ABA Insurance Coverage

Does insurance cover ABA therapy for my Autistic child? Most likely, yes, as ABA insurance coverage for the treatment of Autism Spectrum Disorder (ASD) continues to grow. Autism insurance coverage is now required at some level in all 50 U.S. states.

The U.S. Surgeon General and the American Psychological Association consider ABA therapy to be an evidence based practice. More than 40 years of extensive research literature document ABA therapy as an effective, successful practice and treatment for Autism. ABA therapy reduces problem behavior and increases skills for individuals with intellectual disabilities and ASD.

ABA Insurance Coverage

ABA Therapy Insurance Coverage

ABA therapy insurance coverage is typically funded by most insurance companies when there is a medical necessity. The criteria for medical necessity may vary between insurance companies, so it is best to check with your carrier. Criteria for ABA insurance coverage typically includes an Autism diagnosis.

ABA Health Insurance Criteria For Autism

Autism Spectrum Disorder is a developmental disability that can cause significant social, communication and behavioral challenges. A diagnosis of ASD now includes several conditions that were formerly diagnosed separately: autistic disorder, pervasive developmental disorder not otherwise specified, and Asperger syndrome. States are mandated to provide some coverage for autism treatment through their Medicaid programs. Essentially, each state determines which services are medically necessary. For people with autism, that means each state decides which services (including ABA therapy) are medically necessary and, therefore, covered. A service or supply is medically necessary to diagnose or treat an illness, injury, condition, disease or its symptoms when it meets accepted standards of medicine, as defined by each state.

Common Characteristics of Autism Spectrum Disorder
Common Characteristics of Autism Spectrum Disorder

People with ASD often have problems with social, emotional, and communication skills. They might repeat certain behaviors and might be resistant to change in their daily routine. Many people with ASD also have different ways of learning, paying attention, or reacting to things. ABA therapy is used as a method of treatment to improve or change certain behaviors. Signs of ASD begin during early childhood and typically last throughout a person’s life.

Children or adults with ASD might:

  1. Not point at objects to show interest (for example, not point at an airplane flying over)
  2. Not look at objects when another person points at them
  3. Have trouble relating to others or not have an interest in other people at all
  4. Avoid eye contact and want to be alone
  5. Have trouble understanding other people’s feelings or talking about their own feelings
  6. Prefer not to be held or cuddled, or might cuddle only when they want
  7. Appear to be unresponsive when people talk to them but respond to other sounds
  8. Be very interested in people, but not know how to talk, play, or relate to them
  9. Repeat or echo words or phrases said to them, or repeat words or phrases in place of normal language
  10. Have trouble expressing their needs using typical words or motions
  11. Not play “pretend” games (for example, not pretend to “feed” a doll)
  12. Repeat actions over and over again
  13. Have trouble adapting when a routine changes
  14. Have unusual reactions to the way things smell, taste, look, feel, or sound
  15. Lose skills they once had (for example, stop saying words they were using)

Here are a few questions that may help with gaining more information about ABA coverage from your medical insurance carrier: “Is ABA a covered benefit for my child?”, “What criteria needs to be met for ABA services to be covered (e.g. Autism diagnosis)?”, “What is my co-pay and coinsurance?”, “What is my individual and/or family deductible?”, “Is there a benefit maximum (e.g. some insurances may only fund up to a certain amount for a particular treatment)?”, “Which providers or ABA agencies are in-network?”

Does Medicaid Insurance Cover ABA Therapy?

Medi-Cal and Medicare offer ABA therapy insurance coverage if medically necessary. Behavioral health treatment services for beneficiaries are offered for children diagnosed with ASD. Applied Behavior Analysis is an evidence based and effective treatment for individuals with ASD when offered by qualified professionals.

Most children enrolled in Medicaid receive services through a Medicaid health plan, such as an HMO or other insurance company. The state Medicaid agency and the Medicaid health plan determine if treatments are medically necessary and which providers can be reimbursed for services.

How Much Do Insurance Companies Pay For ABA Services?

Private insurance companies, like Aetna and Cigna, will also provide ABA insurance coverage when medically necessary. However, it is best to speak directly with your medical insurance company to determine the specifics of ABA therapy insurance coverage. You should learn details about copays, coinsurance, deductibles and maximums to ensure that ABA therapy is a covered benefit.

Questions About ABA Insurance Coverage

Here are a few questions that may help you gain more information about ABA therapy coverage from your medical insurance carrier:

  • Is ABA covered by insurance as a benefit for my child?
  • What criteria needs to be met for ABA therapy to be covered (e.g. Autism diagnosis)?
  • How much do insurance companies pay for ABA services? Or, what is my copay and coinsurance?
  • What is my individual and/or family deductible?
  • Is there a benefit maximum (e.g. some insurances may only fund up to a certain amount for a particular treatment)?
  • Which providers or ABA agencies are in-network?

The landscape of insurance is ever-changing and information is constantly updated. ABA insurance coverage continues to become more widely available and more affected individuals are claiming their rights to the benefits of ABA therapy. It is always recommended to speak to your individual insurance carrier to get the most accurate information about ABA insurance coverage.

Frequently asked questions about ABA therapy

What is ABA Therapy used for?

ABA-based therapy can be used in a multitude of areas. Currently, these interventions are used primarily with individuals living with ASD; however, their applications can be used with individuals living with pervasive developmental disorders as well as other disorders. For ASD, it can be used in effectively teaching specific skills that may not be in a child’s repertoire of skills to help him/her function better in their environment whether that be at home, school, or out in the community.  In conjunction with skill acquisition programs, ABA-based interventions can also be used in addressing behavioral excesses (e.g., tantrum behaviors, aggressive behaviors, self-injurious behaviors). Lastly, it can also be utilized in parent/caregiver training.

In skill acquisition programs, a child’s repertoire of skills is assessed in the beginning phase of the services in key adaptive areas such as communication/language, self-help, social skills, and motor skills as well.  Once skills to be taught are identified, a goal for each skill is developed and then addressed/taught by using ABA-based techniques to teach those important skills. Ultimately, an ABA-based therapy will facilitate a degree of maintenance (i.e., the child can still perform the learned behaviors in the absence of training/intervention over time) and generalization (i.e., the learned behaviors are observed to occur in situations different from the instructional setting).  These two concepts are very important in any ABA-based intervention.

In behavior management, the challenging behaviors are assessed for their function in the beginning phase of the services. In this phase, the “why does this behavior happen in the first place?” is determined. Once known, an ABA-based therapy will be developed to not just decrease the occurrence of the behavior being addressed, but also teach the child a functionally-equivalent behavior that is socially-appropriate.  For example, if a child resorts to tantrum behaviors when she is told she cannot have a specific item, she may be taught to accept an alternative or find an alternative for herself. Of course, we can only do this up to a certain point—the offering of alternatives.  There comes a point when a ‘no’ means ‘no’ so the tantrum behavior will be left to run its course (i.e., to continue until it ceases).  This is never easy and will take some time for parents/caregivers to get used to, but research has shown that over time and consistent application of an ABA-based behavior management program, the challenging behavior will get better.

In parent training, individuals that provide care for a child may receive customized “curriculum” that best fit their situation.  A typical area covered in parent training is teaching responsible adults pertinent ABA-based concepts to help adults understand the rationale behind interventions that are being used in their child’s ABA-based services.  Another area covered in parent training is teaching adults specific skill acquisition programs and/or behavior management programs that they will implement during family time.  Other areas covered in parent training may be data collection, how to facilitate maintenance, how to facilitate generalization of learned skills to name a few.

There is no “one format” that will fit all children and their families’ needs. The ABA professionals you’re currently working with, with your participation,  will develop an ABA-based treatment package that will best fit your child’s and your family’s needs. For more information regarding this topic, we encourage you to speak with your BCBA or reach out to us at [email protected].

Who Can Benefit From ABA Therapy?

There is a common misconception that the principles of ABA are specific to Autism. This is not the case. The principles and methods of ABA are scientifically backed and can be applied to any individual. With that said, the U.S. Surgeon General and the American Psychological Association consider ABA to be an evidence based practice. Forty years of extensive literature have documented ABA therapy as an effective and successful practice to reduce problem behavior and increase skills for individuals with intellectual disabilities and Autism Spectrum Disorders (ASD). Children, teenagers, and adults with ASD can benefit from ABA therapy. Especially when started early, ABA therapy can benefit individuals by targeting challenging behaviors, attention skills, play skills, communication, motor, social, and other skills. Individuals with other developmental challenges such as ADHD or intellectual disability can benefit from ABA therapy as well. While early intervention has been demonstrated to lead to more significant treatment outcomes, there is no specific age at which ABA therapy ceases to be helpful.

Additionally, parents and caregivers of individuals living with ASD can also benefit from the principles of ABA. Depending on the needs of your loved one, the use of specified ABA techniques in addition to 1:1 services, may help produce more desirable treatment outcomes. The term “caregiver training” is common in ABA services and refers to the individualized instruction that a BCBA or ABA Supervisor provides to parents and caregivers. This typically involves a combination of individualized ABA techniques and methods parents and caregivers can use outside of 1:1 sessions to facilitate ongoing progress in specified areas.

ABA therapy can help people living with ASD, intellectual disability, and other developmental challenges achieve their goals and live higher quality lives.

What does ABA Therapy look like?

Agencies that provide ABA-based services in the home-setting are more likely to implement ABA services similarly than doing the same exact protocols or procedures. Regardless, an ABA agency under the guidance of a Board-Certified Behavior Analyst follows the same research-based theories to guide treatment that all other acceptable ABA agencies use.

ABA-based services start with a functional behavior assessment (FBA). In a nutshell, a FBA assesses why the behaviors may be happening in the first place. From there, the FBA will also determine the best way to address the difficulties using tactics that have been proven effective over time with a focus on behavioral replacement versus simple elimination of a problem behavior. The FBA will also have recommendations for other relevant skills/behaviors to be taught and parent skills that can be taught in a parent training format to name a few. From there, the intensity of the ABA-based services is determined, again, based on the clinical needs of your child. The completed FBA is then submitted to the funding source for approval.

One-on-one sessions between a behavior technician and your child will start once services are approved. The duration per session and the frequency of these sessions per week/month will all depend on how many hours your child’s ABA services have been approved for—usually, this will be the number recommended in the FBA. The sessions are used to teach identified skills/behaviors via effective teaching procedures. Another aspect of ABA-based services in the home-setting is parent training. Parent training can take many forms depending on what goals have been established during the FBA process. The number of hours dedicated for parent training is also variable and solely depends on the clinical need for it. If a 1:1 session is between a behavior technician and your child, a parent training session or appointment is between you and the case supervisor and with and without your child present, depending on the parent goal(s) identified. Parent training service’s goal is for you to be able to have ample skills/knowledge in order for you to become more effective in addressing behavioral difficulties as they occur outside of scheduled ABA sessions. Depending on the goals established, you may be required to participate in your child’s 1:1 sessions. These participations are a good way for you to practice what you have learned from the case supervisor while at the same time, having the behavior technician available to you to give you feedback as you practice on those new skills.

As mentioned in the beginning, no two ABA agencies will do the same exact thing when it comes to providing ABA services; however, good agencies will always base their practice on the same empirically-proven procedures.

How do I start ABA Therapy?

In most cases, the first item required to start ABA therapy is the individual’s autism spectrum disorder (ASD) diagnosis report. This is typically conducted by a doctor such as a psychiatrist, psychologist, or a developmental pediatrician. Most ABA therapy agencies and insurance companies will ask for a copy of this diagnosis report during the intake process as it is required to request an ABA assessment authorization from the individual’s medical insurance provider.

The second item required to start ABA therapy is a funding source. In the United States, and in cases where Medi-Cal or Medicare insurances are involved, there is a legal requirement for ABA services to be covered when there is a medical necessity (ASD diagnosis). Medi-Cal and Medicare cover all medically necessary behavioral health treatment services for beneficiaries. This typically includes children diagnosed with ASD. Since Applied Behavior Analysis is an evidence based and effective treatment for individuals with ASD, it is considered a covered treatment when medically necessary. In many cases, private insurance will also cover ABA services when medically necessary, however in these cases, it is best to speak directly with your medical insurance provider to determine the specifics of the coverage and to ensure that ABA is in fact, a covered benefit. Additionally, some families opt to pay for ABA services out-of-pocket.

The next step to starting ABA therapy is to contact an ABA provider whom you are interested in working with. Depending on your geographic location, ABA agencies exist in many cities across the United States. Your insurance carrier, local support groups, and even a thorough online search can help you find reputable and properly credentialed ABA agencies near you. Our organization, LeafWing Center, is based in southern California and is recognized for aiding people with ASD achieve their goals with the research based on applied behavior analysis.

Once you have identified the ABA provider with whom you wish to work, they should help you facilitate the next steps. These will include facilitating paperwork and authorizations with your funding source. Once the assessment process begins, a BCBA (Board Certified Behavior Analyst) or qualified Program Supervisor should get in contact with you to arrange times in which interviews with parents/caregivers and observations of your loved one can be conducted. This will help in the process of gathering important clinical information so that with your collaboration, the most effective treatment plans and goals can be established for your loved one. This process is referred to as the Functional Behavior Assessment (FBA) and is elaborated on in different blog posts on our website. With regard as to what can be expected once ABA therapy begins, please read our blog post titled: When You Start an ABA program, What Should You Reasonably Expect from Your Service Provider?

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