Applied Behavior Analysis, or ABA, is a therapy designed for children with autism, grounded in the established science of behavior and learning. It aims to promote positive and appropriate behaviors while reducing undesirable ones.
Considered one of the most effective treatments for autism, ABA therapy offers numerous benefits, including:
Treatment plans, including your child’s ABA therapy, are usually designed and implemented by a BCBA (Board Certified Behavior Analyst).
Yes, ABA therapy insurance coverage is available. 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 ABA therapy insurance coverage in Georgia is limited to individuals 0 to 21 years old. This coverage is subject to a maximum annual benefit of $35,000.
The services covered by the law include the following:
If you live near the Heartlinks’ Lakewood, New Jersey, location, ABA therapy insurance coverage is available. 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.
The services covered by the law include the following:
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 ABA therapy insurance coverage. However, the autism insurance law in Indiana does not require insurers to 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.
If you’re close to our Charlotte, North Carolina, location, it’s important to note that state law dictates services must be covered by private insurance plans for people with autism up to age 18. This implies that families must only pay the session-specific deductible, not the entire sum. Both the diagnosis and treatment of autism are covered. Insurance must pay for at least 25 hours per week of ABA therapy for children 14 and older and at least 30 hours per week for children under 14, according to state law. The annual limit for this therapy coverage is $40,000.
What are the qualifications for ABA therapy insurance coverage?
To be eligible for ABA therapy insurance coverage, North Carolina requires the following specific requirements to be fulfilled:
ABA therapy insurance coverage differs by state in a variety of ways, including:
The insurer’s coverage will depend on several factors, including their insurance plan, state laws, provider network restrictions, and pre-authorization requirements. Reviewing your policy details is vital to understanding their unique ABA therapy insurance coverage and associated costs.
The following is a general overview of coverage from these major insurers who cover ABA therapy.
1. Medicaid: ABA therapy insurance coverage by Medicaid usually includes services for individuals with autism spectrum disorder. The specifics often vary by state. Medicaid generally covers a certain number of therapy hours with minimal or no cost-sharing. In some cases, they require detailed treatment plans and authorization. Medicaid plan specifics and state regulations depend on state laws and plan specifics.
2. Blue Cross Blue Shield: ABA therapy insurance coverage is usually comprehensive in states with autism insurance mandates. Policies generally include ABA therapy services, but specifics such as the number of covered hours and cost-sharing can vary by state and plan.
3. United Healthcare: Usually complying with state mandates, they offer extensive coverage. Plan specifics, such as the number of covered hours and associated costs, fluctuate depending on the plan and state regulations.
4. Aetna: Like the others, they offer insurance for ABA therapy, but it changes depending on the type of plan and state laws. Generally, the coverage includes a set number of weekly therapy hours, but what varies are co-pays and deductibles.
5. Cigna: Usually finances ABA therapy and adheres to state mandates. Their coverage varies in specific areas, such as the number of therapy hours, co-payments, pre-authorization requirements, and deductibles.
6. Humana: Offers coverage for ABA therapy in many regions, with details influenced by local regulations and plan specifics. Coverage often includes a range of therapy hours with differing cost structures.
7. Kaiser Permanente: Depending on the plan and area, they offer ABA therapy insurance coverage with different details. A predetermined number of therapy hours are usually covered, and co-payments and deductibles could apply.
It’s important to under the following terms when searching for ABA therapy insurance coverage.
1. Deductible: This is the out-of-pocket amount before insurance covers ABA therapy services.
2. Co-pay: The fixed amount you pay for each therapy session once you’ve met your deductible.
3. Co-insurance: The percentage of the therapy cost you share with your insurer after you’ve met your deductible.
4. Coverage Limits: The maximum amount of therapy hours or services your insurance plan allows.
5. Pre-authorization or prior authorization: The obligation to acquire insurance clearance before beginning or continuing with ABA therapy.
6. In-Network vs. Out-of-Network: In-network providers have contracts with your insurance carrier, which frequently results in reduced rates, whereas out-of-network providers may charge more or involve more paperwork.
7. Treatment Plan: A thorough plan outlining the precise ABA therapy services and objectives that may be necessary for coverage approval.
8. State Mandates: Specific state regulations that force insurance companies to cover ABA therapy for people with autism, determining the scope and type of coverage supplied.
9. PPO (Preferred Provider Organization): This insurance plan allows you to see any provider, in-network or out-of-network, and has lower fees for in-network services. Pre-authorization for ABA therapy may be necessary.
10. HMO (Health Maintenance Organization): This insurance plan requires a reference from a primary care physician (PCP) to obtain ABA therapy and only covers in-network providers, resulting in reduced total expenses but less flexibility.
Understanding these terms can help you navigate insurance coverage for ABA therapy more effectively.
All U.S. states have an autism mandate, which is a state law requiring insurance companies to cover particular services for people with autism spectrum disorder (ASD), such as Applied Behavior Analysis (ABA) therapy. These rules ensure that individuals with autism obtain necessary treatments without incurring significant out-of-pocket expenses.
The details regarding ABA therapy insurance coverage limits and requirements can vary greatly and are usually in the following areas:
1. Age Limits: Some states have age limits for ABA therapy coverage, while others cover the person’s lifetime.
2. Coverage Limits: States differ in the number of therapy hours covered per week or year and whether annual or lifetime caps on benefits exist.
3. Cost-sharing: The amount of ABA therapy you must pay versus your insurer will vary per state.
4. Provider Requirements: Some states oblige ABA providers to be in-network or meet specific qualifications, while others offer more flexibility.
5. Pre-authorization: Documentation and referrals are some ways the process for obtaining approval for therapy services may differ.
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 autism therapy with insurance clearly and in detail is crucial.
The CDC (the Centers for Disease Control) says 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, a board-certified ABA therapist’s average cost in the U.S. is approximately $120 per hour.
When you add it all up, even just a few hours per week can get expensive pretty fast:
10 hours per week x $120 = $1,200 per week or $62,400 per year
20 hours per week x $120 = $2,400 per week or $124,800 per year
40 hours per week x $120 = $4,800 per week or $249,600 per year
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 cost may also vary depending on the severity of your child’s autism and the medical necessity of the treatment as assessed by their healthcare provider.
Without insurance plans, ABA therapy costs 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 that 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. Our BCBAs perform this at Heartlinks. 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.
In general, many insurance companies do cover an autism diagnosis. However, the extent of the coverage and the associated costs can vary depending on the following:
Regardless of your health insurance type or coverage, your benefits can be precious, helping you save money and manage expenses effectively. This is particularly crucial when investing in therapy for your child with autism. ABA therapy, a cornerstone of autism treatment, plays a vital role in helping each child reach their full potential.
At Heartlinks, we are here to assist with any questions about insurance coverage and ABA therapy. We aim to simplify the process and help you access affordable ABA therapy for your child. For more information, get in touch.