ABA therapy insurance coverage by state and insurance plan | Autism Resources (2023)

ABA therapy average costs

According to Forbes, ABA therapy costs around $17,000 per year, without insurance coverage. But for some children, it may go as high as $45,000 to $100,000 per year. Therapy can span 20-40 hours per week and can continue for multiple years. Luckily, with insurance coverage, ABA therapy costs significantly less.

ABA therapy state coverage

In general, there are 2 types of insurance plans in the US:

• Fully-insured plans: These plans must provide benefits based on state laws. Your coverage is determined by your insurance company.
• Self-funded plans: These plans must follow federal law, not state laws. Your insurance coverage is determined by your employer.
  

The specific benefits of coverage are determined by the employer or insurance company. Here is an interactive tool from Autism Speaks that you can use to determine what type of health benefit plan you have.

According to the American Speech-Language-Hearing Association, here are further details from some of the states that provide coverage for ABA:

• Arkansas: Autism diagnosis and ABA therapy are covered up to $50,000 per year.
• California: If the healthcare plan provides physical treatment coverage, it must also provide mental treatment coverage, including ABA therapy.
• Colorado: ABA therapy is covered with no coverage limit
• Delaware: ABA therapy is covered up to $36,000 per year.
• Florida: ABA therapy is covered up to $36,000 per year.
• Illinois: ABA therapy is covered for individuals under 21 up to $36,000 per year
• Mississippi: ABA therapy is covered with no limitation.
• New York: If the healthcare plan provides physician services, medical, major medical, or similar comprehensive-type coverage, the plan will also cover ABA therapy.
• North Carolina: ABA therapy is covered up to $40,000 per year.
• Texas: ABA therapy is covered up to $36,000 per year.
• South Carolina: ABA therapy is covered up to $50,000 per year.
• South Dakota: ABA therapy is covered up to $36,000 per year for children under 6, $25,000 per year for children between 7-13, and $12,500 a year for ages 14-18.
• Vermont: ABA therapy is covered up to the maximum benefits under the Patient Protection and Affordable Care Act.

ABA therapy insurance coverage

Similar to state coverage, ABA therapy coverage can also vary based on your insurance company.

Here are some examples:

• Aetna: Most plans in all states offer coverage for ABA therapy, you’ll need to speak to the company about the specifics of your coverage.
• Anthem: ABA therapy is covered for those diagnosed with autism.
• Beacon: Most plans in all states offer coverage for ABA therapy, you’ll need to speak to the company about the specifics of your coverage.
• Blue Cross Blue Shield: Multiple health insurers sell under this label so every plan is different. Some states cover ABA therapy under a certain age, while other states require paperwork before treatment.
• Cigna: Some plans cover ABA therapy, but your doctor must submit formal documentation of autism diagnosis before therapy.
• Humana: Most plans cover ABA therapy, you should speak to your company about the specifics of your coverage.
• Kaiser Permanente: Most plans offer coverage for ABA therapy, you’ll need to speak to the company about the specifics of your coverage.
• Magellan: ABA therapy is covered for those diagnosed with autism.
• Medicaid: ABA therapy is covered for those diagnosed with autism in 42 out of 50 states.
• Medi-cal: ABA therapy is covered for those diagnosed with autism.
• Optum: ABA therapy coverage varies per state, you should speak to your company about the specifics of your coverage.
• Tricare: ABA therapy is covered for those diagnosed with autism.
• UnitedHealthcare: ABA therapy is covered.
  

If you aren’t sure, you should call the customer service number on your membership card to ask whether or not ABA therapy is covered by your insurance. You may be asked to provide your member ID, which can also be found on your membership card. For most insurance provided through an employer, ABA therapy is covered, thanks to advocacy from families and the autism community.

Important insurance terms

Here are some of the most important insurance terms you should know (a more complete set of terms can be found here on healthcare.gov):

• Deductible - Amount you must pay before your insurance coverage starts. You may need to check whether the therapy is covered by deductibles.
• Copay - Flat rate you pay for your benefits after you’ve exceeded your deductible.
• Coinsurance - Percentage of costs you pay after you’ve exceeded your deductible
• Out-of-pocket maximum: Maximum amount you pay out of pocket each year for covered services including deductibles, copayments, and coinsurance, but excluding premiums.
• In-network providers: Based on your insurance, you may have a specific network of providers and professionals that you should go to so you can reduce costs.
• Out-of-network providers: Providers outside of your network and may not be covered by your insurance plan. In general, using an out-of-network provider will cost more than an in-network provider.
• Prior authorization: You may need approval from your health insurance carrier for a specific treatment before receiving care, but this is not a promise that your insurance will cover the cost.
• Quote of Benefits (QOB): This quote is available from your medical provider and will provide information from your insurance plan about the amount of coverage for specific services.
  

In general, there are 2 types of provider networks (you can read more here):

• HMO (Health Maintenance Organization): You must stay within your network of providers to receive coverage.
• PPO (Preferred Provider Organization): For a higher monthly premium than an HMO, you can visit doctors outside your network and still receive additional coverage
  

Important tips for ABA therapy insurance coverage

If you already have an insurance plan, here are some tips you should keep in mind before reaching out to your insurance company:

• Know the terminology - Most insurance representatives will use terms such as deductibles, co-pay, and prior authorization. You should understand the terms above before reaching out to the insurance company.
• Double-check your facts - It is important to double-check your information to confirm your costs can be covered with insurance.
• Get names and reference numbers - When speaking with insurance representatives, always get that person’s contact information and reference number to avoid unnecessary confusion.
• Notify your providers if your insurance changes - If you are thinking of changing your insurance, research how it would affect your insurance coverage. You should always inform your therapists and service providers if any changes occur.
• Single Case Agreements (SCA) - Single Case Agreements are contracts between an insurance company and an out-of-network provider for a specific patient. This allows the patient to use out-of-network benefits.

You can maximize your ABA therapy insurance coverage in the following ways:

• Prior authorization - Make sure you have all the appropriate paperwork and formal diagnosis and authorization for an ABA assessment before starting therapy.
• Stay inside your network - Using providers within your network will increase your coverage and reduce your costs.

Follow the guidelines - Some plans may require ongoing documentation of progress. Your child’s therapist might need to submit paperwork to show that the therapy is working on an ongoing basis.

Questions to ask your insurance provider

Here are some helpful questions that you can ask your insurance provider to understand more about your ABA therapy coverage:

• Is ABA therapy covered by my insurance as a benefit for my child?
• What criteria are needed for ABA therapy to be covered? Do I need a specific autism diagnosis or paperwork to be filed?
• How much does my insurance cover for ABA therapy? What is my copay or coinsurance?
• What is my individual or family deductible for ABA therapy?
• Is there a benefit maximum?
• Which specific providers or ABA agencies are in-network? Is Songbird therapy covered?

Conclusion

ABA therapy helps children with autism develop strong communication and social skills. Although it may seem costly on the surface, ABA therapy is generally covered by most insurance policies. Here at Songbird, we accept more than 100 insurance plans to help your child succeed. Some of our major insurance providers include:

• BlueCross BlueShield
• Anthem
• Cigna
• Aetna
• Tricare
• Medicaid (in select states)
• Medi-cal
• Beacon
• Optum
• United Healthcare
• Magellan
• Humana
• and many more.
  

Contact us today to begin life-changing autism care in weeks, not months.

Songbird therapy is a modern provider of in-home ABA therapy. Our approach puts children and families first for better results. Songbird's best-in-class therapists design care plans based on your child's strengths, interests, and goals to help your child succeed and grow.

References

• https://www.autismspeaks.org/health-insurance-coverage-autism
• https://leafwingcenter.org/aba-insurance-coverage/#:~:text=ABA%20therapy%20insurance%20coverage%20is,typically%20includes%20an%20Autism%20diagnosis.
• https://www.forbes.com/sites/forbesbooksauthors/2019/04/18/what-is-covered-the-insurance-landscape-for-autism-services/?sh=292cf90e25c2
• https://www.wethriveaba.com/resources/aba-therapy-insurance/
• https://theplaceforchildrenwithautism.com/how-to-pay-for-autism-therapy/insurance-coverage-for-autism-therapy
• https://www.autismspeaks.org/applied-behavior-analysis
• https://momsbelief.com/blog/what-is-applied-behavior-analysis
• https://www.verywellhealth.com/aba-applied-behavioral-analysis-therapy-autism-259913
• https://emergeprofessionals.com/understanding-aba-therapy-a-simple-explanation-of-applied-behavioral-analysis/