Does Insurance Cover ABA Therapy?

Your child’s autism diagnosis will likely start you on a health insurance journey. Or perhaps you’ve suspected autism for a while and took a peek at your coverage. Either way, eventually, you may ask, “Does insurance cover ABA therapy (Applied Behavior Analysis)? for autism” You’re desperate to make a good choice for your family, and you probably have some questions. What is Applied Behavior Analysis, why is it so often referred to as the “gold standard” of therapy for individuals with Autism Spectrum Disorder (ASD), and is this autism treatment covered by health insurance?

Applied Behavior Analysis is an autism therapy based on the science of behavior and learning. It helps us understand how behavior works and why a person acts a certain way. The primary goal of ABA is to increase appropriate and helpful behaviors while decreasing behaviors that can be destructive and ultimately affect learning.

The benefits of ABA therapy include increased communication and language skills, improved attention, focus, memory, and academic performance. Parents and teachers typically see a decrease in unwanted behaviors. The methods implemented and designed by a Board Certified Behavior Analysts (BCBA) for your child have been studied and analyzed for decades. ABA research started around the 1960s, and its benefits continue to shine!

Is ABA Covered by My Insurance?

The good news is ABA is most likely covered by your insurance. Most insurance plans will cover autism treatment. Coverage varies from state to state and plans to plan, so check with your provider. Or call the ABA Centers of America hotline, and they can verify your insurance coverage for you with no obligation.

State and Federal Requirements for Autism Coverage

At one point, insurance companies could sit down and decide what they would and would not cover. Fortunately, this is no longer the case. Those old policies led to patchwork coverage that bankrupted some after an illness. Since then, legislators have become involved, and now plans must adhere to laws.

However, those laws can get confusing. For example, according to Autism Speaks, there are two types of plan options for individuals in the United States. These are:

• Self—funded plan—This plan must comply with federal laws, but not the state versions. Ultimately your employer decides what is and isn’t covered.
• Fully Insured Plans—This plan must provide benefits per state laws. In this case, the insurance company determines what is covered.

Like many Americans, you may not know which plan you have. This will be your first question. Most likely, you’ll begin the conversation at the state level. All 50 states have some kind of mandate regarding coverage for autism, but benefits can vary. Additionally, insurance may not explicitly support coverage for autism treatment, so it will be critical to ask. Here is a sample of how some state laws are handling insurance for ABA therapy:

• Arkansas—ABA is covered if provided by a supervised, Board Certified Behavior Analyst.
• California—If the plan covers physical treatments, that plan must also cover mental health services. ABA is considered a covered treatment.
• Delaware—ABA therapy and any necessary items or equipment needed for treatment are covered.
• Florida—ABA therapy is covered under meaningful coverage for autism under state-regulated plans. Those diagnosed with developmental disabilities at age eight years or younger are eligible. Coverage is also extended to those older than 18 as long as they are still in high school. Coverage for autism is capped at $36,000 annually and has a lifetime limit of $200,000.
• Georgia—ABA is not explicitly covered.
• Indiana—ABA is not explicitly covered. Still, treatment for autism and other related disorders can’t be subject to limits or deductibles.
• Massachusetts—ABA therapy is covered under MassHealth Standard, CommonHealth, and Family Assistance. Age limits apply. There are also private, fully funded options.
• Montana—ABA is not explicitly mentioned. Treatment for Autism Spectrum Disorder can be capped at $50,000 per year for children under eight.
• New Hampshire—Meaningful coverage for autism is covered under state-regulated plans. For individuals 0 to 12 years of age, coverage is capped at $36,000 per year. For individuals 12 to 21 years of age, coverage is capped at $27,000 per year.

Insurance companies should clearly outline the rules in the policies you can purchase. Moving to another state can have a massive impact on how much ABA therapy may cost your family. Moving to other countries is not unheard of for better treatment options.

How Does ABA Insurance Coverage work?

Because your plan can vary depending on the state, it can also vary from one insurance company to another. Some insurance companies embrace ABA therapy with open arms and fully cover it. Others are more conservative with coverage. By comparing plans side by side, you notice differences in range. Here are some examples of coverage from major insurance companies:

• Cigna—Some plans under this company cover Applied Behavior Analysis. If you have Cigna, most commonly, your doctor or another qualified specialist will submit a formal Autism Spectrum Disorder (ASD) diagnosis before treatment can begin.
• Blue Cross Blue Shield—Each plan is different. For example, in Michigan, ABA therapy is covered for individuals younger than 18 years. Like most other companies, paperwork and preauthorization are necessary before treatment begins.
• Aetna—Their policies cover ABA therapy as medically necessary if certain conditions are met. Talk to Aetna or one of the insurance specialists at ABA Centers of America about the specifics of your coverage.
• Kaiser Permanente—In 2012, Kaiser made the news when it became the first insurance company to cover ABA in Oregon voluntarily. However, not all plans in all states offer that coverage.

Be sure to review the booklet on coverage that comes with your insurance plan. While the language is technical and wordy, do your best to dig in and try to understand. You should be able to find information about whether your plan covers ABA. 

Get the Most Out of Your Coverage

You have health insurance, so now is the time to use it. If you find out you have coverage, allow the experts in the field to help your child flourish developmentally. Finding out about your coverage is the hard part; keeping your bill as low as possible will be the next priority. Get the most out of your coverage with the following tips:

• Fully comprehend any prior authorizations—Ensure you have all the proper paperwork submitted before any ABA sessions begin. Skipping this step could result in you having to pay the entire bill! In most cases, for ABA therapy, you will need a formal diagnosis of Autism Spectrum Disorder and a comprehensive behavior assessment.
• Follow guidelines—Experts suggest that a good plan requires ongoing documentation of progress. Your child’s Registered Behavior Technician (RBT) will need to submit documentation that the treatment is working. It will need to be reviewed by a BCBA. You are not responsible for these progress reports, but they are a critical part of ABA therapy.
• Stay within your network—Work with therapists and BCBAs contracted by your insurance company.
• Stay current with your premiums—Your insurance only works when paid on time. Make this invoice a priority at the beginning of every billing cycle.

How ABA Centers of America Can Help With Insurance for Autism

Your health insurance benefits are valuable and can ensure you save a large amount of money in the long run. Keep these facts and steps in mind when making the most out of that investment. If you have any questions, contact ABA Centers of America for free, confidential insurance verification and to learn about the exact level of coverage needed.