What You Need to Know

Insurance Explained

Receiving an autism diagnosis for your child can be overwhelming. There are different needs for every individual child, and many different therapies available. Applied Behavior Analysis (ABA) Therapy is the nationally recognized and data driven treatment to help address many of the symptoms that can occur with an autism diagnosis. An ABA Therapy prescription commonly accompanies an autism diagnosis, but how is it covered financially? This guide will help explain insurance coverage, common terminology, and also provide resources for alternative funding.

The Basics

Every state in the nation now provides some type of mandate for ABA Therapy coverage for Autism, with both commercial and state insurance plans. Each state’s mandate is unique, so familiarizing yourself with your state’s mandate is beneficial to knowing your rights and options.

In most cases, fully funded commercial insurance policies are required to provide meaningful ABA therapy coverage when an autism diagnosis is present. However, the amount of ABA therapy coverage, age limitations, plan limitations, and other nuances are dependent on the state.

Within the same insurance payor, there are also differences between plans. For example, the patient or member responsibility (what you owe after insurance pays its part of the bill) varies among employers, insurance companies, and insurance plans. Your insurance plan may not cover the same services or reimburse at the same rates as your neighbor’s plan from the same insurance provider.

Commercial Insurance: Terms to Know

Understanding your plan, any limitations, and what your out-of-pocket cost may be, is akin to learning a whole new vocabulary. Below a list of commonly used insurance terms and their definitions. When in doubt, call your provider’s Member Services number for clarification. 

Insurance Premium: The monthly cost of your insurance plan, often shared between you and your employer. 

Patient or member responsibility: Your share of the costs of the medical services received by the subscriber or dependents on the plan. The cost share and total member responsibility can differ based on whether your medical provider is in-network or out-of-network, so know the variations on your plan.

Deductible: A deductible is the amount you pay each year before your health plan begins to share in the cost of covered services. Typically, insurance will not cover anything until you have met your entire deductible. 

Co-pay: A flat daily or per-visit rate you pay, common for in-network services. Your cost-share portion of the medical claim is the copay, and your insurance plan covers the entire remainder of the claim.

Co-insurance: A variable cost-sharing structure more common for out-of-network services. Your cost-share portion of the medical claim is an equivalent or smaller percentage of the medical claim, and your insurance plan covers the remaining percentage. For example, if your plan has a 20% co-insurance, you are responsible for 20% of the allowed amount of the claim and your plan covers the remaining 80%. 

Out-of-pocket maximum: The out-of-pocket maximum is the maximum dollar amount you could possibly owe for covered medical expenses each year. Once you have met your out-of-pocket maximum, insurance will cover everything thereafter at 100%. 

In-network benefits: Your insurance provider likely has a network of participating providers with contracted reimbursement rates. Services from in-network providers are typically covered with a lower out-of-pocket cost for members than services received from out-of-network providers. 

Note: Patient responsibility payments for in-network services typically do not apply to out-of-network benefits and vice versa. 

Out-of-network benefits: Some insurance plans allow members the choice of any doctor or medical service provider, regardless a whether that provider has a contract with the plan. These providers are considered out-of-network. However, the cost share and out-of-pocket maximum for choosing an out-of-network provider are usually higher than choosing an in-network provider.

Notification of Benefits (NOB): Your notification of benefits is a summary of your plan benefits, which is available to you from your insurance plan. It outlines your member responsibility and cost-share, out-of-pocket maximum, and plan limitations. 

Pre-authorization: Pre-authorization is required for a variety of services covered by your insurance plan. When pre-auth is required, your plan will review the documentation of medical necessity of a service or procedure before agreeing to cover it. ABA Therapy almost always requires pre-authorization.

Diagnostic Evaluations

InBloom Autism Services specializes in supporting children diagnosed with Autism, and ABA Therapy coverage requires a medical diagnosis. The diagnostic evaluation must be conducted using a standardized evaluation tool, and the report must include which tool was used as well as the full results. The evaluation must be performed by an M.D. or Ph.D. who is qualified and trained to administer the evaluation.

School psychologists may also be trained and qualified to administer diagnostic evaluations, but unfortunately this is not sufficient for insurance approval for ABA Therapy. If your child received his or her diagnosis from school, this should be considered an indication that your child needs a Comprehensive Diagnostic Evaluation (CDE) from the pediatrician, or licensed psychologist.

Pre-Authorization for ABA Therapy

Because of the intensive nature and expense of ABA therapy, most insurance plans require pre-authorization for your child’s initial ABA assessment, and another separate pre-authorization for ongoing therapy. The medical necessity documentation for the initial ABA Therapy assessment will include your child’s Comprehensive Diagnostic Evaluation from when the autism diagnosis was made, and possibly a referral or prescription for ABA Therapy. The medical necessity documentation necessary for the authorization for ongoing therapy includes the treatment plan that is written by the Board Certified Behavior Analyst (BCBA) after the initial assessment.

The pre-authorization process can be lengthy. Gathering the documentation needed for approval can be overwhelming and writing the initial treatment plan takes time. The speed of the approval process also varies greatly from plan to plan, ranging from a day to several weeks or even months. InBloom Autism Services will help and communicate every step of the process. We also handle most of the work for you; we verify benefits, educate families on their out-of-pocket costs, submit the necessary documentation, and request and monitor the authorization requests. We even fight claim denials on your behalf, to make your experience as stress-free as possible.

Tips for Contacting Your Insurance Provider

When you call your insurance company’s member services line, it helps to know the terminology, and what to ask. Understanding your member responsibility and cost-share is only one component!

Know the Terminology

Don’t only ask if Autism is a covered diagnosis, be sure to also ask if ABA Therapy is a covered benefit with an Autism diagnosis.

Oftentimes plan limitations on other services are waived with an Autism Diagnosis. Services like Speech or Occupational therapy that may have a maximum annual number of covered visits may have an unlimited number of annual visits for children with Autism. 

Always double-check, Always Document

It’s not uncommon to get different information regarding your benefits from different insurance representatives. Representatives may also give conflicting information to the provider and the beneficiary. Always confirm any estimate of costs before treatment.

You can protect yourself from misinformation by collecting the names and reference numbers of every representative you speak with, every time. Take notes on what you were told and save them. Not only can you refer to these notes should you ever get conflicting information, but the plan can also refer to the internal call recording via that same reference number. You have the right to receive accurate information when speaking with your insurance plan. 

Self-educate and self-advocate (or possibly) Stay informed and self-advocate

Even if you keep your same employer and insurance plan year over year, the coverage could still change. Likewise, if you intentionally change plans during open enrollment, or a change of employer, you will want to make sure you research how those changes can affect your coverage. Be sure to let all your medical providers know as soon as possible if you are changing plans, and particularly any ongoing services such as ABA Therapy. Your pre-authorization will likely not be valid if your plan changes, and services that are not pre-authorized are not covered. You could be financially responsible for any non-covered services. 

You are your biggest advocate, and your self-education is your biggest ally! 

What if you still have questions?

InBloom Autism Services is here to help! We always verify coverage and create a Notification of Benefits (NOB) before getting started. Making sure your out-of-pocket cost is predictable, affordable, and understandable is our priority. No one likes financial surprises, and we can help prevent them.

What Plans are In-Network at InBloom Autism Services?

InBloom Autism Services is in-network with almost all major insurance plans in the states where we operate, as well as most state Medicaid plans. We also participate with many smaller or state-specific plans as well. As an in-network provider your out-of-pocket cost will be as small as possible. Check your local Service Area page to see all our participating plans. 

If we are not in your plan’s network, you still have options. Some insurance plans will approve a Single Case Agreement, which allows you to use your in-network benefits on a “single case” basis.

Coverage Limitations

State mandates have universally improved the access to care for families over the last decade. While these laws are good news for many families with private insurance coverage, there are exceptions that allow certain employer-sponsored, and marketplace plans to reduce coverage for ABA therapy insurance or opt-out altogether.

Some states have restrictions on the amount of coverage (annual reimbursement caps), age caps, and other regulations that could affect your child’s coverage. Insurance plans are subject to state laws where the plan is issued, not where the member lives. So even though you live in one state, another state’s laws may apply to your plan.

Fully funded vs. Self-funded:

Fully funded plans are the most common and more traditional way to structure an employer-sponsored health plan. The employer group pays a premium to the insurance carrier, and the insurance carrier covers the cost of the medical claims (aside from any cost-sharing by the individual members). Fully funded plans are not only required to abide by state mandates and a standard set of rules and regulations, but also have standardized provider manuals, pre-authorization requirements, and reimbursement rates.

With Self-Funded health plans, employers operate and fund their own health plan for their employees. Self-funded plans are excluded from the state mandate because of a Federal Law (ERISA) that generally preempts state law mandated applicable to employer sponsored benefit plans. This means they are not required to cover ABA Therapy at all. Other policies and procedures are also up to the employer instead of the health plan, including but not limited to pre-authorization requirements, age limitations, and reimbursement rates

Types of Insurance

There are three main types of insurance coverage available to families.

  • Employer or Group Plans
    • These plans are most likely to cover ABA Therapy.
  • Medicaid Plans
    • As of 2022, every state covers ABA Therapy to some degree.
  • Marketplace Plans
    • May or may not cover ABA Therapy.

How to Find Out What Type of Insurance Plan You Have

When in doubt, talk to your HR department. Just because your insurance plan bears the name of a major insurance carrier does not mean it is fully funded and therefore offers ABA coverage for Autism. Your employer’s human resources department will be able to tell you whether the plan is fully funded or self-funded, and whether ABA Therapy is a covered benefit.

Medicaid Coverage for ABA Therapy

As of 2022, every state offers some degree of ABA Therapy coverage for ASD (autism spectrum disorder). However, every state is different and has different coverage limitations, restrictions, and regulations.

ACA Marketplace Coverage for ABA

For various reasons, not every employer offers insurance to their employees. The employer group may be too small to qualify for a group plan. Individuals who are self-employed or act as independent contractors may also be disqualified from signing up with a group plan. If the family does not qualify for state Medicaid either, the only remaining option may be an Affordable Care Act (ACA) Marketplace plan.

Do Your Research Before Making a Decision

The marketplace offers many options and plan choices for individuals. These may be specific to your state or even your local geographical area. However, beware that often Marketplace plans are not required to cover ABA. This helps keep costs down and make sure the plans remain affordable to individuals and families.

If you are specifically looking to the marketplace for an insurance plan that covers ABA Therapy, be sure to check specifically if ABA Therapy is covered before signing up.

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.

Grant Resources for Children with Autism

There are numerous financial resources available to families of children with Autism or other special needs. Some are in place to help with educational resources, supplemental services not covered by insurance, assistive devices, or member responsibility associated with your existing primary insurance coverage. Some are based on income, child’s age, diagnosis, and even geographical area.

We have compiled a list of grant resources available to families here.

National Grant Resources