insurance and funding
a basic guide to insurance coverage of Applied Behavioral Analysis (ABA)
We know how complicated navigating the world of insurance coverage can be. This page is intended to serve as a reference guide to help better understand your coverage. It is important to understand that every plan is different, so it essential that you verify benefits by talking to your customer advocate. We cannot guarantee the accuracy of the information on this page but we strive to have the most up to date information as it comes down from policy makers. Morning Star Regularly invests in law summits and public policy meetings to best direct the field in an ethical and bright future.
While Applied Behavior Analysis therapy is beneficial in improving behavior regardless of diagnosis, currently the only diagnosis that is considered to be eligible for ABA therapy under commercial insurance is Autism Spectrum Disorder. We are required to have evidence of a diagnosis of Autism Spectrum Disorder diagnosis on file.
types of plans
There are many types of insurance plans.
Group Coverage Policy – insurance policies offered as a benefit to employees by an employer. These policies fall under the state’s mandates for health insurance. Most states have autism mandates that require coverage of ABA services.
Individual Coverage Policy – insurance policies purchased independently of an employer. These policies also fall under each state’s mandates for health insurance. Before purchasing an individual policy, you might want to verify coverage by talking to a customer advocate.
Self-Funded Policy – insurance policies offered as a benefit to employees by an employer, but as a contract with an insurance company. These are not subject to state mandates, and are regulated by the federal government. Many self-funded plans have ABA exclusions. For more information about advocating for ABA benefits under your self-funded policy, refer to the toolkit here:
Medicaid/Missouri – The Center for Medicare and Medicaid Services (CMS) has advised that all states cover all medically necessary treatments for children with Autism Spectrum Disorder. – Some insurance companies have contacts with state Medicaid systems to manage health claims. Coverage under these policies are often consistent with Medicaid coverage.
Autism Law Hub – The Autism Law Hub is a growing repository of valuable information.
Eligibility – We will first confirm your eligibility of benefits by contacting your insurance company.
Preauthorization/Predetermination – insurance companies require different levels of documentation to pre-certify assessment and/or treatment. Some insurance companies require more extensive assessments by a qualified professional and consultations with providers such as Occupational Therapists, Developmental Pediatricians, or Licensed Clinical Psychologists. Some insurance companies also require separate preauthorizations for treatment assessment and treatment, but most often with authorize only 6 months of treatment at a time. At the end of that 6-month authorization period, we send an update on progress to your insurance company along with our request. At times, a clinical professional contracted by the insurance company will review requests by consulting with the child’s provider prior to approval.
Billing – All providers use CPT (Current Procedural Terminology) codes outlined in our contracts with each insurance company. Codes are billed in a variety units of time that are regulated by the American Medical Association. Length of time for billed units can be to the quarter hour. We do not get to choose how codes are used; this is determined by the descriptions in the CPT code manual, the interpretation by individual insurance companies, and our agreements via contracts with insurance companies. We bill in accordance with our clinic fee schedule.
your financial responsibility
Copays – Co-pays are determined by your policy. Oftentimes ABA therapy is considered to be a “Specialty” and will fall under the specialty co-pay rates. Co-pays are billed per date of service, but different services may incur separate co-pays on the same date of service (i.e. ABA therapy and Speech and Language therapy on the same day may have two separate co-pays).
Coinsurance – some insurance plans require that the policyholder pay a coinsurance once a deductible has been reached but until an out-of-pocket maximum amount has been reached. This is typically a percentage of what is billed to your insurance. For more information specific to your insurance policy, please consult one of our billing specialists or contact your customer representative.
Scheduling – ABA therapy is most effective when implemented in intensive dosages, which ranges from 4-35 hours per week and will be scheduled in 15 minute increments (consistent with CPT code unit lengths of time). Recommendations for weekly hours will come from your child’s clinician following a comprehensive assessment of your child’s communication, socialization, and behavior skills. We will work with you to determine a weekly schedule that meets the needs of your family, but please understand that insurance companies will only authorize treatment hours based on scheduled time and not recommended hours. Increasing hours at a later date may not be possible until the authorization is due. Please also note that increased hours over school breaks is not a guarantee.
Attendance – Consistent attendance is imperative to your loved one’s success. Please notify our clinic immediately if your loved one will have a prearranged or unexpected absence. If attendance becomes inconsistent, we will work with you to develop a plan to increase consistency. Please be aware that most insurance companies require consistent attendance, including participation in parent training sessions.