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Autism Insurance Coverage Now Required In All 50 States

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How Do I Start Aba Therapy

Is ABA Therapy Covered by Medicaid

In most cases, the first item required to start ABA therapy is the individuals autism spectrum disorder diagnosis report. This is typically conducted by a doctor such as a psychiatrist, psychologist, or a developmental pediatrician. Most ABA therapy agencies and insurance companies will ask for a copy of this diagnosis report during the intake process as it is required to request an ABA assessment authorization from the individuals medical insurance provider.

The second item required to start ABA therapy is a funding source. In the United States, and in cases where Medi-Cal or Medicare insurances are involved, there is a legal requirement for ABA services to be covered when there is a medical necessity . Medi-Cal and Medicare cover all medically necessary behavioral health treatment services for beneficiaries. This typically includes children diagnosed with ASD. Since Applied Behavior Analysis is an evidence based and effective treatment for individuals with ASD, it is considered a covered treatment when medically necessary. In many cases, private insurance will also cover ABA services when medically necessary, however in these cases, it is best to speak directly with your medical insurance provider to determine the specifics of the coverage and to ensure that ABA is in fact, a covered benefit. Additionally, some families opt to pay for ABA services out-of-pocket.

Options For Families Without Employer Aba Coverage

If your family doesnt have insurance through your employer, consider these options for adding an individual ABA therapy insurance policy:

  • Individual plans purchased through the ACA marketplaceTwo different plans are available in North Texas through the ACA marketplace. Depending on income, some families may qualify for tax credits for plans purchased through the ACA marketplace.

Marketplace plans are only available during open enrollment each year , or if a qualifying event occurs, such as a job loss or loss of insurance coverage from an employer. You can check out plans available on the marketplace by visiting healthcare.gov.

In 2021, the ACA marketplace will be open for an additional enrollment period due to the number of people who may need coverage during the COVID-19 pandemic. The additional open enrollment period is from February 15th to August 15th, 2021. For more information, you can visit healthcare.gov or speak to a health insurance broker.

  • Individual plans purchased through a brokerAdditional types of individual ABA therapy insurance plans are available for children with autism. These plans may be different from those available on the ACA marketplace and do not qualify for the marketplace plan tax credits. There are some brokers in the DFW area who are very experienced in finding ABA therapy insurance coverage for children with autism.

Texas Law Requirements For Aba Therapy Insurance Coverage

Texas law requires most insurance plans to provide meaningful coverage for autism treatment. Bills were passed by Texas lawmakers in 2007 , 2009 , and 2013 . Not all insurance plans in the state are included.

These laws are good news for many families with private insurance coverage. However, loopholes allow certain companies to opt-out or reduce coverage for ABA therapy insurance as a child ages.

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What Is An Autism Mandate

All 50 U.S states have adopted insurance mandates for autism spectrum disorder. This mandate requires that insurance companies provide some type of coverage for individuals with an autism diagnosis. The rules and laws regarding the coverage vary by state and are updated and amended over time.

Disclaimer: Below are brief summaries on the mandates. Information was last gathered in June 2021.

Health Insurance Coverage For Autism

At least 200 million people now have health insurance coverage for ABA due to our efforts and dedicated advocates across the country.

Over the last decade, our advocacy team has focused on improving health insurance coverage for medically necessary treatments such as Applied Behavior Analysis .

Health insurance can be very complicated.

The time and energy often needed to ensure that prescribed treatments are covered can complicate what may already be a stressful time for families faced with a diagnosis of autism.

We are here to help.

Our online resources and staff can help you determine if your health benefit plan provides meaningful coverage for the treatment of autism.

We can also assist with effective implementation and enforcement of the benefits to which you are entitled.

The first question we need to ask is, Which type of health benefit plan do you have?

If you dont already know what type of health benefit plan you have, please refer to our Health Benefits Guide.

If you have trouble or need additional information, contact us at .

Once you have confirmed your plan type, find more information on your plan’s page in the sidebar on the left.

Why do I need to know the type of health benefit plan I have?

Your type of plan determines which health benefits must be covered.

Some plan types must provide benefits directed by state law while other plan types do not.

All fifty states have taken government action to require coverage for ABA.

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Autism Insurance Coverage Requires A Medical Diagnosis Of Autism

Before submitting any requests for ABA therapy insurance, your child will need a medical autism diagnosis. All insurance plans require a medical diagnosis of autism spectrum disorder before authorizing ABA services. The medical diagnosis should also include diagnostic testing for autism and cognitive testing. Plans will require the diagnosis to be conducted by either a medical doctor or a Ph.D.

Professionals who can evaluate for and diagnose autism include the following:

  • Developmental pediatricians
  • Some neurologists
  • Some pediatricians

A medical diagnosis of autism is different from an educational diagnosis. If your child has been diagnosed with autism through his or her public school district, that diagnosis is not likely to be accepted by your ABA therapy insurance plan. Think of the public education and private medical fields as two different worlds. An educational diagnosis of autism does not cross over to the world of private therapeutic treatment, since its based on educational need. In the same way, education professionals may take a medical diagnosis into account, but it does not guarantee special education services in public school districts.

If you have a diagnosis through your childs school, or you suspect your child may need an evaluation, Thrive Behavior Centers has a list of referrals to providers in the DFW metroplex who evaluate children for autism.

Questions About Aba Insurance Coverage

Here are a few questions that may help you gain more information about ABA therapy coverage from your medical insurance carrier:

  • Is ABA covered by insurance as a benefit for my child?
  • What criteria needs to be met for ABA therapy to be covered ?
  • How much do insurance companies pay for ABA services? Or, what is my copay and coinsurance?
  • What is my individual and/or family deductible?
  • Is there a benefit maximum ?
  • Which providers or ABA agencies are in-network?

The landscape of insurance is ever-changing and information is constantly updated. ABA insurance coverage continues to become more widely available and more affected individuals are claiming their rights to the benefits of ABA therapy. It is always recommended to speak to your individual insurance carrier to get the most accurate information about ABA insurance coverage.

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Your Guide To Aba Therapy Insurance Coverage For Autism In Texas

For any parent, receiving an autism diagnosis for your child can be an overwhelming experience. Figuring out just what kind of help your child needs, along with who to trust and where to go thats all hard enough. Eventually, it hits you how am I going to pay for the therapy my child needs? Can I get ABA therapy insurance coverage? This guide explains the options whether you have insurance or not for accessing Applied Behavior Analysis treatment for your child in Texas.

Common Insurance Terms To Know

Colorado Medicaid Waiver Program Application Guide – Children With ADHD, Autism, Down Syndrome

Premium: A monthly cost paid to the insurance company and often partially paid by the employer. Premiums are not applied to out-of-pocket costs.

Patient or beneficiary responsibility: The portion of costs of medical services that the beneficiary pays for before the insurance plan pays its portion.

Co-pay: A set rate you pay for some prescriptions, doctor visits, and other types of services. Not all plans have co-pays, and co-pays do not apply to all services. Co-pays do not typically count toward your deductible.

Co-insurance: A cost-sharing structure in which the insurance company pays a percentage of the care costs and the beneficiary is responsible for the remaining percentage of costs. These costs are usually applied after a deductible is met.

Deductible: A deductible is the amount you pay each year before your health plan begins to share in the cost of covered services. Some medical fees may or may not be included in the deductible.

Out-of-pocket maximum: Out-of-pocket maximum is the most you could pay for covered medical expenses in a year. Most co-pays will count toward your out-of-pocket maximum.

In-network benefits: Most insurance plans have a network of providers that meet the plans credential requirements and accept the plans reimbursement rates for services. Services from in-network providers are covered at a higher rate for the beneficiary than out-of-network providers.

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Frequently Asked Questions About Missouri’s New Autism Insurance Law

When does the autism coverage mandate go into effect?

The new provisions regarding mandated benefits for autism and autism spectrum disorder go into effect for policies that are issued or renewed on or after Jan. 1, 2011. As an example, if you have a health plan that renews each year on June 1, then your policy will reflect the new coverage requirements when it renews on June 1, 2011.

Does the mandate apply only to autism?

No. The new law requires coverage for autism spectrum disorders including autistic disorder, Aspergers Disorder, Pervasive Developmental Disorder, Retts Disorder and Childhood Disintegrative Disorder, as defined in the Diagnostic and Statistical Manual .

What insurance plans are affected?

The autism coverage mandate applies to:

  • All small group or large group health insurance plans written in Missouri.
  • All small group or large group health insurance plans written in other states but insuring Missouri residents, to the extent not already covered by the plan.
  • All self-insured governmental plans .
  • All self-insured group arrangements, to the extent not pre-empted by federal law.
  • All plans provided through a multiple employer welfare arrangements or other benefit arrangements, to the extent not pre-empted by federal law.
  • All self-insured school district plans.

For the following types of insurance, the coverage is not automatically included, but must be offered to the insured and dependents:

What treatments are required under this law?

  • Psychiatric care

Employer Plans For Aba Therapy Insurance

For families who get health insurance through an employer, every year brings new choices. If your child needs ABA therapy, its a good idea to examine those choices a little more carefully. In Texas, many employer insurance plans do cover ABA therapy due to the state law requiring insurance coverage of treatment for children with autism. Ask the following questions before assuming your companys plan covers ABA therapy:

  • Do the plans offered by your employer cover ABA therapy?Texas law requires many employer plans to cover ABA, but there are some exceptions. Self-funded employer plans may not cover ABA therapy for a child with autism.
  • What are the costs associated with ABA therapy?Most insurance plans have several ways of splitting covered costs between the insurance company and the beneficiary. Premiums, deductibles, co-pays, co-insurance, and out-of-pocket maximums all play a part in how much money you will actually pay for ABA therapy for your child. Finding this information may be a deep dive into the benefit information provided by your plan during open enrollment. Ask your human resources representative to assist you in finding out more information about ABA therapy.
  • Are there any coverage caps or limits on the number of visits?Texas laws only apply to insurance plans that originate in the state of Texas. For plans that originate outside of Texas or self-funded plans, there may be caps or limits on ABA therapy services.

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Increasing Insurance Coverage Through Governmental Mandates

ASD insurance reforms often impact the scope of services required for all health insurance plan types available to people with ASD. These include government-subsidized plans in the state marketplace exchanges, the Childrens Health Insurance Program , Medicaid, private health insurance, and self-funded programs. Since 2001, ASD insurance reform laws have been enacted either by legislation or administrative mandates in 39 states and the District of Columbia . These laws provide varying degrees of services to people with ASD and are often limited by age classifications and maximum benefit amounts . Nearly half of children and youth with ASD have private health insurance coverage , one-third of all children and youth with ASD are covered by Medicaid and CHIP, and 17.7 percent are dual enrollees in governmental and private health insurance . Eighty-six percent of Americans live in a state with some ASD reform statutes or administrative regulations, but more than 54 million people live in states without explicit ASD-specific state laws that clarify the breadth, length, and eligibility details for coverage beyond the federally mandated baselines for ASD care .

Figure 1. Enactments of State Autism Laws by Year

Data include autism spectrum disorder reforms enacted either by statute or by administrative mandate .

Figure 2. Health Insurance Coverage for Children and Youth With Autism Spectrum Disorder and Other Special Health Care Needs

What Is Aba Therapy Used For

ABA-based therapy can be used in a multitude of areas. Currently, these interventions are used primarily with individuals living with ASD however, their applications can be used with individuals living with pervasive developmental disorders as well as other disorders. For ASD, it can be used in effectively teaching specific skills that may not be in a childs repertoire of skills to help him/her function better in their environment whether that be at home, school, or out in the community. In conjunction with skill acquisition programs, ABA-based interventions can also be used in addressing behavioral excesses . Lastly, it can also be utilized in parent/caregiver training.

In skill acquisition programs, a childs repertoire of skills is assessed in the beginning phase of the services in key adaptive areas such as communication/language, self-help, social skills, and motor skills as well. Once skills to be taught are identified, a goal for each skill is developed and then addressed/taught by using ABA-based techniques to teach those important skills. Ultimately, an ABA-based therapy will facilitate a degree of maintenance and generalization . These two concepts are very important in any ABA-based intervention.

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Required Autism Spectrum Disorder Coverage By Law

Each state has its own laws governing the required amount of coverage regarding ASD treatment. In many states, the bare minimum requirement is for insurance companies to provide coverage for screening, diagnosing, and treating ASD. Some states even mandate that health insurance companies also offer the same coverage for any other condition listed in the Diagnostic and Statistical Manual of Mental Disorders .

Here are a few examples of ASD health plan coverage laws from specific states:

Leafwing Center Works With Insurance Providers Who Cover Aba Therapy

LeafWing Center works with an ever-growing number of insurance provides who cover ABA therapy for the treatment of autism. Here are just a few of the providers with whom we work:

  • United Health Care
  • Windstone Behavioral Health

If your insurance provider is not on the list, we recommend you contact them directly to learn more about their coverage. Please contact LeafWing Center if you have any questions about whether or not your provider offers insurance coverage for ABA therapy to treat autism.

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Aba Therapy State Coverage

In general, there are 2 types of insurance plans in the US:

  • Fully-insured plans: These plans must provide benefits based on state laws. Your coverage is determined by your insurance company.
  • Self-funded plans: These plans must follow federal law, not state laws. Your insurance coverage is determined by your employer.

The specific benefits of coverage are determined by the employer or insurance company. Here is an interactive tool from Autism Speaks that you can use to determine what type of health benefit plan you have.

According to the American Speech-Language-Hearing Association, here are further details from some of the states that provide coverage for ABA:

Autism Insurance Coverage By State

Georgia Medicaid Waiver Program Application Guide – Children With ADHD, Autism, Down Syndrome

The American Speech-Language-Hearing Association compiled data on a list of states. Here is a sample list:

  • California: If a plan covers physical treatments, that plan must also cover mental health services. The good news is ABA therapy is considered a covered autism treatment.
  • Indiana:Ã ABA therapy isn’t explicitly covered here, but therapy for autism and related disorders may not be subject to limits or deductibles.
  • Georgia: ABA therapy isn’t explicitly covered here.
  • Montana: ABA isn’t explicitly mentioned. Autism treatments can be capped at $50,000 per year for children 8 years old or younger.
  • Arkansas: ABA therapy is covered when provided by a board-certified and supervised expert.
  • The following states have specific autism mandates, which require certain insurers to provide coverage for autism spectrum disorder.

  • Anthem -> Read More
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    Behavior Analyst Licensing Legislation

    Michigans Behavior Analyst Licensing Legislation went into effect on January 3, 2018. PA0403 establishes licensure for Behavior Analysts and Assistant Behavior Analysts in Michigan and PA0404 establishes a licensing board for behavior analysts and assistant behavior analysts.

    PA0403 and PA0404 include the following highlights:

  • Establishes licensure for behavior analysts and assistant behavior analysts based upon the requirements of the Behavior Analyst Certification Board .
  • Behavior Technicians must have completed a training program based upon the BACBs RBT task list. This is required three years after PA0402 goes into effect.
  • Establishes a nine-member licensing board for Behavior Analysts and Assistant Behavior Analysts.
  • Four behavior analysts
  • Which States Are Most Supportive For Raising A Child With Autism

    By Emily Ansell Elfer, BA Hons, Dip

    NOTE: This article serves as guide information only and we recommend parents do up-to-date research before choosing where to base their family. The content in this article was last reviewed on April 30, 2021 and a methodology/references list can be found at the bottom of the content.

    Here at Autism Parenting Magazine we understand that making decisions for any child is difficult, but making a decision for a child with autism spectrum disorder can add an extra-layer of difficulty. Were always looking for ways to give our readers as much valuable information as possible. We know deciding where to live with a child with ASD can be extremely overwhelming, so weve created a guide of the most supportive, and least supportive states.

    To conduct our research we looked at the best states in the USA for resources and merged these with the states that offer the most in terms of insurance mandates, grants, and inclusion of the ADDM Network. We found that Colorado, Massachusetts, and New Jersey are the most supportive states overall. On the other end of the scale, West Virginia, New Mexico, and Tennessee are the least supportive.

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