The number one question we receive from most parents is, “Will my insurance pay for or reimburse the cost of ABA services?” We want to offer some general guidance to help you make informed decisions when you are exploring your options for insurance coverage and ABA services.
Currently, in the state of Texas there is a mandate that insurance must provide ABA coverage for children that received a diagnosis of autism from a medical provider before the age of 10. However, the state mandate only applies to insurance plans that are fully-funded. With a quick phone call to member services, you can find out if you have a self-funded or fully-funded plan. For those who find out that their plan is self-funded, do not be discouraged by the news, there are other options!
The Affordable Care Act, otherwise referred to as the Health Insurance Mandate, released individual and family private insurance plans in 2013 that were fully-funded. This is great news for families who have self-funded plans without ABA benefits, and benefit exclusions for autism services. Parents now have the choice to purchase individual plans for their children that has coverage for ABA services. As listed on the Marketplace website (https://www.healthcare.gov), open enrollment to purchase a plan begins on November 1, 2018 and runs through December 15, 2019. All plans have an effective date of January 1st, 2019.
Based on Texas mandate, if you purchase a plan through the affordable care act, that plan is required to offer ABA benefits. There are however important questions you should ask to ensure that you are selecting the plan that is best for you.
- Is this a copay or coinsurance plan?
- Copay plans result in a flat rate per day, or per service code depending on the insurance company.
- Coinsurance plans result in the client being responsible for a percentage of the cost of services provided. This percentage may vary per plan. Additionally, the patient responsibility may decrease once deductibles are met.
- Do I have out-of-network benefits?
- It is important to know if your current or potential service provider is an in-network or out-of-network provider. If your insurance company does not cover out-of-network benefits, you may be responsible for the full cost of services.
- What is my out-of-pocket max?
- Generally, an out-of-pocket max is the maximum amount an insurance will require a client to pay out of pocket before the plan covers services at 100%. For example, if your plan has an out-of-pocket max of $2,000, once you have paid $2,000 in patient responsibility (copay or coinsurance), your may no longer be responsible for any copays or coinsurance.
- Are there any plan restrictions?
- While plans through the marketplace must follow the state mandate, some employer plans that are self-insured have plan restrictions such as a set dollar cap amount for services (i.e. ABA services may be covered up to $36,000 per year). There may also be restrictions in the number of visits (i.e. ABA services may be covered up to 10 visits per year), or the type of service provider (i.e. the service codes are covered if billed by a Psychologist).
We have included links that discuss the ABA mandate under SB 1484, HB 451, and HB 1919 for the State of Texas.
Additional resources:
- www.healthcare.gov
- http://www.tdi.texas.gov/bulletins/2007/cc51.html
- http://www.legis.state.tx.us/tlodocs/81R/billtext/html/HB00451F.HTM
- http://www.capitol.state.tx.us/tlodocs/83R/billtext/pdf/SB01484F.pdf
Disclaimer: Spectacular Kids ABA Therapy, it’s employees, and representatives are not affiliated with, nor do we represent the Healthcare Market Place or Affordable Care Act. These are tips that we have used to help families obtain access to insurance coverage for ABA services for their children from our experience.
