Navigating health insurance can be complex when you’re the parent of a child on the autism spectrum. While the CDC estimates that 1 in 54 children have autism spectrum disorder (ASD), treatment coverage can vary greatly depending on your insurance plan and state of residence. There is no “cure” for autism, but early intervention treatment programs have been shown to be highly effective in alleviating symptoms and improving daily functioning for children with ASD. Fortunately, it’s likely that some forms of autism treatment willbe covered by your insurance.
In this guide, we’ll break down the details of what you can expect when seeking health insurance coverage for your child’s autism treatments and also will tell is autism treatment covered by insurance?
Autism Screening and Treatment Under the Affordable Care Act
Under the Affordable Care Act (ACA), all Marketplace insurance plans must cover preventative services for children, which includes autism screening for children at 18 and 24 months. If you have a Marketplace plan, you will not be charged a copayment or coinsurance for the screening.
It’s also important to note that Marketplace plans are not allowed to discriminate against those with pre-existing conditions, which includes ASD. This means that if your child does receive a diagnosis for autism, your ACA provider would not be able to charge more for coverage or limit your services.
Applied Behavior Analysis
The most widely used therapeutic intervention for ASD is Applied Behavior Analysis (ABA). This treatment focuses on understanding and improving certain behaviors, such as communication or adaptive learning skills. On average, ABA therapy costs $17,000 annually, and can even reach as much as $100,000, so choosing an insurance plan that includes ABA coverage is crucial for many parents of children with ASD.
There are 33 states where ABA is currently included in the “Essential Health Benefits” package for ACA insurance plans. If you live in one of the following states and purchase a plan through the Marketplace, your child’s ABA therapy should receive coverage: Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Idaho, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Tennessee, Texas, Vermont, Virginia, Washington, West Virginia, Wisconsin and Wyoming.
Marketplace plans are also required to offer child-only options. So, for example, if your employer-based health insurance doesn’t cover ABA, you could purchase a child-only plan through the Marketplace that offers the coverage your child with autism needs. If you have employer-based insurance, your child-only plan cannot be subsidized, but it still might help round out the gaps in your child’s autism treatment coverage.
Other Forms of Treatment
Unfortunately, ABA is not currently a covered essential benefit in Marketplace plans in Alabama, Florida, Georgia, Iowa, Kansas, Minnesota, Mississippi, North Carolina, Nebraska, Oklahoma, Pennsylvania, Rhode Island, South Carolina or South Dakota.
However, all new Marketplace health plans must cover essential benefits such as hospitalizations, preventive services, and prescription drugs. Forms of treatment like speech, physical, and occupational therapy, as well as psychiatric services, are likely to fall under these categories. They can help your child with autism, despite the fact that they’re not autism-specific services. Additionally, some physicians prescribe medications that can assist with certain symptoms of autism, like aggression and anxiety, and these would be covered under the essential health benefits. TrueCoverage can help you research your Marketplace health insurance options in your state, so you can have a better understanding of what specific types of treatment will be covered.
Purchasing a plan through the Marketplace will also mean that your provider cannot put a dollar limit on your lifetime insurance benefits or most annual benefits. Under the ACA, your child will also be able to stay on your plan until they turn 26 years old.
Autism Screening and Treatment Under Non-Marketplace Insurance Plans
Forty-six states and the District of Columbia have passed mandates that require certain private health insurance plans to cover ABA and other autism services, treatment, and diagnosis.
The laws for these states vary. For example, while ABA isn’t included under Alabama’s Marketplace plans, the state mandate requires all insurance plans delivered to employers with over 50 employees to offer applied behavioral therapy. The practitioner must be certified with the Behavior Analyst Certification Board in order for the treatment to be covered. North Carolina, on the other hand, mandates that health benefit plans cover autism services, but does not explicitly include behavioral therapy as a type of treatment that must be covered.
Other states might require coverage for autism services, but have different stipulations about practitioner certifications, the age of children that can be covered, and the types of plans included in the mandate (i.e. group plans vs. individual plans). Many states cap the annual benefits covered for autism services around $36,000. The American Speech-Language-Hearing Association has a helpful guide that breaks down the specifics of what is protected under each state’s mandate. Understanding the laws in your specific state and discussing your options with providers is crucial for determining which plan will be right for your child with autism.
Autism treatment is a complex topic that varies on a case-by-case basis, depending on your child’s unique situation. TrueCoverage is here to help you throughout the process, so that you can find the best health insurance plan at the lowest cost, all while giving your child the autism coverage they need. If you have any questions, please reach out. Our insurance experts are ready to help!