Empowerment Through Understanding: Insurance Coverage for Your Child’s Autism Care

Exploring Out-of-Network Providers, Educational Support, Coordination of Care and Continued Coverage Criteria for Autism Services

“Is ABA therapy covered by insurance?” and “How much is an autism diagnosis with insurance?” are common questions without simple answers. The truth is that each insurance plan is different, making the answers vary, too, but with nearly two decades in the pediatric autism service industry, we constantly work to unravel the intricacies surrounding insurance for our families.

As part of our mission to make sure kids have quality, compassionate and accessible options for care, our Hopebridge Care and Benefits team addresses the key questions many caregivers have about health insurance for autism services deemed medically necessary. As it relates to applied behavior analysis (ABA) and diagnostic evaluations for autism spectrum disorder (ASD) we aim to provide clarity on how insurance handles services beyond therapy, the complexities of out-of-network coverage and the criteria set for the ongoing support that is crucial to the well-being of children with autism.

Is applied behavior analysis treatment covered by insurance?

Many insurance companies do offer coverage for ABA services, but not all of them. Health benefits covered by a state or federally regulated insurance plan are required to cover ABA as an essential health benefit (EHB). However, some employer-sponsored insurance (ESI) plans, self-funded group plans and limited medical benefit plans, often referred to as “catastrophic coverage,” do not cover ABA services. We recommend calling the insurance company to ask about covered services or checking the member manual/evidence of coverage for the list of all covered services. If you have both a primary and secondary insurance plan, the secondary plan may or may not cover ABA services and out of pocket expenses. It’s important to confirm coverage and Hopebridge’s network status from all plans before initiating treatment.

Is Hopebridge an in-network provider for any insurance companies?

Hopebridge actively works a number of insurance partners and is scheduling autism assessments and ABA services for patients with plans from these providers. For instance, in Florida, Hopebridge partners with Aetna, Blue Cross Blue Shield (Florida Blue), Cigna (Evernorth Behavioral), Florida Medicaid, Meritain Health and UHC United Healthcare (Optum). In Ohio, we partner with Aetna, AmeriHealth Caritas Medicaid OH, Buckeye Medicaid, CareSource Marketplace, Cigna (Evernorth Behavioral), Humana, Meritain Health, UHC United Healthcare and UHC United Healthcare Community Plan Medicaid. Click here for an up-to-date list of all Hopebridge insurance partners. If you’re unsure of Hopebridge’s contract status with your insurance company, contact your insurance company directly to confirm participation with their plan. Many large insurance companies offer multiple plans with different coverage. Hopebridge may not have a contract for all plans or may be limited by the services offered under a plan. For example, speech, occupational and physical therapy could be delegated to The Therapy Network by multiple plans, but Hopebridge may not contracted with that plan. In these cases, we could offer ABA services but could not provide the additional therapy modalities.

Hopebridge is out-of-network for my current plan; how do I switch insurance plans?
The ability to change insurance plans and the process of doing so can vary. Typically, if you want to change health insurance, you must be within the open enrollment window, which is the period each year when individuals and families can change plans without state approval. If you would like to change your plan outside of the enrollment window, then you must have a state-approved “For Cause” reason or qualifying life event, such as a change in marriage status, birth, adoption, a change of residence, or a loss of existing health coverage. If you have insurance coverage from your employer, you likely cannot change the insurance company but you may be able to select a different plan to adjust cost-sharing requirements and possibly network access from a PPO instead of an HMO. A qualifying life-event, such as a marriage or birth of a new child, is required to change plans outside of the open enrollment period.

Does the insurance plan cover any educational or behavioral support services for children with autism?

Beyond therapy, educational and behavioral support services are crucial for the holistic development of children with autism. Review your insurance policy to identify coverage for services such as educational assessments, specialized tutoring, or behavioral support programs. Understanding the scope of coverage ensures a comprehensive approach to your child’s needs.

How does the insurance plan handle coordination of care for a child with autism who may need multiple types of services?

Many children with autism require a multidisciplinary approach to care, involving various services such as ABA therapy, speech therapy, occupational therapy and educational support. Look into how your insurance plan coordinates care for children needing multiple services. Clear communication between providers and a streamlined approach to authorization can enhance the effectiveness of a comprehensive care plan. Many insurance companies have care management teams and may be able to assist in coordinating services with your child’s entire team for all types of services.

Are there any specific criteria that must be met for continued coverage of autism services?

Understanding the criteria for continued coverage is vital for long-term planning. Some insurance plans may have specific criteria, such as periodic reevaluations or progress assessments, to determine the ongoing need for services. Review your policy to identify any such criteria and work closely with healthcare providers to meet these requirements and ensure continued coverage. At minimum, a reassessment and updated behavior plan to renew prior authorization for continued services must be completed every six months.

Advocating for Your Child Through Autism Care and Insurance Support

We hope you have a better understanding of the nuanced aspects of insurance for autism-related care, empowering you to make informed decisions and advocate for your family. We want to work with you to remain informed, keep open communication and champion the care your child deserves on their unique journey with autism. If this sounds like a match for you and your child, please reach out to us today so we can help your child reach their full potential and serve as a partner to assist in navigating insurance benefits and reimbursement.

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