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Insurance and ABA Services: What You Need to Know

If you are raising a child with autism, you understand how useful Applied Behavior Analysis (ABA) can be.  Research has established that early intensive behavior therapy, based on the principles of ABA, is medically necessary for individuals who are diagnosed with autism spectrum disorder (ASD).

In November 2011, Governor Cuomo signed into law new requirements for health insurance companies to provide coverage for the diagnosis and treatment of individuals with autism. This law went into effect in November 2012 and opened the door for families to obtain services that had previously been deemed medically unnecessary.

What You Need to Know About Autism Insurance Coverage in NYS:

What is autism insurance coverage?

NYS regulated health insurance plans now cover treatment of ASD, including behavioral health treatments, psychiatric care, psychological care, medical care, therapeutic care and specified pharmacy care.

Who can obtain these services?

To be eligible for coverage, an individual must be diagnosed with ASD and have a medical need for services.

What is a medical need?

ABA is deemed medically necessary when a physician or licensed professional demonstrates that the symptoms of ASD are present and treatment is needed.

How do I access services?

Services must be prescribed by a medical doctor or a licensed psychologist and they must be able to provide proof of an Autism diagnosis ( F84.0). This should include a standardized test for adaptive skills (Vineland),  a Full-Scale Intelligence Quotient (IQ) (WISC-V) and a diagnostic screening tool (ADOS).

What are the costs associated with ABA through insurance?

There may be  a co-payment  associated with treatment,  as well as family and individual deductibles that need to be met.

What is the process of accessing ABA through insurance?

Beyond Boundaries’ Insurance Intake Coordinators are here to assist you in obtaining the highest quality ABA for your loved one with autism.  We will help guide you through a multi-step process, which includes:

  • ABA Benefits Verification

We will call your insurance company and verify that your plan includes coverage for ABA therapy and get information regarding your estimated out-of-pocket costs.

  • Assessment Authorization

We will request authorization from your insurance company for an initial ABA therapy assessment.

  • Initial Assessment

We will schedule an initial assessment appointment with the BCBA who will be leading your child’s therapy team. The assessment may take up to 8 hours – which will be conducted in multiple visits.

  • Therapy Authorization

The results of the assessment and our treatment plan will be submitted to your insurance company. It can take up to 15 business days for the insurance company to review the information and make a determination on services.

We will contact you with the approval or denial as soon as we hear back from your insurance company.

  • Therapy Begins!

For more information about Beyond Boundaries and eligibility for insurance based ABA, visit us at: www.beyondboundaries.com

Contact: Kristen Schreck-Many at kristen.schreck@beyondboundaries.com




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