Applied Behavior Analysis (ABA) therapy is a highly effective, intensive treatment for children with autism. ABA therapy is typically delivered by a trained therapist for 10 hours/week or more. As a result, ABA can be expensive, with annual costs often exceeding $20k. Health insurance generally covers most costs, however it’s important to understand how much you can expect to pay out-of-pocket.
Insurance funding for ABA therapy can feel complex, but with the right information and organization, it’s manageable. Here are some key steps!
Step 1. Verify ABA Therapy Coverage with Your Insurance Provider (Documentation Requirements)
- Insurance Coverage: Check if your health plan covers ABA therapy and understand the approval process.
- ASD Diagnosis Requirement: Most insurance plans require an official autism diagnosis for ABA therapy coverage. Some state Medicaid plans allow coverage with a medical recommendation from a provider like your child’s pediatrician. Once you have clarity on this requirement, schedule the necessary appointments. If autism is diagnosed and/or ABA is deemed medically necessary, collect the required documentation (i.e., diagnostic report or medical prescription).
- Connect with Your Insurance Provider: Contact your insurer for detailed coverage info, including:
- Coverage Limits: Maximum annual support for services.
- Deductibles: Amount you pay before insurance contributes.
- Copayments: Fixed fees per service visit.
- Co-insurance: A percentage of the allowed cost that you pay, after any deductible is met.
- Out-of-Pocket Maximums: Cap on personal spending for covered services within a year.
- Pre-authorization Requirements: Authorization may be needed before starting services.
- In-network Providers: For cost savings and simplified billing.
Step 2. Choose an ABA Provider
Select an ABA therapy provider who is experienced and qualified. Ensuring the provider is in-network can significantly reduce out-of-pocket expenses. If you prefer a specific provider who is out-of-network, inquire about possible options or exceptions. Some health plans will approve a “single case agreement” for a provider who is out-of-network if there is a reasonable case to be made as to why a child needs to work with that particular provider.
Step 3. Submit Documentation Required by Insurance
Work with your chosen ABA provider to submit all necessary documentation to your insurance company. This typically includes the diagnosis, treatment plan, and provider credentials.
Step 4. Follow Up Regularly
Stay proactive by following up with your insurance company. Keep detailed records of all communications, including dates, names of representatives, and any reference numbers.
Step 5. Appeal Insurance Claim if Necessary
If your claim is denied, don’t be discouraged! You have the right to appeal the decision. Gather supporting documents, including letters from your child’s healthcare providers, and submit them with your appeal.
Step 6. Explore Additional ABA Therapy Financial Assistance
If insurance coverage is insufficient, research other financial assistance options. Non-profit organizations such as The National Autism Association, state programs, and grants like the United Healthcare Children’s Foundation or Doug Flutie Jr. Foundation for Autism can provide additional support for ABA therapy costs.
Step 7. Stay Informed
Insurance policies and regulations can change and vary by state. Keep yourself informed about any updates that might affect your coverage by regularly checking with your health plan, provider, and community forums.
Meet the Garcias: An Example of ABA Therapy Costs with Insurance
Let’s walk through a hypothetical example, with round numbers, of a family navigating insurance coverage for ABA services at the start of the year. These numbers are for illustrative purposes only. Actual session costs, reimbursement rates, and family contributions vary depending on your insurance plan.
- The Family: The Garcia family has a child diagnosed with autism who needs ABA therapy. Their insurance plan has a $3,000 deductible, a 20% co-insurance rate after the deductible is met, and a $5,000 out-of-pocket maximum for the year.
- Estimated Costs: In January, the Garcias start ABA therapy. They plan to pursue ABA therapy at a cost of $900 per week for 24 weeks, totaling $21,600 estimated therapy cost for the treatment period.
- Paying the Deductible: Initially, the Garcias pay the full $900 per week out of pocket until they reach their $3,000 deductible. This takes approximately 3 weeks.
- Co-Insurance Phase: After meeting the deductible, they enter the co-insurance phase. They now pay 20% of the cost of ABA services. The Garcias pay out-of-pocket $180/week. Out-of-Pocket Maximum: As the weeks progress, the Garcias continue paying $180 per week until their out-of-pocket expenses (including the deductible) reach the $5,000 maximum. This takes approximately 14 weeks – the first 3 weeks when they paid fully out of pocket up to their deductible, followed by about 11 weeks of paying $180/week.
- Insurance Covers 100%: Once the Garcias hit their $5,000 out-of-pocket maximum, their insurance covers the full cost of ABA therapy for the rest of the year.
ABA Therapy Insurance Process: Key Takeaways
- Most U.S. insurance plans cover ABA therapy for children with autism.
- Verify your plan-specific requirements such as a formal ASD diagnosis and pre-authorization.
- Choose an experienced ABA provider and understand whether they are in-network or out-of-network with your insurance.
- Track deductibles, co-insurance, and out-of-pocket maximums carefully.
- If denied, appeal the decision and explore non-profit grants or state programs for financial assistance.
Navigating insurance for ABA therapy takes patience, but with persistence and the right approach, you can secure the necessary coverage for your child. Remember, you’re not alone—resources and communities are here to support you in helping your child thrive! Our Client Services team at Kyo can help with any insurance-related questions and work directly with your insurance provider to verify your coverage.
