INSURANCE ACCEPTED!Insurance Coverage For ABA
Many families want to know if their health insurance covers ABA therapy services. Currently, 42 states have enacted a mandate for coverage of these types of services. Unfortunately, the state of Tennessee is currently without a mandate for coverage for these types of services, but that doesn’t mean you don’t have or can’t get coverage. The answer to whether your plan has coverage or could cover it isn’t a simple one, and often depends on numerous factors.
*Note: this blog is intended for basic informational purposes about insurance and not to be taken as a guarantee of insurance coverage or denial. Each member’s benefits are unique and only your insurance carrier can authorize or deny services through a provider*
Types of Plans
Whether your insurance plan covers ABA services depends largely on such as the type of insurance coverage. There are a few types of plans: (a) Private, such as a major commercial carrier like BlueCross BlueShield, (b) Public, such as Medicaid like TennCare, and (c)Federal, such as plans offered to government beneficiaries like Tricare.
Currently, plans offered through Federal programs like Tricare and Public programs like BlueCare or TennCare Select do cover ABA services for most members. What this means is that assuming your actively covered under one of these plans and your child meets *medical necessity guidelines you are likely eligible to receive ABA coverage under your insurance carrier.
The biggest hiccup can come from Private programs like most major commercial carriers. Further, more confusion arises when plans are defined as either “fully insured” or “self funded”. The difference lies in who is ultimately financially responsible for paying claims, a third party contracted agency in the case of “fully insured” or the employer in the case of “self funded”. These differences don’t mean much in terms of likelihood of ABA coverage, but the difference IS important when it comes to fighting for the coverage you want.
Members of fully insured plans should contact their HR department with coverage questions.
Members of self funded plans should contact the US Department of Labor at 1-866-444-3272 with coverage questions.
To learn more about what type of plan you have and your options, visit: https://www.autismspeaks.org/advocacy/insurancelink/navigator
Meeting The Requirements
There is another consideration for whether services or covered are not and it lay in the hands of “medical necessity guidelines”. Insurance carriers have their own rules for what constitutes medical necessity in terms of coverage. There are no general assumptions that can be made here, and all coverage decisions fall to the decision of your insurance carrier. Carriers have outlined what they consider medically necessary for ABA services and what is not considered medically necessary. The only way to determine medical necessity is to submit an ABA authorization request and wait for the decision of the carrier.
To learn more about how to advocate for insurance coverage of ABA services, visit: https://www.autismspeaks.org/advocacy/insurance
Using Your Coverage
If you are one of few in Tennessee that does have ABA coverage or have the type of plan that generally covers ABA services you might be wondering what the next step might be.
First, find a provider that accepts your insurance plan. Ask whether the provider is in-network or considered an out-of-network provider. It is always best to choose an in-network provider when possible.
Second, organize your documents to take to your first appointment with the ABA provider. Insurance carriers typically request documents stating your child’s diagnosis and recommendations. If you have an order from a physician or pediatrician for ABA services, that information is helpful as well. Always make a copy of your child’s insurance card so that your provider can have it when they call to verify benefits.
If you services are approved, your insurance carrier will give your provider an authorization code regarding services. Remember that your provider must work within the, often strict, requirements of the insurance carrier. This means that some services like assessment and treatment may be covered, but other services like group treatment or social sessions may not. Your insurance carrier should provide you a copy of the services they have authorized. If not, contact the carrier directly to obtain a copy for your records. Also, remember that your carrier may impose service caps on how many hours you can receive based on *medical necessity guidelines. Stay in touch with your carrier and provider to be sure you know what to expect for scheduling purposes.
Helping Others Benefit From Coverage
Whether you are fortunate enough to find yourself with coverage for these essential Autism services or not, we all can help one another by becoming an advocate. Fight for the rights of all citizens of Tennessee to find ABA coverage by:
- Getting to know your legislator, they can help your cause where it counts!
- Enlist your friends and family to join the cause.
- Visit advocacy.autismspeaks.org/register