When your child has a diagnosis such as autism, starting services recommended by providers like ABA is a priority for many parents. But navigating the world of insurance coverage for therapy can be time consuming and stressful.
Research shows that although ABA (applied behavior analysis) can benefit a child’s social interaction and social communication skills, the cost of treatment is often a barrier to receiving services.
Luckily, a federal mandate now requires insurance companies in all 50 U.S. states to provide coverage for services like ABA for individuals with an autism diagnosis.
Staying on top of details about coverage can empower parents to navigate the world of insurance to help their child receive beneficial services like ABA. Here’s what parents should know.
Federal Mandate: The Basics
In 2014, the Centers for Medicare and Medicaid Services released a bulletin stating that Medicaid programs nationwide were required to offer children with autism “medically necessary diagnostic and treatment services”.
By 2021, every state in the U.S. had adopted this insurance mandate. This was a huge win for the autism community, and a result of years of efforts and dedicated advocacy.
ABA is often referred to as the gold standard treatment for autism, due to the scientific approach’s highly effective methodology. The passing of the federal mandate has provided millions of people with insurance coverage for ABA and other therapy services.
The Challenges
While the federal mandate was a critical step forward in improving families’ access to services, there are still several potential challenges in navigating insurance coverage for ABA services.
Certain types of insurance plans (for example, “fully insured plans”) are required to provide benefits as directed by state law. Benefits are determined by the insurance company in a fully insured plan.
Self-funded insurance plans are regulated by federal law. They are not required to provide benefits as directed by state law. Benefits for self-funded plans are determined by the employer.
Navigating Insurance Coverage
Understanding the key components of insurance plans and advocating for your child’s needs can have a positive impact on his or her access to ABA services.
1. Know Your Insurance Plan.
Start by familiarizing yourself with the details of your health insurance plan. AutismSpeaks.org has a Health Benefits Guide that can help you determine your health benefits plan type. Review the coverage policy. Contact your plan administrator for clarification. Look for any exclusions or limitations that are related to ABA therapy.
2. Review State-Specific Mandates.
In addition to the federal mandate, some states have specific autism mandates. These provide details regarding ABA coverage. It’s important to review state-specific regulations for coverage of ABA services.
The American Speech-Language Hearing Association (ASHA) has a list of these specific autism mandates by state. State mandated coverage may have limitations for specific age groups, annual spending caps, limits on number of annual visits.
For example, the state of Arizona mandates coverage for medically essential behavioral therapy treatments that are subject to a $50,000 maximum benefit per year for eligible individuals up to age nine. A $25,000 maximum benefit is allowed for eligible individuals between the ages of nine and 16.
3. Advocate When Necessary.
4. Consider an Appeal.
If coverage for ABA services is initially denied by your insurance provider, remember that families have the right to appeal these types of decisions.
Additional Resources
Applied behavior analysis, or ABA, is an effective, widely used intervention that approximately 64% of children diagnosed with autism spectrum disorder receive. ABA can help children increase positive behaviors, reduce negative behaviors, and teach new behaviors.
Navigating insurance coverage for ABA services, like other therapy services, isn’t always easy. Due to the federal mandate for autism intervention services, ABA may be covered by your child’s Medicaid or private health insurance plan.
TherapyWorks is here to help your child succeed. Our team of specialists are experts in working with children on the autism spectrum, and offer ABA, speech therapy, occupational and physical therapy in-clinic (Northfield, Illinois), in-home (in Illinois and Michigan), and through teletherapy (nationwide).
References
Michael D. Kogan, Catherine J. Vladutiu, Laura A. Schieve, Reem M. Ghandour, Stephen J. Blumberg, Benjamin Zablotsky, James M. Perrin, Paul Shattuck, Karen A. Kuhlthau, Robin L. Harwood, Michael C. Lu; The Prevalence of Parent-Reported Autism Spectrum Disorder Among US Children. Pediatrics December 2018; 142 (6). DOI: https://doi.org/10.1542/peds.2017-4161
