Health Insurance & Autism

Getting health insurance to cover certain needs can be a pain in many cases. Health insurance and autism, however, are in a category of their own.

The most recent data from the CDC estimates that 1 in 54 children will be diagnosed with autism–a number that seems to be increasing every year. Health insurance plans and policies are changing due to the prevalence of autism, but it can still be hard to get coverage.

Here’s what you need to know.

Getting an Autism Diagnosis

If you are concerned about the development of your child, speak to your pediatrician as soon as possible. Your pediatrician will be able to help you find a suitable professional to conduct an autism evaluation.

A diagnosis needs to be made by a licensed medical professional before insurance will offer any coverage (pediatric psychologist, developmental pediatrician). Many states have laws that require insurance providers to pay for autism evaluations. If you are unsure if your provider covers evaluations, be sure to speak to a representative to make sure.

After a diagnosis, you will get a prescription for services from the doctor, most likely for ABA therapy. You will need prior authorization from your insurance provider to get coverage for a new autism diagnosis/prescription before starting any programs.

Costs of Autism

According to the CDC children with autism have medical expenditures around $4,000-$6,200 more than a neurotypical child. On top of this, paying cash for an intensive inpatient behavioral program (20-40 hours per week) can cost around $50,000 per year.

Costs like these are why it is extremely important to know what your insurance provider will cover and what they won’t. If you currently have a family health insurance policy, it is best practice to call your provider and speak to a representative about your options.

Common Issues with Insurance Coverage & Autism

Many medical conditions and procedures come with ‘hidden strings.’ Autism is no different. Insurance plans often have policies in place that block coverage based on the type of service/therapy being used, the provider, or the health plan itself.

Common issues families face with insurance companies and autism coverage include:

  • Coverage only specifies one type of autism therapy (usually ABA)
  • Specific plans or therapies are denied coverage due to certain insurance plans categorizing some therapy coverage as being for disabilities only (not autism)
  • Out-of-network providers are not covered in any way, even partially (it can be hard for some people in rural areas to find nearby in-network providers)
  • Services not being covered due to a policy classifying them as ‘educational,’ thus not health care

Issues like these (and other related ones) need to be taken up with your insurance provider as soon as possible–preferably before any sessions have started. Also, be sure to talk to any provider you are considering about billing. Misbilling certain services can create an issue with your insurance provider–make sure the healthcare provider you choose knows their billing!

Autism, Health Insurance, & the Law

Each state has different laws and regulations regarding how insurance providers provide coverage for autism. The National Conference of State Legislatures has a great list of these laws, broken down by state.

The laws vary by state, meaning that some people may have trouble getting an insurance provider to cover a specific service–especially those who have recently changed residence. 

ABA Therapy from IABA Consultants

If you have questions regarding autism treatment, education, or plans to use ABA therapy, we are here for you! Our goal is to make sure no family is turned away due to financial constraints. Our therapy team would love to talk to you. Find the location closest to you and give us a call. We’re here for you.

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