If you are the parent of a child with autism, then you know that ABA therapy is essential for their development. ABA therapy can help children learn important skills and improve their quality of life.
But what happens if you can't afford to pay for this therapy yourself? In this article, we will answer some common questions about insurance coverage for ABA therapy in Texas.
Give us a call if you want to work with the best ABA therapy provider in Houston.
Is ABA therapy covered by insurance in Texas?
Texas law requires most insurance companies to provide coverage for autism treatment.
However, insurance companies are not required to cover the full cost of treatment. There are loopholes which enable certain companies to opt out or reduce insurance coverage for ABA therapy as a child gets older.
It is important to speak with your company's human resources department to find out the details of the coverage your insurance offers for ABA therapy, and check if the plan is fully funded or self-funded.
If the plan is self-funded, ask if you have ABA therapy coverage. It is important to ask about information specifically on autism coverage; you might have to be in touch with the plan administrator and ask them about benefits for ABA therapy for children with autism.
Does Medicaid cover ABA therapy in Texas?
After a hard battle, Medicaid now covers ABA therapy for children with autism in Texas.
Beneficiaries must satisfy the conditions established in the Autism Services benefit description, and the treatment must be deemed medically required. Beneficiaries may obtain further information from their Medicaid insurance plan's benefits representative as it becomes available.
Are there any caps on insurance coverage for ABA therapy?
In Texas, a law passed in 2013 which eliminated the previous age limit on insurance coverage for autism treatment (it was previously 10 years old). Currently, there is no limit.
However, plans can restrict ABA therapy reimbursement to $36,000 per year for children over 10 years old. Furthermore, to be eligible for coverage, a child must be diagnosed before age 10.
Some insurance plans also attempt to reduce coverage for ABA therapy as children ages. Insurers have their own standards for approving benefits for ABA therapy and do not always adhere to clinical recommendations.
Even though there is no formal cap on coverage for plans until age 10, obtaining insurance authorization for intensive ABA therapy can be more difficult as children get older.
Exceptions from insurance coverage in Texas
State of Origin
Check with your insurance provider to find out where your health insurance plan is based.
Some businesses, particularly those that operate in multiple states, may provide their employees with an insurance plan from a different state. Requirements and laws on ABA therapy insurance coverage differ from state to state.
Some states have limits on the amount of coverage, age caps, and other rules that might affect your child's insurance.
Insurance plans are governed by the state law where the plan is issued, not the beneficiary's location. So even if you live in Texas, Texas laws may not apply to your insurance plan.
Realizing that your plan is administered out of state is easy when it’s named something like “XYZ Insurance of Illinois.” Others may not be as recognizable.
If your plan is issued outside of the state, contact your human resources department or insurance provider to learn about rules and regulations in that state regarding covered autism therapies. Make sure you inquire about any restrictions or exclusions in ABA therapy insurance coverage.
Fully funded or self-funded?
Be sure to check if your company’s insurance plan is self-funded or fully funded. The Texas law only applies to fully funded (large and small) plans, not self-funded ones.
Options for families without employer ABA coverage
Consider these alternatives for obtaining an individual ABA therapy insurance plan if your family doesn't have insurance through your employer:
Through the Affordable Care Act marketplace
In North Texas, there are two distinct insurance coverage plans accessible through the ACA (Affordable Care Act) marketplace. Some families may be eligible for tax credits for plans bought through the ACA marketplace, depending on their income.
Marketplace options are only accessible during open enrollment, which happens once a year (usually from November 15th to December 15th) or when a particular event occurs, such as a job loss or loss of insurance coverage from an employer. You can check out what plans are available on the marketplace by visiting healthcare.gov.
Individual plans can be purchased through a broker
There are also other kinds of individual insurance plans for ABA therapy available for children with autism. These alternatives may not be the same as those available through the Affordable Care Act insurance marketplace, and they do not qualify for the same tax credits.
There are brokers in the DFW area who are very experienced in finding insurance coverage for children with autism through ABA therapy.
How do I apply for ABA therapy?
To apply for ABA therapy, you will need to contact your insurance company and request an authorization for ABA therapy benefits. The insurance company will likely require a diagnosis and letter of medical necessity from a licensed psychologist or psychiatrist in order to process the authorization.
How can Hidden Talents help with ABA therapy?
Our focus is to help children grow and thrive by improving communication, social and adaptive skills. Hidden Talents ABA specializes in services for children from birth to age 12.
Our experienced team of BCBAs develops programs to fit each child’s specific needs. The dedication of our clinicians and our comprehensive, collaborative approach will allow our clients to truly shine and succeed.
