Summary: This article explains whether or not insurance covers ABA therapy, and what other options there are for financing.
Applied Behavior Analysis therapy, or ABA therapy, is an evidence-based treatment used to help children diagnosed with autism. This form of treatment is something that comes from qualified professionals with a focus on helping children with autism to:
- Build adaptive behaviors
- Do away with difficult behaviors
- Improve communication skills
- Cultivate social skills
As a scientifically proven treatment for autism, and something that is often medically necessary, many insurance plans will offer some form of coverage.
Does Insurance Cover ABA Therapy?
Yes, though the exact coverage varies by insurance provider and plan. It’s important to check your specific insurance plan to verify things like deductibles, co-pays, and coverage options.
For example, all 50 states now offer Medicaid coverage for autism treatment, whereas providers like Blue Cross Blue Shield will cover treatment for children under the age of 18 based on State and plan. Most insurance companies will only apply benefits to ABA therapy costs after a formal autism diagnosis and prior authorization or pre-authorization.
This type of diagnosis can come from an official evaluation, which itself is often covered by insurance. From there, you may or may not need to find a provider that works as an in-network provider, meaning they are already covered as part of your insurance plan. If you opt for an out-of-network provider, that simply means that the ABA therapy provider does not have a pre-existing pricing plan with your insurance company, and as such, you might be required to pay more out of pocket or have a higher deductible.
It is important to determine whether your insurance provider requires things like pre-authorization as well, which typically means moving forward with somewhere like Caper ABA for an evaluation and then the creation of an individualized treatment plan for your child, which is then submitted to your insurance company for approval.
This process can be somewhat difficult to navigate, but speaking with qualified therapists can help you better understand what to expect, not just from the ABA therapy but from your specific insurance provider, based on the details of your plan.
Getting Treatment at Caper ABA
Insurance typically covers the cost of therapy and autism evaluations, but there can be limits on things like:
- Age restrictions
- Cost-sharing amounts
- The number of hours per week or her lifetime
At Caper ABA, our goal is to make treatment accessible for everyone, no matter their financial situation. That is why our team is there to help clients understand what their insurance coverage is, what types of behavioral therapies can be offset by insurance benefits, and what alternatives exist. As part of this, we provide assistance navigating things like Medicaid and Medicare, as well as other forms of financial aid for those who qualify.
Does insurance cover ABA therapy? Call Caper ABA at (847) 996-9832 to get help verifying your coverage and finding financial aid.
FAQ
How Much is ABA Therapy?
The cost of ABA therapy differs based on the type of plan you receive for your child. Without insurance or any type of financial aid, it can cost between $60,000 and $250,000 per year. With insurance, however, costs can go down to things like a deductible and co-pays.
Is ABA Therapy Free with Insurance?
ABA therapy is not free with insurance, but it can be significantly cheaper. Depending on the plan you have and the level of coverage your plan contains, your therapy costs might be a percentage of the total treatment cost, or you might be required to fulfill your deductible, after which the remainder of your costs are covered. This is something that you can confirm with your insurance provider or with our team of admissions specialists.
Do I Need Prior Authorization for ABA Therapy?
Most insurance companies do require some form of pre-approval or pre-authorization before you can start ABA therapy. This is something that is typically handled by an ABA therapy provider, as it requires the submission of treatment plans and other documentation to your insurance provider.
Are There Limits on Insurance Coverage for ABA Therapy?
Each insurance provider is different in terms of the limits to coverage. Some insurance plans will cover a specific number of hours per week, like 20 hours per week. Other plans might have annual maximums for the number of hours. Still, some plans have a lifetime maximum.
That is why it’s important to work with a provider like Caper ABA Therapy to create a personalized treatment plan for your child with autism, and from there, be in a better position to determine not only how many hours of therapy are recommended for your child, but which types of therapy might be recommended. Working with your insurance company, you’ll be in a better position to figure out the limits your policy might have and what your financial options are outside of those limits.
Does Insurance Cover ABA Therapy That’s Out-Of-Network?
In some cases, plans will cover out-of-network providers with higher out-of-pocket costs for you as the policyholder. Other policies do not cover any out-of-network services. This will vary significantly based on your plan, which is why it’s important to reach out to your insurance provider for details on both the requirements and the benefits your plan has, or to let our team help you go through alternative financial aid.
Do I Need an Autism Diagnosis to Use Insurance Benefits for Therapy?
Most insurance companies will require a formal diagnosis in order to apply your benefits to ABA therapy. This can be done through a primary care physician. If you are unsure about the coverage your policy offers, you can reach out to your insurance provider by calling the number on the back of your card to confirm whether an official diagnosis is required. You can also call our team to help you better understand what financial options you have for ABA therapy.
Sources
https://www.bcbsil.com/docs/provider/il/standards/cpcp/2024/cpcp011-10072024.pdf
https://iidc.indiana.edu/irca/articles/how-do-i-fund-my-childs-applied-behavior-analysis.html