Applied Behavior Analysis (ABA) is one of the frequently prescribed therapies for people with autism. Private insurance began covering ABA therapy in 2011, under a Massachusetts law known as ARICA. Following passage of the Autism Omnibus Bill in 2014, MassHealth began covering ABA in 2015.
Frequently Asked Questions
Who is eligible?
Children under age 21 who are diagnosed with autism can obtain ABA services through MassHealth Standard and CommonHealth; ABA benefits for children enrolled in MassHealth Family Assistance are available until the child turns 19.
How does someone access coverage?
The child’s doctor (usually a developmental pediatrician, neurologist, psychologist) recommends ABA for a child that has been diagnosed with autism. The family then locates an ABA provider through their MassHealth Plan. Depending on your specific MassHealth plan, ABA may be covered by one of three provider networks: Mass Behavioral Health Partnership (MBHP), Beacon Health Options, or TuftsHealthTogether. To find out which network you should be accessing ABA through, we recommend contacting your Plan or MassHealth Customer Service or reviewing the list on the last page of this sheet.
Once you’ve initiated a request for ABA services, the provider will seek authorization from MassHealth, perform an initial evaluation, and develop a treatment plan.
How long will this process take?
This depends on how long it takes to locate a provider with availability and how long it takes them to complete the initial evaluation and receive authorization for the treatment plan. Families should ask specific providers they are thinking of using for an estimate of how long it will take to start services. For more information on finding a provider, see our Fact Sheet “Finding an ABA Provider.”
Are there limitations on coverage?
Coverage is based on the plan’s “medical necessity” criteria. There are no annual or lifetime dollar or unit of service limitations on coverage.
Are Social Skills Groups covered?
Yes, subject to “medical necessity” criteria.
My child receives ABA through Early Intervention (EI) – will MassHealth also pay for ABA services?
Children receiving In-Home Behavioral Services or services similar to ABA in Early Intervention (EI) are eligible for coverage under MassHealth if the services are deemed 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, MassHealth will cover ABA after they turn 3 – again, subject to the medical necessity criteria. We recommend you start working with your team as early as possible to avoid or minimize a gap in service delivery at the time your child turns 3.
I have private insurance, but it doesn’t cover ABA. Can I get ABA for my child through MassHealth?
Yes, as long as your child is also enrolled in MassHealth (CommonHealth or Standard). For information about CommonHealth and how to enroll, we encourage you to contact our Center. You can find our Mass Health CommonHealth Fact Sheet on the Center’s website.
I have private insurance and CommonHealth. Will MassHealth cover my co-pays for ABA?
MassHealth may cover the co-pays for ABA, but the claims must be submitted by the primary insurer (i.e., the private insurance company). MassHealth will cover co-payments that are not being paid by the primary insurer, even if that provider is not in network with MBHP. However, providers who are not in network with MBHP will need to obtain a single-case or out-of-network agreement in order for co-payments to be paid. We recommend checking with your provider. Contact us if you need additional assistance.
How are educational 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. Read the DESE Memo.
Can I also apply for the Children’s Autism Medicaid Waiver?
Families covered by MassHealth with children under age 9 can also apply for the Massachusetts Children’s Autism Medicaid Waiver through DDS. Children receiving services through the Autism Medicaid Waiver may also receive ABA through MassHealth, as long as the ABA doesn’t duplicate services being obtained through the waiver.
I am an ABA therapist and want to provide services through MassHealth. What should I do?
Providers should contact the Managed Care Entities (MCEs) who are administering the ABA benefit through MassHealth: MBHP, Beacon Health Options, and Tufts Health Public Plans. For more information or assistance, please contact our Center.
How do I find out which Behavioral Health Plan to contact?
Review the attached list of MassHealth Plans. Once you locate your plan in the first column of the table, you will see the plan’s Behavioral Health phone number in the third column. You can also contact the number on your MassHealth card and ask for the phone number for your Behavioral Health Provider.