Yes, ABA Therapy is Covered by Insurance in Arizona, But…

Arizona hosts approximately 1,000 Board Certified Behavior Analysts (BCBAs), a number that has doubled since 2021. This number only continues to grow as more children are diagnosed with autism spectrum disorder. According to the Arizona Developmental Disabilities Surveillance Program (ADDSP), it is estimated that about 1 in 36 children (around 2.7%) have autism. With a significant population of individuals diagnosed with autism, Arizona has seen a consistent rise in demand for applied behavior analysis (ABA) services. Thankfully, on both the federal and state levels, insurance companies have also been evolving with an increasing recognition of the benefits of ABA therapy. This shift has helped thousands of families with more comprehensive coverage options for families.

Understanding ABA Therapy

ABA therapy is often considered to be the “gold standard” for the treatment of autism spectrum disorder and other developmental disabilities, as well as different job fields, and work environments. It has evolved immensely since its early history in the 1960s and is now one of the most empirically-backed and utilized treatments for autism. ABA therapy along with physical therapy, occupational therapy, and speech therapy are among the most popular forms of treatment.

Insurance Coverage for ABA Therapy in the United States

Navigating the healthcare system and insurance companies in the United States is far from a simple task. It is about as complicated as a task can get, and there are hundreds of terms and rules that people are expected to know before seeking out services. There are federal rules, state rules, company policies, and individual package policies depending on which specific plan you choose.

The Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (MHPAEA) have been incredibly helpful, along with the general shift in states toward support of ABA sessions and behavioral health becoming more important for insurance companies to cover. Sadly, a lot of the rights and laws on the federal and state level are up to the individuals to educate themselves about to best advocate for themselves, since a lot of the times these rules are inconsistently implemented.

Arizona’s Legislation on ABA Therapy Coverage

In Arizona, the Arizona Autism Mandate, which also known as Steven’s Law, was enacted in 2008 and requires insurance companies to cover autism treatment. This requirement also includes the coverage of ABA therapy. It is important to remember though that even with this mandate, individual insurance companies can still have coverage caps, limitations, prior authorization requirements, and other obstacles that are usually put into place when it comes to healthcare coverage through insurance.

For example, by the mandate, the coverage for ABA therapy is typically only active until the age of 17. In addition, there is a cap on coverage depending on the child’s age ($50,000 for children under 9 years old, $25,000 for children over 9 years old). Arizona has also expanded Medicaid to include ABA therapy coverage, which is a huge step in the right direction for families who otherwise would not have access to ABA services due to financial hardship.

Types of Insurance Plans in Arizona Covering ABA Therapy

Is ABA therapy covered by insurance in Arizona?


Private insurance is a good option to look into for families who are looking for specific coverages or providers. They are able to compare a large number of policies and can choose which best works for them, depending on their desired outcome (e.g., lower deductibles, in-network providers they want, fewer limitations, etc). Private insurance plans are ideal for individuals who want to compare different companies and choose from a large number of plans to best fit their budget and lifestyle. The main drawback of private insurance providers is that they can be incredibly costly. Most insurance policies are costly, both private and others, but private insurance can easily cost families the most in comparison to the other options.

Employer-sponsored insurance options are great for families whose jobs offer them. The main benefit of these types of plans is that employers will pay for the entirety of or a large portion of the cost of the insurance policy. This can be incredibly cost-effective for families that cannot afford to foot the entire bill on their own.

One major drawback, however, is that it does not leave room for many options for families. They may get to choose from a few different available plans, but they do not get to choose beyond what one company offers. They don’t necessarily have a choice of which insurance provider they are assigned. Most companies have health insurance liaisons who serve as a great source of information about coverage for families.

As mentioned above, Medicaid also covers ABA therapy in Arizona. This is the most cost-efficient option, although there are requirements that families must meet to enroll in Medicaid. In addition, Medicaid recipients are also more likely to run into barriers, prior authorizations, caps, limits on coverage, and limitations on in-network providers.

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Which Insurance Providers Cover ABA Therapy in Arizona?

Here are some possible options for insurance providers that cover ABA therapy in Arizona:

ABA Therapy Coverage Requirements in Arizona

As mentioned, nearly all healthcare plans cover ABA services, with the exception of self-insured employer plans (which we’ll get to later). Coverage specifics, however, can vary widely among providers. For nearly all insurance providers, an autism diagnosis from a qualified medical professional is required prior to starting services. The provider should also provide the family with documentation of the medical necessity of services.

Each insurance company can provide families with a specific outline of what is required before being able to receive ABA services through their coverage policy. They can also give families more information about in-network providers, coverage limits, deductibles, out-of-pocket costs, age limits and coverage caps, and any other possible scenario that families may run into before starting services.

How to Obtain Prior Authorization for Coverage of ABA Therapy?

It is almost guaranteed that parents will need prior authorization before starting ABA therapy. The first and main step in gaining authorization is to talk to the child’s doctor. They will be able to start the process with a referral to a developmental specialist or other professional healthcare provider who will be able to assess and diagnose autism spectrum disorder. In addition, these professionals will provide the documentation for medical necessity, along with any other paperwork required to receive services. Finally, insurance companies may require a treatment plan that includes the goals of treatment before approving the authorization.

How to Determine Your Coverage

Thankfully, all official insurance providers are required to cover ABA services, so it is just a matter of figuring out what limitations or caps may be in place with the chosen insurance provider. It is important to note that self-insured employer plans are not covered by Steven’s Law and may not provide coverage for ABA services. These types of plans aren’t technically insurance companies, but they do provide health insurance benefits directly managed by the employer.

With these types of plans, the cost of your healthcare is paid directly by your employer, not through an insurance company. If you have one of these plans, it is necessary to talk to your employer to determine whether or not they cover the cost of ABA sessions. For families with more traditional insurance plans, they should look over their policies or call their providers directly to get more information on what to expect before starting services.

Challenges and Common Issues with Coverage

AZ-insurance


Figuring out insurance coverage for ABA therapy in Arizona presents challenges like coverage denials, caps on coverage, and a shortage of in-network providers. If an insurance company denies a claim, it’s usually because the therapy isn’t seen as necessary or the patient doesn’t meet the policy’s criteria. Families facing these obstacles need to review the denial letter, gather necessary documents and submit a formal appeal; if unsuccessful, they can request an external review according to Arizona law.

Insurance advocates can significantly ease this process. They guide families through policy and legal issues, prepare and file necessary documents, negotiate with insurance providers, and offer overall support. Families can find advocates through local autism support groups or referrals from healthcare professionals experienced with ABA therapy.

Additional Resources and Support in Arizona

Here are some organizations and resources available to individuals in Arizona who are seeking out ABA therapy:

Tips for Advocating for Better Coverage

Education is the most important and first step toward advocating for optimal coverage and care when it comes to ABA services. Families should take the time to understand the benefits of ABA therapy and explore the best options available to them. The resources mentioned earlier can certainly help to provide a solid foundation for advocacy, accessing grants, and discovering additional information. Trying to be active in policy regarding special needs rights is another powerful way to advocate.

This can feel like a lot for families that are especially busy and stressed, but there definitely are ways to participate that can fit into busy schedules. Actions such as voting, writing to politicians, and raising public awareness play critical roles in influencing change. Finally, stay talking! It’s always important to stay in communication with others to keep up-to-date on new things that may have an impact on the child’s care. Other families and services are a great source of information, and keeping in contact with insurance providers if there are any questions or concerns is important to making sure there aren’t any issues with coverage.

Conclusion

Thankfully, Arizona has made it much easier for families to receive ABA services through insurance providers. They may still go through concerns with out-of-pocket costs, finding providers that accept their insurance, waiting periods and more, but continually asking questions and pushing for support can help families immensely.

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