ABA Therapy Coverage by Insurance in Texas (In Plain Language)

According to the Behavior Analyst Certification Board website, there are nearly 4000 BCBAs that are certified in the state of Texas as of May 2024. This number has continued to rise as the need for applied behavior analysis (ABA) services has continued to grow. Texas has one of the largest populations of autistic adults in the United States (around 449,000 in 2017, according to the CDC), and that number can only be assumed to be much greater if you were to include the number of children with autism spectrum disorder. It’s no wonder that ABA services are growing! Thankfully as the need for and evidence for the effectiveness of ABA has increased over the years, insurance companies have become more accepting of ABA coverage and have been making ABA services more available to individuals.

Understanding ABA Therapy

ABA therapy, in a nutshell, uses behavioral principles to help teach, support, and uplift individuals with autism and other developmental disabilities. It is backed by decades of research and is becoming increasingly available to families across the state of Texas. ABA for the treatment of autism spectrum disorders is especially important when you consider that over 13% of students who receive special education services are autistic.

Insurance Coverage for ABA Therapy in the United States

Insurance navigation can be… a lot. There are about a thousand things for individuals to remember and juggle when it comes to their own insurance coverage, and it can feel like there are way too many parties involved. Insurance coverage for ABA therapy, for example, is influenced by both federal laws and specific state-level regulations, on top of company-specific rules. Mandates like the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (MHPAEA) have definitely made the process much easier for mental and behavioral health services, including ABA therapy. Implementation of these laws and mandates can be very inconsistent depending on where someone is, so the burden of navigation often comes down to the person or family seeking out services.

While federal statutes usually cover general or overall items when it comes to insurance coverage, the finer details are usually laid out by the state or by the companies. Texas has made it so that ABA coverage is required by most insurance companies, although there are certainly loopholes that insurance companies have found so that they do not have to cover the entire cost of services. The level of coverage offered by insurance plans can differ greatly, and is usually dictated by the individual company.

Texas’s Legislation on ABA Therapy Coverage

The battle for getting ABA therapy covered in the state of Texas has been long and arduous. While many significant strides have been made, there is often constant pushback and loopholes at the expense of individuals who want the best possible care for their loved ones. In 2007, HB 1919 helped to significantly expand coverage for autism spectrum disorder within the state of Texas. It helped to establish coverage for children ages 2 to 6. This bill went through some changes and eventually paved the way for SB 1484 in 2013, which removed the age cap, with the condition that they were diagnosed with autism by 10 years of age. Sadly, this bill also sets a cap on benefits for individuals older than 10 years old, limiting to $36,000 per year. While these bills were a step in the right direction, there are some limitations that families must know about and consider before being able to have ABA sessions covered.

As of February of 2022, ABA therapy is covered by those enrolled in Medicaid in Texas. It is a fairly recent change that has its own set of rules and regulations, so families should seek out resources to aid them in navigating Medicaid. They should also more than likely expect some possible hiccups in the process.

Types of Insurance Plans in Texas Covering ABA Therapy

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Private insurance companies can be a good option for people who have specific wants or needs when it comes to their coverage. With private insurance, families have the ability to shop around and see which companies offer the best and most coverage for ABA services. Families should be sure to ask about deductibles, out-of-pocket costs, limits, pre-authorizations, what providers are in-network, and any other possible barriers to receiving services before signing up for any insurance plans. It may be a good idea to create a list of possible private insurance companies, along with their pros and cons so that they can easily compare providers. Employers may also offer insurance to employees, which is a good option if covering 100% of the cost of private insurance isn’t possible. Again, it is important to ask about possible costs and obstacles to receiving services. Thankfully, many employers have a health insurance liaison at the company that can answer any questions a person may have about their coverage. Calling the healthcare provider directly is also possible if the liaison is not able to answer specific questions.

As mentioned above, Medicaid now covers ABA therapy in Texas, although this type of coverage can be complicated. It is fairly new and there are many Medicaid recipients waiting to start services. There are a fair amount of limitations and requirements when it comes to Medicaid. Recipients usually have to deal with limited provider networks, prior authorization requirements, caps, and other obstacles before they can start receiving services. Not to mention, as a newly covered service, it may take time before the individual companies start accepting Medicaid. Families who are enrolled in Medicaid and want ABA services should definitely prepare by talking to their providers, gaining as much knowledge as they can, and preparing to advocate assertively.

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Which Insurance Providers Cover ABA Therapy in Texas?

Here is a list of some insurance providers that cover ABA in Texas. This list is not exhaustive, but it may be a great place to start the search:

ABA Therapy Coverage Requirements in Texas

Insurance coverage in Texas can vary incredibly from provider to provider. For nearly all plans, an autism diagnosis is required. This can be done by bringing the child to a qualified medical professional, which typically starts by getting a referral from their primary care provider. They may need to document medical necessity of services. Parents should also consider that some providers, like Medicare, may require a diagnosis before a certain age. More than likely, any insurance company will require prior authorization before starting services and require documentation stating a diagnosis, need for services, specific goals, and objectives for treatment.

There also may be caps, coverage limits, age limits, provider networks, out-of-pocket costs, and other possible barriers to services. These are all provider-dependent, and so families should take extra care while searching though possible providers.

How to Obtain Prior Authorization for Coverage of ABA Therapy?

Prior authorization is the insurance provider’s way of making sure that therapy is necessary before starting to pay for sessions. For the more specific requirements about prior authorization, families should contact the providers directly for more information. More than likely, the providers will want the information mentioned above (documentation of need for services, autism diagnosis, treatment goals, etc.). The most important step to take for prior authorization is to make an appointment with the child’s PCP and address the need for an autism assessment. The PCP will then more than likely refer the family to a specialist, where an assessment can be done and a diagnosis may occur. Once all of the documentation is gathered and assessments are done, an authorization request can be made. This request may be approved or denied, and families have the right to appeal a denial.

How to Determine Your Coverage

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As always, the first step to determining coverage is to talk directly to the coverage providers. The insurance companies themselves will always be the best possible source of information regarding their own coverage plans. They will be able to all parts of their own policies. Families are provided with copies of their own policies to read, but talking to the providers about parts they are unsure of will be the best possible route to understanding what is written. In addition, families may want to familiarize themselves with some terms related to ABA and coverage. Some of these terms include autism, behavioral health, co-pays, deductibles, limitations, and provider networks. Knowing these terms may help when going over policies and can help to figure out where to find key information in a written policy.

Challenges and Common Issues with Coverage

As frustrating as it is, challenges should be expected while seeking coverage. Most people seeking medical assistance through insurance are no strangers to coverage caps, deductibles, limited in-network providers, prior authorizations, denials, high co-pays and deductibles, waiting lists, and more. Seeking coverage for ABA services is no different, and is arguably more complicated and stressful than other medical services sometimes.

As mentioned, families have the right to appeal if they are denied. In these instances, families should seriously consider seeking out the help of insurance advocates. Most people aren’t experts in health insurance policies, but these advocates are. They can help to support families and advocate for them when the insurance companies are less than willing to.

Additional Resources and Support in Texas

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

Tips for Advocating for Better Coverage

The first step to advocating for the best possible coverage and care is education. Families need to learn about the benefits of ABA and how to search for the best possible options. Going through some of the resources provided above is a great place to start for advocacy, grants, and even more sources of support and information. Trying to be involved in state policy when it comes to special needs rights is also a great way to advocate. Voting, writing to politicians, and spreading awareness are great ways to get involved. Keeping in communication with your insurance provider is also necessary to be aware of any possible changes to your care.

Conclusion

Navigating insurance coverage isn’t easy. Loopholes, deductibles, finding quality providers in-network, complex confusing policies, being on hold for an hour waiting to ask a question, there are way too many things that families have to juggle when it comes to caring for their loved one. It is incredibly stressful. Hopefully, some of the information in this article can help lead parents in the right direction. If there is one thing to take from this article, however, it is the importance of education and available resources.

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