Your child has been diagnosed with autism spectrum disorder (ASD), and your doctor recommends a form of therapy you've never heard of before. Will your insurance cover that care?
Applied behavior analysis (ABA) is often referred to as the "gold standard" of therapy for people with ASD. Given that status, many people assume it's automatically covered by insurance.
It's true that the majority of insurance plans cover autism treatment, but coverage varies from state to state and plan to plan. In most cases, insurance will cover a large portion of the costs of ABA therapy.
Federal & State Requirements
At one point, insurance companies could sit down and decide what they would and would not cover. That led to a patchwork quilt of coverage, and some people paid for policies that left them bankrupt after short illnesses. Legislators got involved, and now, the plans you buy must adhere to laws.
Those laws can get confusing. For example, Autism Speaks says there are two types of plans in the United States, with radically different coverage types. These are:
- Fully insured plans. A plan like this must provide benefits per state laws. Your insurance company determines what is covered.
- Self-funded plans. A plan like this must comply with federal laws, but not the state versions. Your employer makes the final call about what is and isn't covered.
You may not know what type of plan you have. Plenty of people don't. Autism Speaks offers an interactive tool to help you find out.
That knowledge will help you understand where to petition for a change in benefits. Often, you'll start that conversation at the state level.
Plenty of states mandate coverage for autism, but the benefits vary dramatically. Coverage for ABA may not be explicitly supported.
The American Speech-Language-Hearing Association compiled data on multiple states. This is a representative sample:
- Arkansas: ABA is covered when provided by a supervised, board-certified expert.
- California: If a plan covers physical treatments, that plan must cover mental health services too. ABA is considered a covered autism treatment.
- Delaware: ABA is covered, along with any items or equipment needed for the therapy.
- Georgia: ABA isn't explicitly covered.
- Indiana: ABA isn't explicitly covered, but therapy for autism and related disorders may not be subject to deductibles or limits.
- Montana: ABA isn't explicitly mentioned. Treatments for autism can be capped at $50,000 per year for children ages 8 and younger.
Each state has different rules and interpretations. The rules are outlined in most insurance policies you buy. Moving to another state could have a significant impact on how much ABA might cost your family.
How Do Insurance Companies Cover ABA?
Just as your coverage can vary from state to state, it can also vary from plan to plan.
Some insurance companies are quick to embrace ABA, and they cover it automatically. Others are much more conservative.
Comparing plans side by side can help you spot coverage differences.
- Cigna: Some plans cover applied behavior analysis. If you have a plan like this, your doctor must submit formal ASD diagnosis paperwork before therapy starts.
- Blue Cross Blue Shield: Multiple health insurers sell products under this label, and every plan is different. In Michigan, for example, ABA is covered for people younger than 18 years old. But some plans require paperwork or preauthorization before treatment starts.
- Aetna: ABA therapy is not explicitly covered by Aetna, but it may be allowed. Talk to the company about the specifics of your coverage.
Every insurance plan comes with a booklet of coverage. The language is technical, and the terminology can be hard to understand. But dig in, and you should see information about whether or not your plan covers ABA.
If you don't see that information, or you're not sure you're interpreting the plan properly, call the customer service number on your membership card and ask.
Insurance Terms You Should Know
Imagine that you don't have insurance now or that you're searching for a new plan to help you pay for your child's ABA care. What should you look for? Speaking the language of insurance can help.
HealthCare.gov offers a complete glossary of insurance terms. These are a few that might be helpful:
- Copayment or coinsurance: This is what you are expected to pay after the insurance company pays a bill.
- Deductible: You must pay this amount before your benefits kick in. Some services, like wellness checks, don't count. You can receive these services without a fee even if you haven't met your deductible.
- Out-of-pocket maximum: This is the maximum amount you can expect to pay out of pocket each year for covered services. It includes copayments, deductibles, and coinsurance, but premiums are not factored into this number.
- Network: Your network includes providers and professionals with contracts with your insurance company. If you step out of that network, you may pay a bigger portion of that bill or the whole thing.
- Prior authorization: You must get approval before you sign up for a service.
You might also encounter terms about the type of plan you hope to purchase.
- HMO: This acronym stands for "health maintenance organization," and it's a form of insurance delivery. Typically, you have a network of providers you must use to access insurance benefits.
- PPO: This acronym stands for "preferred provider organization." You have a network of professionals to choose from, but you can still access some benefits if you step outside the network.
You have choices as you shop. Ask plenty of questions before you commit to a plan.
Make the Most of Your Coverage
You have a health insurance plan, and you know your child can have applied behavior analysis therapy through that plan. You've done the hard work, but there's more to do. The choices you make now can keep your bill as small as possible.
Maximize your benefits by:
- Understanding prior authorization. Make sure you have all the proper paperwork submitted before treatment starts. Skip this step, and you might be responsible for the whole bill. For ABA, you’ll need a formal diagnosis of autism and authorization for a functional behavior assessment.
- Following guidelines. Experts say some plans require ongoing documentation of progress. Your child's behavioral technician might need to submit paperwork showing that the therapy is working. You don't have to complete that documentation yourself, but make sure it gets done.
- Staying in the network. You'll pay less if you work with providers contracted by your insurance company.
- Paying your premiums. Insurance only works when you pay your bills on time. Put this invoice at the top of your list of monthly bills to pay.
Your health insurance benefits are valuable, and they can save you a great deal of money. Following these few steps can ensure that you make the most of that investment.
Most ABA providers will help you determine your exact level of coverage and how much you can expect to pay out of pocket. Talk to providers as well as your insurance company to get solid numbers on your costs.
- Health Insurance Coverage for Autism. (September 2019). Autism Speaks.
- State Insurance Mandates for Autism Spectrum Disorder. American Speech-Language-Hearing Association.
- What Do I Need to Know About Autism Coverage? Blue Cross Blue Shield Blue Care Network of Michigan.
- Autism Spectrum Disorders. (March 2020). Aetna.
- Kaiser Becomes First Health Insurer to Cover Autism Treatment. (November 2012). The Lund Report.
- Glossary. HealthCare.gov.
- What Is Covered? The Insurance Landscape for Autism Services. (April 2019). Forbes.