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Deciphering what your insurance covers sometimes means learning a whole new language! We can help! Keep in mind, each insurance plan has its own rules, so confirm with your plan representatives what they cover and what they don’t, or contact us and we'll do the work! Consider the example in the associated visual as you review the below list of commonly used insurance terms and definitions:
Before submitting any requests for ABA therapy insurance, your child will need a medical autism diagnosis. All insurance plans require a medical diagnosis of autism spectrum disorder before authorizing ABA services. The medical diagnosis should also include diagnostic testing for autism and cognitive testing. Plans will require the diagnosis to be conducted by either a medical doctor (M.D.) or a Ph.D.
Professionals who can evaluate for and diagnose autism include the following:
A medical diagnosis of autism is different from educational eligibility. If your child receives specialized supports through an Individualized Education Plan (IEP) at school, however, does not have a medical diagnosis of autism, most likely, this educational eligibility will not be accepted by your ABA therapy insurance plan. Think of the public education school systems and medical fields as two different entities. An educational eligibility of autism does not cross over to the world of private therapeutic treatment, since it’s based on educational need. In the same way, education professionals may take a medical diagnosis into account, but it does not guarantee special education services in public school districts.
If your child has an educational eligibility, but not a medical diagnosis of autism, or you suspect your child needs an evaluation, we may be able to provide a list of referrals to providers in your area who evaluate individuals for autism. Call or email us for more information.
Many states across the nation now have mandates for employers and insurance plans to cover services for individuals with autism including ABA. Information on the state mandates in Texas are as follows:
Medicaid in Texas is scheduled to cover funding for ABA services in February of 2022.
Each state that has a current mandate to cover ABA services may be a little different. If your health plan is not based in Texas you will need to know a little about your state’s mandate. You can find out more information by using the Insurance Link on the Autism Speaks website.
Below are resources to utilize if your health plan does not cover ABA services: