ABA Resource for Parents
Health Insurance Coverage for ABA
Will my Health Insurance provider cover ABA? If so, how much ABA is covered? If I don’t currently have Health Insurance, or my provider doesn’t cover ABA can I purchase Health Insurance that will cover it? The answer to all of these questions is, it depends on your location.
How to determine if your child is covered
In the US, the state that you reside in will determine whether or not your child will be covered. Find out if your State mandates that insurance providers cover Autism Treatments; specifically ABA. This can be done by going to the website for the National Association of Insurance Commissioners (NAIC) and from there selecting the link to your state’s individual website. Here's a link to the site:
If the specifics for ABA and Autism coverage are not readily available on your individual state website, contact details for a department that can provide these specifics to you should be.
The autismspeaks.org website also has a comprehensive listing of what each state currently covers. Please note, this can be a little confusing. Even though each state mandates its own annual dollar amount maximum that insurers are required to cover, the mandates in The Affordable Care Act supersede these maximum state limits, because it mandates that there cannot be a limit on ABA coverage, once the treatment has been prescribed by a Medical Doctor. Simply put, if your state mandates that insurers cover ABA, your insurer will cover it without an annual dollar amount cap.
There is one exception to this; If your health insurance is "self-funded", the mandates in The Affordable Care Act probably do not apply to it. Self-Funded health care is care whereby an employer funds employees' health care from its own funds. It's typically implemented in very large corporations that have the funds to do this. If you're unsure whether or not your insurance is self-funded, check with your employer.
How do I verify if ABA will be covered by my insurance provider? Speak with the ABA Treatment provider that you are considering and ask them for the billing code or codes, that they would submit to the insurance company for your child’s treatment. Then contact the insurance provider, provide them with the codes and clarify what the annual limits are, if any, for hours submitted under these codes. Also verify with them whether or not the ABA Treatment provider is within the network that your insurance policy is associated with. It's important to check this before purchasing a policy.
Purchasing Coverage
Can I buy a health insurance policy to cover ABA treatment if I do not currently have a policy that does? This comes back to whether or not the state that you live in mandates that insurance providers cover ABA. You may purchase a policy in any state through the healthcare.gov Marketplace website, and can generally purchase directly from the insurance providers themselves. All of the policies that will be available to you through the Marketplace and from the private insurers directly will abide by the laws of your individual state in terms of what they will cover for ABA treatments.
One thing to keep in mind if you're enrolling in a policy through the Marketplace is the "Open Enrollment" period. This is the time period where you can enroll in a new policy. This is between November 1st and December 15th. Outside of this period, policies can be purchased once you meet a specific criteria, based on qualifying events that cause you to now need to purchase coverage; loss of a job and subsequently your insurance coverage for example.