Please note that all of the information on this page may not always be up to date as it changes frequently. Look at the dates on the resources for reference. A document that might be helpful to both you and your provider in filing for insurance is: Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers. This resource from the Behavior Analyst Certification Board (BACB) contains general guidance and basic descriptions of typical ABA service delivery. For the most recent version see the www.bacb.com website and look under Documents.
A good source of current information is Autism Speaks. See: https://www.autismspeaks.org/health-insurance-coverage-autism You will find information on the various types of insurance coverage and may even be able to find some personal assistance with insurance matters.
Where do I begin?
Getting your health insurance to reimburse/cover ABA therapy can range from as easy as submitting a claim or as hard as taking your insurance company to court. There are many variables that affect how much your particular health plan will cover in your child’s particular case: type of plan, child’s diagnosis, type of provider, etc.. However, take heart in that there are more people getting reimbursement for ABA therapy every day. Filing claims with the insurance company can become overwhelming—especially if you have several young children at home. You may wish to hire a claims specialist. This is someone who can file the claims on your behalf and charges you a fee. There are two national organizations through which you can find a professional who may help you.
- Alliance of Claims Assistance Professional http://www.claims.org/
- Medical Billing Advocates of America http://www.billadvocates.com/.
First your child must have a diagnosis from doctor, and the doctor must prescribe Applied Behavior Analysis and specify that ABA is “medically necessary”. (Sample Letter from a parent to a pediatrician.)
Next you need to know what type of health plan you have: fully funded, self-funded, individual, etc. Knowing the name of your insurance company does not tell you what kind of plan you have. Blue Cross Blue Shield, for example, can administer a self-funded plan for one company and offer fully funded plans to another. (NOTE: You cannot compare the benefits that your insurance company, say Blue Cross Blue Shield, offers you to the benefits of another person at another company that uses Blue Cross Blue Shield. Each employer buys a unique set of benefits to offer their employees based on the cost of the benefits to the company.)
Use your employer’s HR department as a resource to learn what coverage your child has access to. Ask to see the Summary Plan Document for your company’s insurance program.
You may want to request a case manager from the insurance company so that you are not speaking with a new person each time you contact them.
Keep a log of your conversations with the insurance company. You can download a suggested log format here. Try to get as much in writing as possible.
About half the people in Texas are insured through self-funded plans. This term describes plans in which the company directly pays for the health care costs and contracts with an insurance company, like Aetna or Blue Cross Blue Shield, to administer its health plan, keeping track of the claims and paying them, for example. The good news is that your company is the one who decides which benefits to include or exclude in the contract that they sign with the administering insurance company. The first health plans that reimbursed for ABA programs were self-funded plans. They did this after employees advocated to secure reimbursement for ABA programs. The amount of advocacy required has varied significantly from company to company—from a written request to the human resources department (HR) of the company to years of appeals within the company to a full blown lawsuit– but it has been done. If your self-funded plan does not currently cover ABA, you, as an employee, can appeal directly to those decision makers within your company.
This link will provide you with detailed information about self-funded plans including what the appeal process looks like: http://www.dol.gov/dol/topic/health-plans/
Another bright spot is that in 2008, as a part of the economic bailout package, the “Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008” was passed to close the previously existing loopholes in mental health coverage that allowed limitations on the number of visits and dollar amounts for therapy. The number of therapy visits has been one of the largest barriers for getting coverage of ABA because ABA differs significantly in intensity and duration from other mental health therapy models for other conditions. If a company offers a mental health benefit, the benefits, copays and financial limits must match those offered under the plan’s medical/surgical coverages.
Fully Funded Plans
Fully funded plans are regulated by the Texas Department of Insurance (TDI), https://www.tdi.texas.gov. As of January 1, 2010, state funded plans were mandated to provide coverage to children up to age 10 years old with autism in Texas. The legislation in the 2009 session and the 2007 sessions of the Texas Legislature:
- redefined autism as a medical, neurobiological disorder
- mandated that if a physician prescribes evaluations and assessments, ABA, speech, behavior training and management, occupational therapy, physical therapy, medications or nutritional supplements for a child with autism ages 3 – 10, they must be paid for out of surgical and medical benefits rather than mental health benefits.
- provided definitions or criteria that allow board certified behavior analysts and board certified associate behavior analysts to be considered approved providers for reimbursement.
- included language that the mandated age range cannot be used as an excuse to stop benefits just because a child turns 11 years old.
FEAT-Houston lauds the work that Sen. Eddie Lucio Jr., Rep. John Davis, Rep. Juan Garcia, and Rep. Todd Smith have done to obtain better insurance coverage for children with autism in Texas. The bills that accomplished this passed only as the result of grassroots advocacy throughout the state of Texas. It is one of a series of mandate bills that have been passed in various states.
Clearly, more work needs to be done so that all persons with autism spectrum disorder can have appropriate services reimbursed through their insurance plan as well.
Please note that plans that are fully funded by the company or organization providing them (self-funded plans) are NOT governed by ERISA, and so are NOT affected by the passage of the “Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008”
If you find yourself in a dispute with your insurance company, please contact TDI, https://www.tdi.texas.gov/. It is also wise to “cc” all your correspondence with your state representative and state senator as well so that your case can be resolved quickly. You can find out who represents you here: https://wrm.capitol.texas.gov/home
Federal Medicaid requires that all reimbursable services be provided by a “licensed practitioner of the healing arts”.