Parents are frequently asking: how do I find ABA therapy that accepts Medicaid near me? At Blue ABA, we have you covered:
- What is Medicaid?
- How Does Medicaid Work?
- How to Apply for Medicaid
- Medicaid Benefits For Autism Therapy
- Medicaid Limitations
- Tips For Utilizing Medicaid Coverage For ABA Therapy
- Medicaid FAQs
- Additional Medicaid Resources
- Final Thoughts
What is Medicaid?
Medicaid is a healthcare program funded jointly by the federal and state governments. It provides healthcare coverage to millions of people across the United States. Medicaid is available for low-income families, individuals with disabilities, and individuals 65 years of age and older.
How Does Medicaid Work?
Medicaid was created in 1965 as a public insurance program. The federal government sets guidelines for Medicaid. Each state then has the flexibility to create its own programs, using the guidelines set forth by the federal government. Because of this flexibility, eligibility and benefits vary from state to state.
The federal government requires the state’s Medicaid programs to include coverage for the following populations, at minimum:
● Children under the age of 18, in families with income under 138% of the federal poverty line
● People who are pregnant and have an income under 138% of the poverty line
● Certain parents or caretakers with low income
● Most seniors and people with disabilities who receive cash assistance through the Supplemental Security Income (SSI) program.
Individual states include coverage for additional populations, such as children under 18 in families with income above 138% of the poverty line.
States have flexibility in what benefits to cover for Medicaid recipients. However, the federal minimum requirements include hospital and physician care, laboratory and x-rays, home health services, and nursing facility services for adults. Additionally, comprehensive services are required for children. This is known as the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. The EPSDT benefit provides Medicaid recipients with comprehensive screenings and preventative care, as well as medically necessary treatment for any medical, dental, mental health, or developmental conditions identified during screenings. The EPSDT allows children to access ABA and other services for autism spectrum disorder (ASD).
How to Apply for Medicaid
There are a few ways to apply for Medicaid. You can apply via the health insurance marketplace. Or if you prefer, you may reach out to your local Medicaid agency. Before you apply, gather information regarding all members of your household. This includes social security numbers, dates of birth, income information, etc. You may need to provide supporting documentation as well, such as proof of income.
Medicaid Benefits For Autism Therapy
Thanks to the EPSDT, autism therapies are a covered benefit under federal guidelines. This includes applied behavior analysis (ABA), speech, occupational therapy (OT), and more. As of 2022, all 50 states are required to provide funding for ABA and other autism-related treatments to children with autism. Treatments that are deemed medically necessary to treat the associated symptoms of autism (i.e. communication deficits) are authorized under Medicaid guidelines.
While Medicaid provides medically necessary treatment for millions of individuals, there are some limitations to be aware of. For one, there are age caps on certain treatments. Many services guaranteed for children with autism are no longer covered past 21 years of age. Adult coverage for autism treatment is lacking. Additionally, each state has different service coverage and may set limitations regarding the type of clinicians who may provide services. This leads to another limitation including the availability of providers. Not all providers accept Medicaid. Those who do accept Medicaid may be more likely to have waitlists for services.
Tips For Utilizing Medicaid Coverage For ABA Therapy
- Even if you have private health insurance or have income above the federal Medicaid threshold, you may be able to obtain Medicaid coverage for your child with autism or other developmental delays. Check the individual requirements for your state. If your child is approved for Medicaid benefits, their ABA provider may be able to bill Medicaid as secondary insurance. Medicaid may then cover the leftover costs after your primary insurance company is billed.
- When using Medicaid for ABA therapy, it is important to stay on top of any requirements for re-authorization. You may need to complete steps for annual renewal. When you receive communication from your local Medicaid office, be sure to return communication before the deadline. A lag in coverage may affect your child’s ability to receive continued care.
How much does ABA therapy cost if I have Medicaid Insurance Coverage?
ABA therapy is generally covered at 100% with Medicaid coverage. Therefore, there should not be any out-of-pocket costs for Medicaid recipients. However, Medicaid will only provide what is deemed medically necessary. If you choose for your child to receive more hours than recommended and approved, there may be out-of-pocket costs associated with the hours that were not approved.
What do I have to pay out of pocket for ABA services?
While ABA therapy can get quite expensive, you should not have any out-of-pocket costs in most circumstances when using Medicaid benefits. It is always best to double-check with your therapy provider before initiating services though.
How many hours will we be approved for?
The number of hours approved is individualized based on the needs of your child. Medicaid typically authorizes between 10 and 40 hours of ABA therapy per week. Your child’s board-certified behavior analyst (BCBA) will first conduct an assessment to determine the child’s strengths and needs and identify goals. Based on this information, the BCBA will recommend a specified number of weekly hours. They are then responsible for submitting a request to Medicaid for the recommended number of hours. Medicaid has the ability to return the request and suggest a different number of hours. However, your BCBA will advocate for the number of hours that are in the best interest of your child.
How do I apply for the Medicaid waiver?
A Medicaid waiver allows the federal government to waive rules that typically apply to the Medicaid program. This allows individual states to expand coverage and improve care for certain populations. For families of children with autism, this includes services and supports such as respite care, communication devices, daily living skills training, and much more.
In order to apply for a Medicaid waiver, first, check what waivers are available based on your state of residence. Each state has different policies and benefits. Kidswaivers.org provides resources regarding what types of waivers are available in each state and how to apply.
Additional Medicaid Resources
Autism Speaks and The Autism Legal Resouce Center provide a free ABA Through Medicaid Toolkit. It provides a detailed overview of the legal ramifications of the EPSDT and what you can do to advocate for your child to ensure they are accessing medically necessary treatment if they qualify for Medicaid services.
Some families experience challenges accessing medically necessary services such as ABA for their child with autism. If you experience any barriers, reach out to an autism advocate. The National Autism Law Center is one foundation that provides advocacy resources related to autism treatment laws.
Medicaid is a highly beneficial program for millions of Americans, including those with autism and other developmental, medical, and mental health challenges. If your child has an autism diagnosis, it is worth exploring if Medicaid is an option for your family. Even if your income is above the Medicaid income limits, your child may still qualify, depending on your state’s guidelines. Check with your local Medicaid agency today to see if your child may qualify.