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.
ABA Therapy & Medicaid
ABA therapy is not cheap. Thankfully, many insurance companies provide coverage for the cost of the therapy. But what if you don’t have private insurance?
Applied Behavior Analysis is the only empirically-based therapy for children with autism. As research findings validated this, researchers and parent advocates began the hard work of passing legislation that required insurance carriers to cover ABA services for children with autism. In Illinois, in 2008, the Autism Mandate was passed stating children with autism were entitled to ABA therapy and thus insurance must cover this therapy. However, because this was a state law self-funded plans and national plans (like Medicaid) did not have to follow the law. In 2017, Medicaid passed a federal mandate that state plans provide ABA coverage to children with autism. However, because BCBAs hold a national license, not a state license, Illinois Medicaid pushed back.
For the past five years, providers and parent advocates have been working with Illinois law to find a way to get ABA coverage on Medicaid. Finally, in October of 2020, the ABA benefit was awarded on Medicaid insurance for children with autism with the requirement that BCBA’s are supervised by clinicians that also hold state licensure. This means that for over 13 years children with autism and Medicaid funding were largely left without access to the only evidence-based treatment.
While this is great, it can still be very difficult to find a provider who will accept Medicaid for payment due to the lower reimbursement rates of Medicaid insurance and the new supervision requirement of BCBAs..
How Do I Get Medicaid to Cover ABA Therapy & Services?
Your child must be diagnosed with ASD by a certified professional before any steps can be taken. If your child has not been formally diagnosed with ASD, the Medicaid website has resources to get you started.
To get Medicaid coverage on ABA therapy you need to find a service provider who accepts Medicaid. Representatives at Medicaid should be able to give you nearby providers that accept the benefits. You can always call local service providers to see if they accept Medicaid (as their website or database may be missing an update).
As of December 2021, the majority of ABA service providers have not signed up for the Medicaid Program. Make sure to ask any provider you speak to about Medicaid coverage.
What Does Medicaid Cover for ABA Therapy?
Therapy & services provided by an ABA clinic will not differ from Medicaid or private insurance families. ABA providers use the only evidence-based therapy for ASD; the program will be used for all children, Medicaid or not. Programs will be modified based on individual needs.
Medicaid coverage for ABA therapy only covers services provided by Board Certified Behavior Analysts (BCBA) and Registered Behavior Technicians (RBT). Any ABA services provided by or overseen by other professionals will not be covered. Any program covered by Medicaid must be supervised by a licensed clinical psychologist or licensed clinical social worker who will oversee BCBAs and RBTs. All ABA goals must be authorized by Medicaid.
The coverage Medicaid provides for ABA therapy will vary from person to person. Speaking to the billing department at any clinic will help you understand what will be covered on an itemized basis. Medicaid will cover all provider expenses.
More Help With ASD & Medicaid
Recently, many Medicaid programs, both nationally and in-state, have upped the support offered for ASD. ABA therapy was ruled to be included in Medicaid benefits over 5 years ago, but Illinois (and other states) have only recently caught up to Medicaid requirements. Aside from just financial assistance, Medicaid programs are making a concerted effort to have more ASD services widely available.
As Medicaid coverage becomes more comprehensive in regards to provider reimbursement, it will be much easier for families to find the help they need. The program is still young, so the number of providers that accept Medicaid for ABA and other ASD therapies & services should grow quickly over the next few years.
IABA Consultants & Medicaid
Here at IABA, we are working very hard to have everything ready to accept families with Medicaid by March 2022 for Naperville & Oak Lawn and May 2022 for Glenview. We are finishing the enrollment process which will let us bill Medicaid quickly and efficiently.
We have been helping families for almost 10 years now and Medicaid will allow us to help those who might otherwise have no options. We are looking forward to being able to accept any family in need of ASD services regardless of their insurance standing.
Accepting Medicaid strongly supports our mission and core beliefs. Our foundation was built on several principles, one being no child with autism will ever be turned away, regardless of funding source. Being able to accept funding from Medicaid greatly expands our ability to help children from all backgrounds. Every child deserves equal care, no matter their background or funding source.
If you have any questions on getting Medicaid to cover ABA therapy & services, please send us an email. We’d be happy to answer any of your questions or put you in touch with one of our associates who can help meet your needs.