A diagnosis of autism for your child can often signal the start of a long, complicated, and sometimes frustrating journey for health insurance coverage. You will undoubtedly have a million questions, such as ‘Does insurance cover ABA therapy?’
At Heartlinks, we aim to provide the utmost care for your child and your family. Part of that includes helping you navigate your health insurance journey.
In our experience, the more you learn about ABA therapy and insurance, the more questions you will have. We’ll be here to answer them; if we can’t, we’ll direct you to those who can.
So let’s embark on this journey together. Affordable ABA therapy is within your reach.
Applied Behavior Analysis, or ABA, is a therapy for children with autism. It is based on the proven science of behavior and learning. It was created to encourage positive and appropriate behaviors while minimizing negative ones.
The benefits of ABA therapy include increased language skills and communication, improved academic performance, better memory, and social skills. All of this while seeing a decrease in less desirable behaviors that can affect learning and be destructive to themselves and others.
Treatment plans, including your child’s ABA therapy, are usually designed and implemented by a BCBA (Board Certified Behavior Analyst).
Yes, ABA therapy is most likely covered by your insurance. However, coverage can vary depending on where you live. Most insurance plans will cover varying portions of your child’s autism treatment.
If you live near the Heartlinks’ Atlanta location, you’ll want to know that coverage for autism treatment in Georgia is limited to individuals 0 to 21 years old. This coverage is subject to a maximum annual benefit of $35,000.
If you live near the Heartlinks’ Lakewood, New Jersey, location, it’s essential to know that the state does offer coverage for autism treatment. Currently, there is no dollar limit on coverage of ABA therapy in New Jersey. However, coverage for autism treatment is limited to individuals with autism spectrum disorders 21 years old or younger.
If you live near the Heartlinks’ Indianapolis, Indiana location, know that treatment prescribed by a child’s treating physician per a treatment plan will be covered by insurance. There are no limits on coverage. However, the autism insurance law in Indiana does not require that insurers provide coverage for treating autism in individual health insurance policies. Instead, it stipulates that insurers offer such coverage. This is known as a ‘mandated offering.’
Depending on the treatment plan your BCBA prescribes, some children with autism can require upwards of 40 hours per week of ABA therapy to unearth their true potential. Paying for this type of therapy can be daunting. Examining the cost of ABA therapy with insurance clearly and in detail is crucial.
The CDC (the Centers for Disease Control), children with Autism Spectrum Disorders, compared to neurotypical kids, require a range of $17,000 to $21,000 annually in additional extra care. These costs include medical appointments and ABA therapy.
With insurance, the basic cost of ABA therapy in the U.S. is about $120 per hour with a board-certified ABA therapist.
When you add it all up, even just a few hours per week can get expensive pretty fast:
Individuals with health insurance policies must only pay the agreed deductible. So if, for example, your family’s insurance plan has a $50 deductible, you’ll be obligated to pay this out-of-pocket cost every time your child sees an ABA therapist. In a situation where your child is seeing a therapist four times a week, that will end up costing you $200 a week.
However, there are many ways to reduce this cost apart from insurance, including the following:
The cost of ABA therapy without an insurance plan can vary greatly depending on your location, the cost of living, the therapist’s certification level, experience, and education. The price tag can also change depending on the severity of your child’s autism and the medical necessity of the treatment as determined by their medical provider.
Without insurance plans, ABA therapy cost an average of $62,400-$249,000 annually. To break that down, the costs per month for ABA therapy can be anywhere between $4,800- $20,000. To break it down further, ABA therapy can cost from $240- $600 daily if you don’t have an insurance plan.
If you’re new to the world of insurance plans and health insurance policies, Heartlinks can help by explaining a few basic concepts first.
Coverage means you’re legally entitled to either reimbursement or payment for a specific treatment or procedure.
By comparison, health insurance is a legally binding contract that mandates an insurance carrier to pay a portion or all of a person’s health care costs. This is done in exchange for a regularly paid premium.
Even if your child with autism spectrum disorders has health insurance, there may be specific treatments, including ABA therapy, may not be covered. This means you may not get reimbursed for certain expenditures.
One of the first questions you should ask yourself is, what type of health benefit plan do you have? Your benefits will be determined based on the kind of health insurance policies you and your family have.
If you’re fully insured, you’ve entered into a contract with an insurance carrier. According to that contract, you will pay a certain amount every month. In return, the insurance company is obligated to pay covered health care claims.
Yet you still might be obligated to pay copays, coinsurance, and any deductibles which apply to the plan.
Self-funded plans are usually the type of insurance that either unions or larger companies choose. They differ from fully-insured plans because healthcare costs are drawn from a fund that employees contribute to and are established by the employer.
Public health plans are run jointly by the state and federal governments. The government pays your healthcare costs if you’re enrolled in a public health plan. One of the most popular types of public health plans is Medicaid.
At Heartlinks, we regularly work with insurance providers of all types. These are some of the questions we tell our parents to ask their insurance companies regarding their coverage.
Traditionally, an insurance company usually only covers ABA therapy with a formal Autism diagnosis. At Heartlinks, this is performed by our BCBAs. Some companies also require an official letter from your child’s doctor indicating why it’s medically necessary for them to have ABA therapy. Consequently, checking with an insurance representative what is required before beginning treatment is crucial.
Regardless of the type of health insurance or coverage you have, your benefits are valuable. They can ensure you save a great deal of money and spend what you have efficiently.
This is incredibly important when you’re looking to invest in therapy for your child with autism. As one of the cornerstones of autism treatment for children, ABA is crucial in ensuring each one reaches their full potential. At Heartlinks, we’re ready to help answer any questions about insurance coverage and ABA therapy. We aim to make the journey easy and help you reach affordable ABA therapy for your child.