When your child receives an autism spectrum disorder (ASD) diagnosis, one of the first questions that comes to mind is often about treatment costs. Applied Behavior Analysis (ABA) therapy is widely recognized as the most effective, evidence-based treatment for autism, but understanding how insurance coverage works can feel overwhelming. This comprehensive guide breaks down everything you need to know about ABA therapy insurance coverage to help you navigate this critical aspect of your child’s care.
ABA therapy is a notable behavioral treatment for people with ASD that encourages desired behaviors and discourages undesired behaviors to improve a variety of skills. ABA is often referred to as the gold standard treatment for autism, due to the scientific approach’s highly effective methodology.
Without insurance coverage, the financial burden can be significant. ABA therapy costs can range from $62,400 to $249,600 per year, with monthly costs ranging from $4,800 to over $20,000, and weekly costs starting at $1,200 and going up to $4,800. Even ABA on a very part-time basis can cost $17,000 per year.
The landscape of ABA therapy insurance coverage has dramatically improved over the past two decades. A federal mandate requires insurance companies in all 50 U.S. states to provide coverage for services like ABA therapy for individuals with an autism diagnosis. This mandate, adopted by every state, has expanded insurance coverage for ABA therapy and other therapy services.
At least 200 million people now have coverage for ABA therapy. Most insurance plans cover ABA therapy. In fact, in 2014, the Affordable Care Act (ACA) mandated that insurance companies cover medically necessary treatments for autism, including ABA therapy.
Not all insurance plans work the same way when it comes to ABA coverage. Understanding your plan type is crucial:
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.
While federal mandates provide a foundation, the exact coverage may still vary from state to state and plan to plan. All 50 U.S. states have enacted mandates requiring insurers to cover autism-related services.
Some examples of state-specific provisions include:
Medicaid does cover Applied Behavior Analysis (ABA) therapy for children and youth under 20 diagnosed with autism spectrum disorder (ASD). This coverage is mandated by federal law, requiring all 50 states to provide funding for ABA therapy through Medicaid as of 2022.
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.
It’s essential to check with your insurance provider to understand the specific coverage details, including deductibles, co-pays, and any limitations or restrictions that may apply.
Insurance coverage for ABA therapy typically involves: a diagnosis of ASD from a qualified healthcare provider, ABA therapy recommended by a qualified healthcare provider with a treatment plan developed, and prior authorization from insurance companies to ensure medical necessity.
Insurance policies may require that families use in-network providers to receive coverage.
Some states have expanded coverage by increasing age limits – for example, Senate Enrolled Act 345 in Indiana expanded coverage for ABA therapy by increasing the age limit for coverage from 6 to 18 years old.
Insurance policies may have limits on the number of hours or sessions of ABA therapy that they will cover each year.
Prior authorization is a health plan cost-control process by which health care providers must obtain approval from a health plan before a specific service is delivered to the patient to qualify for coverage.
If your initial request is denied, don’t give up. If coverage for ABA services is initially denied by your insurance provider, remember that families have the right to appeal these types of decisions.
If you have a self-funded benefits plan, you can advocate at the level of your employer for coverage of ABA services.
Parents can work with therapists and other providers to obtain documentation such as assessments that report on the child’s needs and explain recommendations for ABA services. Because insurance coverage may differ depending on the needs of the child, parents can advocate for coverage of their child’s recommended individualized treatment plan.
The financial relief provided by insurance coverage cannot be overstated. Fortunately, insurance coverage can significantly reduce the cost of ABA therapy. With insurance, however, the cost can be significantly less.
Research shows that state insurance mandates have had measurable impacts: studies indicate that mandates have been associated with modest increases in autism-related healthcare utilization and spending, while making services more accessible to families.
The trend toward expanded coverage continues to evolve. Over the last decade, AutismSpeaks.org’s advocacy team has focused their efforts on improving health insurance coverage for medically necessary treatments such as ABA.
As awareness grows and more research demonstrates the effectiveness of early intervention, we can expect continued improvements in coverage policies and accessibility.
Understanding how insurance coverage works for ABA therapy services is essential for families navigating autism treatment. While the landscape has improved significantly with federal mandates and state laws requiring coverage, the specifics can vary considerably based on your location, insurance plan type, and individual circumstances.
The key is to be proactive: understand your coverage, work closely with providers to ensure proper documentation, and don’t hesitate to advocate for your child’s needs. With proper preparation and persistence, most families can access the ABA therapy services their children need through their insurance coverage.
Remember that it’s crucial to gather all the necessary information, communicate with insurance providers, and work closely with healthcare professionals to maximize insurance benefits and ensure individuals receive the ABA therapy they need.