If you suspect that your baby or child has autism spectrum disorder (ASD), you will probably be eager to seek whatever resources you can as soon as possible. As you have probably read, ASD cannot be cured, but it can be treated.
Applied Behavior Analysis (ABA) is considered by most to be the “gold standard” of care when it comes to children with ASD. The Centers for Disease Control (CDC) describes ABA as being a “notable treatment approach” that is “widely accepted among healthcare professionals.”
However, ABA is time-intensive and, because of this fact, not cheap. In this article, we will guide you through the process of getting an initial diagnosis of ASD and whether or not ABA therapy is covered by insurance.
Getting the Diagnosis
Before calling insurance companies and looking through plan information, you first need a diagnosis. A diagnosis is essential for two reasons:
- Your child may not actually have ASD. Symptoms of autism vary with each child (which is why the word spectrum is used), and many indicators overlap with other learning disorders.
- ABA therapy is not inexpensive. It involves hours of weekly therapy with technicians who are overseen by Board Certified Behavioral Analysts (BCBAs). Your health insurance will likely cover the costs, or most of the costs (more on that below), but it will require a medical diagnosis first.
Because ASD is difficult to diagnose, your doctor will need input from you to support what is noted in checkups. All details are helpful, but one useful starting point is the Modified Checklist for Autism in Toddlers (M-CHAT). This is a 20 question online screening for parents to complete that calculates a risk score and a pdf that can be printed out and given to your pediatrician.
The American Academy of Pediatrics (AAP) recommends developmental and behavioral screening for all babies at the following checkups:
- 9 months
- 18 months
- 30 months
Because ASD is so prevalent in the United States, occurring in 1 out of every 59 children, the AAP recommends specific screening for autism at 18 and 24 months. By the age of 24 months, an autism diagnosis is believed to be reliable but is not the final word.
You do not have to wait until your child is due for one of these milestone checkups to bring your concerns to your pediatrician, however. Some children are at high risk for ASD; also, your concerns and observations will be considered whenever you present them.
If the pediatrician’s screening tool indicates an area of concern, you will be referred to a specialist to perform a more formal developmental evaluation. For more details about how to properly diagnose autism, please read our comprehensive blog, Recognizing Autism.
What’s next?
When you first contact GBC Autism Services, we will begin a thorough intake process with the following steps:
- Insurance Benefits Coordination
- Intake Questionnaire Phone Call
- Assessment
- Kick-off Meeting
- Authorization for Services
- Therapy Sessions
The first step is one that you may have concerns about; however, health insurance companies in all 50 states have mandates requiring some level of coverage for the treatment of autism, but each state and insurance company has slightly different requirements.
What Does Insurance Cover?
Health insurance is a stressor for a lot of people, but especially for families that are already dealing with a recent diagnosis of ASD. The truth is that what treatment and how much is covered by health insurance depends entirely on what state you’re in and what plan you have. However, ABA is considered a “medical necessity” and is, therefore, largely covered by health insurance
For example, the state of Illinois requires all individual and group accident and health insurance to provide coverage for the diagnosis and treatment of ASD for individuals less than 21 years of age.
This seems pretty cut and dry, however, there is a loophole. These state law provisions only apply if you have a fully insured plan. If you have self-funded health insurance (one that is funded and run by your employer), it only has to comply with federal laws, not state laws.
Self-funded insurance depends on the employer to determine what services are covered or not. If you are not sure which type of insurance you have, Autism Speaks has an interactive tool to help you determine what will be covered by your insurance.
The good news is that you don’t have to go through this process and figure it out on your own. Our first step in your child’s treatment is to help you coordinate the insurance side so that you can stress a little less and focus on your child’s treatment instead.
At GBC Autism Services we provide individualized care and treatments for children with Autism Spectrum Disorder based on the principles of Applied Behavior Analysis (ABA). Our mission is to help transform the lives of children with autism and their families by utilizing research-proven techniques to help them reach their goals and lead fulfilling lives.
If you’re looking to change insurance plans to improve coverage for your child’s ABA therapy, open enrollment season is right around the corner. Check out your options in the Health Insurance Marketplace to ensure you are getting the best possible coverage.
You can find more information about our services and ABA Therapy here. Start with a free no-obligation phone consultation.
