Will My Insurance Plan Cover ABA?

Navigating your insurance benefits can be confusing and overwhelming. We often hear questions like, “Will my insurance plan cover Applied Behavior Analysis (ABA) therapy for my son?” or, “I just don’t know who to contact to find out if we have benefits or what to ask about when I call.” Hopefully, this blog post will help answer some of your questions about ABA benefits.
We suggest that you contact your insurance carrier first to determine if ABA is a covered benefit under your specific plan. This can be the tricky part for parents. Most insurance companies have a separate department that handles ABA services. Sometimes the contact information for this department is not listed on the back of your insurance card and it can take several phone calls before reaching the correct department. It can be an extremely frustrating process!

  • First, try calling the Mental Health Benefits or Member Benefits number on the back of your insurance card. Ask to speak to someone regarding Applied Behavior Analysis (ABA) services for your child with autism. If that does not work, try requesting to speak to an autism specialist.
  • Once you reach the appropriate department, ask the representative if ABA is covered under your policy? If the representative is not sure, or you think you should be covered, confirm what state your policy is based. If it is a Colorado plan then it may be subject to Health Insurance Mandated Autism Treatment (HIMAT) in Colorado.  Some out state insurance companies may choose to cover autism treatment services, but they may not be required to do so. If you question the information you have received, or if the representative doesn’t appear to know the answers to your questions, ask to speak to a benefits manager or an autism specialist.

If your insurance covers ABA, you may still have some out of pocket expenses. These are some additional questions to ask your insurance provider:

  • When does my annual plan year begin and end?
  • What is the maximum annual benefit for autism treatment services?
  • Is my policy subject to HIMAT? (If it is, ask what the maximum annual benefit is for your child based on his/her age.)
  • Do I have a deductible? If so, is it a family or an individual deductible? How much is the annual deductible?
  • Do I have a co-pay? If so, what is it? Are co-pays charged per day or per visit?
  • Do they require pre-authorization of ABA services? If so, what is required to complete the pre-authorization process?

We suggest keeping a record of your phone conversation by asking the representative for a call reference number. If they do not provide reference numbers, document the date, time, and representative’s name.
If you have ABA benefits, make sure you have a current evaluation stating your child’s diagnosis as insurance companies often require proof of diagnosis before they will cover ABA services. Most companies only cover ABA therapy with an Autism Spectrum (299.0) diagnosis. Also, some insurance carriers require a letter from your child’s treating physician stating why ABA is medically necessary so be sure to ask the insurance representative if you will need a letter in order to start services.

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