Autism and ABA Therapy: Will My Health Insurance Cover It?

If your child has autism, you might want to start thinking about health insurance.

Maybe you have already thought about it and checked your coverage and wondered, “Does insurance cover the ABA therapy for autism?”

This is a very important question and you would want to make the right choice for your family. Additionally, you might want to ask more questions, like what is Applied Behavior Analysis and why is it often called the best therapy for Autism Spectrum Disorder (ASD)?

Simply put, ABA therapy is based on how behavior and learning work. It helps us understand why someone acts a certain way with the main goal being to increase good behaviors and reduce harmful ones that can affect learning.

The benefits of ABA therapy include better communication and language skills, improved focus and memory, and doing better in school. Parents and teachers usually see fewer bad behaviors when ABA therapy is conducted.

So now, let’s check if your health insurance will cover this expense.

Does Insurance Cover ABA Therapy?

Short answer is, yes, your insurance probably covers ABA therapy for autism. Most insurance plans cover autism treatments, but coverage can differ depending on where you live and your specific plan, so it’s best to check with your insurance provider.

Autism Coverage Requirements

Insurance companies used to decide what they cover, causing problems for many who got sick along the way.

However, things have changed and are looking better today. Laws prevent financial hardship for those with health issues by requiring insurance plans to cover necessary treatments.

These can be tricky, especially about, since in the United States, there are two main types of plans for individuals:

• Self-funded plan – your employer decides what’s covered, following federal laws but not state ones.
• Fully Insured Plans – the insurance company decides what’s covered, following state laws.

If you are unsure about your plan, start by asking which one you have, which means that most likely, you’ll talk about it at the state level.

Every state has rules about autism coverage and they can differ as some insurance policies may not clearly say they cover autism treatment, so asking is important.

Here’s how some states handle insurance for ABA therapy:

• Arkansas: Insurance covers ABA therapy only when provided by a supervised, Board Certified Behavior Analyst (BCBA).
• California: If your plan covers physical treatments, it must also cover mental health services, including ABA therapy.
• Delaware: ABA therapy and necessary items or equipment for treatment are covered.
• Florida: ABA therapy is covered for those diagnosed with developmental disabilities up to age eight, and for those over 18 who are still in high school, with coverage capped at $36,000 annually and a lifetime limit of $200,000.
• North Carolina: ABA therapy in Charlotte NC is covered under state-regulated plans for individuals up to 18 years old, with coverage capped at $40,000 per year.
• Georgia: Insurers are not explicitly required to cover ABA therapy.
• Indiana: ABA therapy is not specifically mandated for coverage, but limits and deductibles on autism treatments are prohibited.
• Massachusetts: Certain state programs and private insurance options cover ABA therapy, but age restrictions apply.
• Montana: Coverage for ABA therapy is not explicitly stated, but treatment for Autism Spectrum Disorder may have an annual cap of $50,000 for children under eight.
• New Hampshire: State-regulated health plans offer capped coverage for autism treatment, with amounts varying by age.

ABA Insurance Coverage – How It Works

Coverage can vary by state and even among different insurance companies, as some provide full coverage of ABA therapy, while others may not.

Here are examples from major insurers:

• Cigna: Some plans cover ABA therapy after a formal ASD diagnosis.
• Blue Cross Blue Shield: Coverage varies by plan, with preauthorization needed.
• Aetna: ABA therapy is covered if certain conditions are met.
• Kaiser Permanente: Coverage for ABA therapy varies by state and plan.

Check your insurance plan’s coverage booklet for details, although the language may be a bit technical, so it’s best to get advice from a lawyer.

How to Get The Most of Your Coverage

Figuring out your coverage is the first step, then you should focus on keeping costs down. Use these tips to make the most of your coverage:

• Understand prior authorizations: Make sure all paperwork is in before starting ABA sessions to avoid unexpected bills. Typically, you’ll need a formal ASD diagnosis and behavior assessment.
• Follow guidelines: Keep track of progress with ongoing documentation from your child’s therapist and BCBA.
• Stay in-network: Work with therapists and BCBAs approved by your insurance.
• Keep up with premiums: Pay your insurance bill on time every billing cycle to keep your coverage active.

Is ABA Therapy Covered by Insurance?

Your health insurance benefits are valuable and can save you money in the long term.

Therefore, make sure to remember these facts and steps to maximize your coverage and ensure you’re safe in the knowledge that your child will have access to proper care at any time.