Missing Piece Blog

State Insurance Mandates

Over the past 20 years, all U.S. states have adopted legislation that compels health insurance providers to cover treatments and services related to the care of autistic children. This encompasses a wide range of services, from physical and behavioral healthcare to various therapies like speech, occupational, and physical therapy, in addition to applied behavioral analysis (ABA) therapy. 

While these state mandates do have their exceptions, their primary objective has been to tackle the increasing rate of diagnoses of autism spectrum disorder (ASD). Classified as a neurologic and developmental disorder that starts in early childhood, ASD commonly requires up to 40 hours per week of educational interventions and substantial, continuous healthcare services throughout childhood and adolescence. This makes the need for health insurance paramount to parents and guardians of autistic children. 

ABA therapy insurance coverage

The question on everyone’s mind is, “Is ABA covered by insurance?” and the answer is a resounding yes… with certain criteria. In the United States, coverage for ABA therapy varies significantly across different insurance policies and state mandates. In recent years, there has been a positive shift toward recognizing the importance of ABA therapy in the treatment of ASD, leading to an increase in states mandating private insurance coverage for autism services, including, but not limited to, ABA therapy. 

ABA therapy billing codes have been developed to facilitate billing and insurance claims for ABA therapy. These codes are critical for healthcare providers and insurance companies in the identification, processing, and reimbursement of ABA therapy services. However, parents and guardians should be diligent in understanding their specific insurance plan’s coverage details, as there may be variations in coverage limits, co-pays, and deductibles depending on the state and the insurance provider.

Autism benefits by state

In the United States, each state enacts specific health insurance mandates to ensure coverage for ASD diagnostics, screenings, and treatments, with specific variations across states. For the most part, these mandates encompass a wide range of treatments – as determined by medical necessity and recommended by a licensed physician or therapist. Typically covered services may include behavioral interventions, pharmaceutical management, psychiatric support, psychological counseling, and varied therapeutic care, with the last point inclusive of services by licensed speech therapists or ABA practitioners.

In terms of eligibility age, mandated funding options for autistic children vary significantly from state to state. For instance, Maine provides funding options for children up to 5 years old, whereas Delaware, Illinois, and Iowa extend coverage up to 21 years of age. Each state’s specific mandates reflect a tailored approach to providing care across different stages of an individual’s development.

Furthermore, the financial provisions allocated for ASD care differ considerably, offering monthly, yearly, and/or lifetime budgets. Some states adopt a more generous allocation in the early developmental years, which gradually decreases as the child ages. For example, Florida, Illinois, and Iowa allocate an annual budget of $36,000 for ASD care. Michigan adopts a tiered budget system, providing $50,000 annually for children up to 6 years old, $40,000 for those aged 7 to 12, and $30,000 for teenagers aged 13 to 18. Meanwhile, Kentucky sets its coverage limits at $50,000 annually for children from 1 to 7 years old, and transitions to a monthly cap of $1,000 for individuals aged 7 through 21. Thankfully, most states do not restrict the number of visits to autism service providers.

Discover more about autism and insurance with Missing Piece

Navigating the complexities of ABA insurance coverage can often feel overwhelming. Allow Missing Piece to streamline your revenue cycle management, empowering you to concentrate fully on patient care. 

We provide bespoke solutions uniquely designed for your organization. With over a decade of expertise in serving ABA providers by providing comprehensive billing services, Missing Piece is your partner in ensuring smooth and efficient reimbursement processes. Our turnkey billing solutions grant you access to unparalleled payer and billing knowledge for optimal reimbursement. 
Missing Piece adapts to your practice’s evolving needs, removing the future hassle of changing providers as your billing requirements evolve.

Contact us to discover how we can transform ABA therapy billing for your practice.