There are many services that can be beneficial for you to explore for your autistic child, including speech therapy, occupational therapy, and applied behavior analysis (ABA), and consulting with your child’s primary care physician or school team for recommendations on services is an important step. ABA therapy is a frequently recommended service that incorporates positive approaches to teach functional skills, decrease non-functional skills, and help individuals become more independent and successful in home, school, and community settings. ABA programs generally focus on increasing language and communication skills, social and play skills, learner readiness skills, and self-care skills.
If you decide to pursue ABA services for your child, you can consider obtaining services through your medical insurance. This can be a daunting endeavor, especially if you are not familiar with the process. There are several areas that you will want to familiarize yourself with as you look to secure ABA services for your loved one within the medical model. This includes navigating access to care issues, selecting a provider aligned with your values and best practices in the field, and understanding the nuances of insurance authorization approval.
Access to Care
While Medicaid eligibility requirements vary by state, commercial insurance requires a diagnosis of autism spectrum disorder (ASD) for ABA therapy to be covered. If your child does not have a formal diagnosis of ASD, that will be the starting point to access needed care. You will want to start by discussing any concerns with your primary care doctor or pediatrician. They can sometimes provide initial screenings or refer you and your loved one to a specialist, such as a developmental pediatrician, child psychologist, or neurologist, who can conduct comprehensive testing for ASD. Often, caregivers must endure long waitlists to secure a diagnostic testing appointment, which is a barrier to accessing care. Caregivers should look to explore multiple avenues to secure a diagnostic evaluation appointment. Contacting local autism clinics or centers that specialize in developmental disorders may also provide diagnostic testing. It is important to stay in communication with healthcare providers to inquire about waitlist updates and availability.
Waiting for diagnostic testing and the final report is just one of many access to care issues. While obtaining an ASD diagnosis is a necessary step, the diagnosis alone does not necessarily guarantee access to services. It is important to be educated on the specific coverage associated with your insurance plan. You will need to review your health insurance policy to ensure that you understand the benefits available for ASD related services, if your plan has them at all. Many self-funded insurance plans are not required to comply with state mandates to cover ABA services since they are regulated at the federal level. You may need to consider obtaining secondary insurance for your child to bridge any coverage gaps found within your primary insurance. You will also need to familiarize yourself with deductibles, copayments, coinsurance, maximum out-of-pocket limits, and coverage criteria for specific treatments. It is also important to stay up to date regarding changes in your insurance coverage because you will ultimately be financially liable for services provided that are not covered due to insurance changes or lapses.
Finding an ABA Provider
Once your child has an ASD diagnosis and you have confirmed your insurance benefits cover ABA therapy, the next step is finding an ABA provider. You will first want to confirm that your insurance is accepted by the provider and that you are aware of any responsibility for out-of-pocket costs. If a provider accepts your insurance, completing intake paperwork and starting the process to initiate therapy is something you should work quickly to do, as many providers, unfortunately, have waitlists for assessments that extend several weeks or even months out. You can complete the intake process with as many providers as you would like but will only be able to move forward with the assessment process with one provider.
Just because a provider accepts your insurance and adds your child to their waitlist does not mean their approach and philosophy to care is appropriate for your child and aligns with your values and goals. ABA providers are not created equal, and there is not a one-size fits all approach when it comes to treatment. Programming and teaching approaches should be individualized to your child and include the use of evidence-based treatment that is overseen by a Board Certified Behavior Analyst (BCBA). Quality care providers focus on child-centered approaches and trauma-informed care, and compassion and relationship building are the foundation of their model. Quality care providers also incorporate your input at each step of the process to ensure your perspective and priorities remain at the forefront of treatment, collaborate with other service providers to ensure care is coordinated and consistent across all aspects of your child’s environment, and make data-driven decisions to treatment to ensure programs are consistently reviewed and updated.
Authorization Approval
ABA therapy covered through insurance is considered a medically necessary treatment. For your child to receive medically necessary ABA services, several criteria need to be met. For example, there must be documentation of severe challenging behavior and/or communication and social interaction issues related to characteristics of ASD. Furthermore, the challenges documented would need to present a health or safety risk to self or others or present a significant functional interference within the home and/or community. It also would need to be demonstrated that behaviors are developmentally inappropriate and pose a significant obstacle to the individual’s performance of developmentally appropriate daily functioning.
Once medical necessity is determined through an assessment, it will be the provider’s responsibility to develop goals and interventions that address symptoms of ASD, including but not limited to: deficits in social-emotional reciprocity, difficulties with transitions, insistence on sameness, deficits in verbal and non-verbal communication skills, fixated interests, deficits in flexibility and routine, and restricted and/or repetitive patterns of behavior, interests, or activities. While specific skills can be targeted in ABA therapy, goals need to be aligned with the symptoms of ASD. Your child may struggle with tying his shoes, but not being able to tie your shoes does not meet medical necessity criteria. Instead, a goal to reduce your child’s insistence of sameness and flexibility with novel stimuli should be developed in which he learns to wear a variety of types of shoes with different fasteners, laces, zippers, toe coverings, etc.
Successful authorization approval requires a clinical recommendation of service hours aligned with general standards of care within typical dosage guidelines (i.e., number of weekly hours for direct therapy, program supervision, and parent training), daily maximum hours usage (i.e., number of daily hours covered for each service), and covered locations (i.e., home, clinic, or school, though many insurance plans do not cover services rendered at school locations). Authorizations also require key components such as assessment data, progress on goals, titration and discharge criteria, and an estimated service duration.
As you can see, there is much to be done and learned on the front end to secure ABA therapy through insurance. Educating yourself and understanding that many barriers can arise throughout the process is important to successfully navigate the healthcare service model. Above all else, do not let the process deter you from seeking out these services if you believe they are the best fit for your child.
Brandon Sierchio, MA, BCBA, is Director of Quality and Training, Kristen Daneker, MS, BCBA, is VP of Clinical Services, and Howard Savin, PhD, is Clinical Advisor at First Children Services.
