Navigating Healthcare Insurance Coverage for Autism and Other Developmental Disorders: Where to Start
If you’ve determined that your child or another family member would benefit from behavioral healthcare services to treat autism or a similar developmental disorder, an important next step is to explore and understand the benefits available to you from your healthcare insurance provider. But where should you start?
In California, healthcare insurance companies – and the health plans they offer – are regulated by the state and are required to provide coverage for behavioral health services, including coverage for treatment of conditions such as autism.
This means that if your child or other family member has healthcare insurance through a health plan in California, your insurance provider should help you cover the costs for appropriate and necessary treatment for autism and other similar conditions. That’s the good news. But benefits and coverage can vary, and even if your health plan covers treatment for autism, you still need to explore and understand the details of the specific coverage you have.
This is a short primer on insurance coverage for behavioral healthcare services. Consider these questions and issues either before you find a provider or after you’ve found a provider but before beginning treatment for your child. Understanding the ins and outs of insurance will help you make the most of your health insurance coverage.
Important Documents You May Need
Insurance plans usually will require the following documents:
- A diagnostic report from the licensed clinical psychologist who conducted the diagnostic testing process. This report follows the assessment of the child and states how and why the healthcare professional concluded that the child has autism or another disorder.
- A plan from a qualified autism treatment services provider specifying the proposed course of treatment for the child, including a statement saying the treatment is medically necessary.
- A prescription/referral from your pediatrician stating the diagnosis and the number of hours recommended for ABA therapy.
Issues Specific to Applied Behavior Analysis (ABA) Services for Autism
Some insurance companies have assessment and supervision requirements specific to ABA services for the treatment of autism. In other words, the insurance company sometimes requires that the assessment be conducted by a person with a specific type of license or credential, or that the clinician providing the therapy be supervised by a professional with a particular license or credential. Be aware that these issues may come up. Your healthcare provider can help you address them.
Your insurance company may specify:
- Who can perform the assessment
- How long can the assessment be
- When re-assessment is required
Your insurance company may specify:
- Who can provide supervision
- Whether it can be billed on the same day as direct ABA services
- How many hours are approved
- Whether supervision must be provided in the presence of the person receiving treatment
Although insurance can be challenging to navigate, the good news is the benefits under many health plans are robust, and there are resources to help you navigate the system.
For patients whose employers offer health plans not subject to California state mental health mandates (i.e. self-insured plans), the organization Autism Speaks offers more information. Learn more by visiting Autism Speaks.
With preparation and understanding, you’ll be able to make the most of your health plan’s coverage and any other resources, and your child should benefit from the treatment.
If you believe you believe someone in your family needs help to diagnose or treat autism or other similar condition, or if you need help to determine if costs for these services are covered by your healthcare insurance provider or other agency, please visit 360 Behavioral Health to schedule a complimentary 30-minute phone or in-person consultation.