Who is eligible?
A person must have a diagnosis of autism.
How does someone access coverage?
A clinician (usually a developmental pediatrician, neurologist, psychologist), recommends ABA. The family then locates an ABA provider through their primary insurance (commercial or MassHealth plan). Contact your health plan to obtain a list of in-network ABA providers.
How do I know what benefits are available in my health plan?
Ask your insurance provider or employer’s Human Resources representative for help. Obtain a copy of your health plan statement of benefits, which gives details on your plan’s specific benefits. Employees with self-funded plans can obtain a “Summary Plan Description” (usually by written request). Coverage is subject to an insurer’s specific “medical necessity” criteria.
Questions to ask include:
- What documents are required to demonstrate an autism diagnosis?
- How does my policy define autism and the services provided?
- What treatments are covered?
- What types of providers are covered by my policy?
- What are my out-of-pocket expenses for each visit?
- Are there visit limits or dollar caps in my policy?
- What are my total out-of-pocket expenses and deductible per calendar year?
- Are my child’s current providers considered “in-network”?
- What is the process for appealing a denial?
How long will it take get started with ABA services?
This depends on how long it takes to locate a provider with availability and the time it takes that provider to complete an initial evaluation and receive authorization from your insurer for the proposed treatment plan. Families should ask each provider they are thinking of using for an estimate of how long it might take to start services. It is reasonable to expect a provider to start therapy within 30 days of treatment plan approval.
Are Social Skills Groups covered?
Yes, subject to medical necessity criteria. If your health plan includes ABA coverage, it also includes Social Skills Group coverage.
My child receives ABA through Early Intervention (EI) – can they also access ABA through insurance?
Children receiving In-Home Behavioral Services or services similar to ABA in Early Intervention (EI) are eligible for ABA services covered by insurance if those services are judged to be medically necessary and do not duplicate services they are receiving through EI.
My child receives ABA through Early Intervention (EI) – what happens when they turn 3?
If your child is receiving ABA in EI, your commercial health plan or MassHealth will cover ABA after they turn 3, if they meet medical necessity criteria. We recommend that you start working with your team as early as possible to identify an ABA provider that is in-network for your insurance. This will help to avoid or minimize a gap in service delivery at the time your child turns 3.
Given the frequency of ABA sessions, I am concerned about affording the co-pays.
The transition from Early Intervention to insurance often results in an increase in your out-of-pocket costs due to co-pays. Your ABA provider will bill you for co-pays (and the deductible, if it has not been met for the plan year). Many families explore the option of applying for MassHealth CommonHealth as secondary health insurance. MassHealth CommonHealth will pay many of your primary insurance co-pays and your deductible.
I have private insurance, but it doesn’t cover ABA. Can I get ABA through MassHealth?
Yes, as long as your child is also enrolled in MassHealth (CommonHealth or Standard). Information about CommonHealth and how to enroll can be accessed by contacting the Center. Note: MassHealth CommonHealth is not a free health plan. Your child’s autism diagnosis establishes eligibility, but your family’s income determines the monthly premium. The monthly CommonHealth premium is based on a sliding scale, using the Federal Poverty Limit as a baseline. The less you earn, the lower the premium. The more you earn, the higher the premium. There is no cap on a CommonHealth premium.
I have private insurance and CommonHealth. Will MassHealth cover my deductible and co-pays for ABA?
MassHealth will cover the costs for ABA, but the claims must be submitted by the provider to the Mass Behavioral Health Partnership (MBHP). Providers who are not in-network with MBHP will need to obtain a single case agreement or out-of-network agreement in order for co-payments to be paid. We recommend checking with your provider to confirm that they are in-network with MBHP and contacting us if you need additional assistance.
What could cause my insurance to deny ABA coverage for my child?
Reasons for a denial typically fall into two categories:
- Your coverage is through a “self-funded” plan that allows the employer to decide what benefits to offer (subject to federal requirement), and ABA services are not a covered benefit under your plan.
- ABA services are covered under your plan, but clinical issues related to the medical necessity requirements are not being met or the ABA provider submitting the claim is not an approved provider.
Insurers are required to have an appeals process, which you should pursue if you believe the denial was issued in error or you do not agree with the decision. View the Denials and Appeals FAQs.
How are education services under my child’s IEP affected?
ABA services accessed through medical insurance should in no way limit the educational services that your child is entitled to receive through his or her IEP.