As of right now, all 50 states have mandates that require some level of insurance coverage for the treatment of Autism. 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 Disorder. Therefore, ABA therapy is typically funded by most insurances when there is a medical necessity. The criteria for medical necessity may vary from insurance to insurance, so it is best to check with your carrier, however the criteria typically (though not always) include an Autism diagnosis.
With respect to Medi-Cal and Medicare, these insurances 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 carrier to determine the specifics of the coverage (copays, coinsurance, deductibles, maximums) and to ensure that ABA is in fact, a covered benefit.
As most of us already know, the landscape of insurance is ever-changing, with information constantly being updated. Overall, insurance coverage of ABA therapy continues to move in a desirable direction, with more and more affected individuals having access to covered ABA services. However, it is always recommended to speak to your individual insurance carrier to get the most up-to-date and accurate information about ABA coverage.
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?”
Please note, the questions above are meant to serve as examples and are not a comprehensive list. We hope this post has provided you more information about insurance funding for ABA therapy!