally funded networks cover every state and territory and cost nothing.

Parent Training and Information Centers (PTIs) are funded by the US Department of Education under IDEA itself, they "provide services in every state, the District of Columbia, Puerto Rico, the U.S. Virgin Islands and Pacific entities", and information and assistance from them "are available free of charge". They work with families of children with disabilities from birth to 26, and their whole purpose is helping parents participate effectively in their child's education -- which in practice means IEP meetings, evaluation requests and disputes. Start here.
Paid special education advocates and attorneys are a real and sometimes necessary option, particularly for a contested out-of-district placement. But the free networks above cover a great deal of the same ground, and the honest advice is to exhaust them first rather than start with a retainer.
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Advocacy organisations

Help with evaluations and IEPs

Free legal advocacy

Run a service that helps families with IEPs, evaluations or due process? List your service — we review every submission before it goes live.

This is general information gathered from the sources linked above, not legal or medical advice, and it isn't a substitute for advice on your child's specific situation. Income limits, waiver rules and state processes change — check the linked source before relying on a figure. Every claim on this page was last verified against its source on 2026-09-13.