Does Aetna Cover ABA Therapy? What You Need to Know

DISCLAIMER: While many Aetna plans cover ABA therapy, eligibility and approval are not guaranteed. Aetna’s latest guidance on ABA therapy coverage can be obtained here.

If you have health insurance with Aetna and you’re wondering whether ABA therapy is covered, this article should help.

While only your individual policy can determine the coverage you’re eligible for, we try to explain how to determine your eligibility and summarize the key steps likely to be required for you to obtain ABA therapy as an Aetna client.

We also look at some frequently asked questions about Aetna’s ABA therapy coverage, including wait periods, out-of-network providers, and more.

First thing’s first…

We Provide ABA Therapy for Aetna Clients in Multiple States

At Blue ABA, we have helped many clients with Aetna get ABA therapy. We can help you get started even if:

• You’re not sure which policy you have with Aetna
• You’re not sure what’s covered on that policy
• You can’t find your diagnosis paperwork 
• You can’t access your Aetna member portal

In these situations, families simply sign a release form so that we can contact their doctor and insurance company on their behalf to obtain then complete the relevant paperwork.

Most importantly, we have no waiting list for ABA therapy services. If you are eligible for Aetna services, we can start the process of establishing ABA therapy immediately.

To see how we can help, enter your details below for a free, no-obligation consultation:

If you’re looking to establish ABA Therapy with Aetna on your own, here is a general guide to the major steps you’ll need to take. Note again, this information is general and based on Aetna’s documentation as referenced.

NOTE: If possible, we recommend checking your policy documents before looking at the general guidelines:

Step 1: Obtaining ASD Diagnosis

In general, the first step in obtaining any form of autism care, with any insurance provider, is to get the necessary evaluations and diagnosis. At the top of this page of their website, Aetna explains their criteria for determining when autism evaluations and diagnosis are necessary, stating:

“Aetna considers autism spectrum disorder (ASD) evaluation and diagnosis medically necessary when developmental delays or persistent deficits in social communication and social interaction across multiple contexts have been identified and when the evaluation is performed by the appropriate certified/licensed health care professional.”

Then, in this Aetna document, they expand on this criterion to explain the kind of diagnosis that will be necessary to obtain ABA therapy, stating that:

“a DSM-V diagnosis of Autism Spectrum Disorder (ICD‐10/ F84.0; F84.3 – F84.9) obtained by an appropriate provider (i.e. licensed psychologist/psychiatrist, physician, or other health care professional qualified to diagnose mental health conditions within their scope of practice).”

Bottom line: The first step to obtaining ABA therapy through Aetna is obtaining that diagnosis.

Step 2: Additional Evaluation

According to their document here, Aetna also requires an additional evaluation, such as the Vineland Adaptive Behavior Scales 3 (VABS-3), the Adaptive Behavior
Assessment Scale (ABAS), VB-MAPP or ABLLS in order to initiate ABA therapy. This evaluation must show:

“demonstration of functional impairment on a standardized scale of functioning in the past 12 months.”

and requires that

“The impairment must be at least one standard deviation below the population mean OR represent a significant risk of harm to self or others.“

NOTE: This is also a standard step to obtaining ABA therapy, and will be required by most insurance providers. But don’t panic if this seems like an extra step. These assessments are performed by Board Certified Behavior Analysts (BCBAs) who are a part of the ABA therapy company that will eventually provide your child’s therapy.

When you speak to Aetna after your ASD diagnosis, they will typically send you a list of in-network ABA therapy providers to choose from. This “Step 2” that I’m calling an Aetna step is really just the first step in any ABA therapy provider’s process to establishing therapy.

Oh, one more thing: Reputable ABA therapy providers should help parents obtain these evaluations and submit paperwork to insurance companies prior to starting coverage.

Step 3: Aetna’s Essential Elements

In the same document, Aetna describes the “Essential Elements” that will be required for ABA therapy to begin. In addition to the necessary diagnosis, there are five Essential Elements that the ABA therapy will need to include or show to be covered, including:

• Documentation of identifiable target behaviors,
• A time-limited, individualized treatment plan,
• Commitment from parents to participate in treatment
• and more.

If you can manage it, a quick read over the list of Essential Elements on page two of this document might be helpful.

Once again, note that this is not exactly extra work you’ll have to do before obtaining ABA therapy. Any reputable ABA therapy provider should be able to help you with this documentation as part of the process of starting treatment.

Put another way, these aren’t individual items that you’ll need to compile from different professionals and appointments; with a good ABA therapy provider, this should all be “bundled in”, if you like, with their service.

Step 4: Check for Pre-Authorization

Individuals and families should review their insurance policy (a physical copy can be obtained by calling the number on the back of your card, or the policy can be reviewed online through Aetna’s member portal), looking specifically for sections related to behavioral health benefits, autism spectrum disorder (ASD) coverage, or ABA therapy.

Prior to starting ABA therapy, it is advised to determine if your plan requires pre-authorization (e.g., pre-certification, prior authorization). This involves an ABA provider obtaining approval from Aetna to ensure that the treatment plan designed for the child/individual meets Aetna’s coverage criteria.

NOTE: For your reference, this is a link to Aetna’s ABA Therapy treatment request form.

A Note on Plan Types

Understanding the difference between fully-insured and self-insured insurance plans is important for families seeking ABA therapy coverage. Typically, fully-insured plans must adhere to state-mandated coverage requirements for ABA therapy for autism. This means that if ABA therapy is covered under your state’s insurance mandates, the insurance company must provide this coverage up to the specified limits and guidelines.

Self-insured (or self-funded) plans are not always subject to state insurance mandates. Therefore, coverage for ABA therapy can vary widely based on the specific plan established by the employer or organization. Some self-insured plans may choose to cover ABA therapy comprehensively, while others have more limited coverage or exclude it altogether.

Frequently Asked Questions about Aetna’s ABA Therapy Coverage

Does Aetna cover ABA therapy for all children with autism spectrum disorder (ASD)?

Individual policies determine coverage. Follow the methods listed above to determine if your policy covers ABA services. Start with Aetna’s guidance on ASD services here, and their ABA Therapy coverage guide here..

How many ABA therapy sessions does Aetna cover?

Sessions are clinically advised by Board Certified Behavior Analysts, who write a clinical recommendation for a specific number of hours over fixed period (often six months or a year). Once eligibility is proven (via diagnosis and ABA assessment as above), Aetna can cover up to 40 hours of direct ABA services a week.

NOTE: Here is Aetna’s guide to medical necessity for ABA therapy.

Does Aetna cover out-of-network providers for ABA therapy?

Depending on the specific plan, Aetna can cover out-of-network providers. It is advised to check with your individual plan to see if out-of-network providers would be covered and the associated cost, which could be increased.

Is there a waiting period before coverage for ABA therapy begins?

Some families experience waiting periods for ABA therapy services, for reasons that have little to do with Aetna. For example, if the in-network providers in your area do not have availability, you will be placed on their waiting lists, and will not be able to start ABA therapy until space is free.

But if you are in this situation, we recommend contacting Aetna to discuss your options. You can ask them whether out-of-network providers might be covered, given the high need in your case and your area.

Cost and Coverage Limitations

Aetna’s coverage for ABA therapy has limitations and exclusions, that will vary depending on your individual plan and your state of residence. The number of hours of therapy covered, the providers used, the location of the therapy, and more will be limited depending on individual policies.

Conclusion

If you have an insurance policy with Aetna, it is likely that you will have some amount of coverage for ABA therapy, determined largely by the mandate in your state. You will need to demonstrate medical necessity and select an in-network ABA provider.

If we can leave you with one piece of advice, it is to start your research as soon as possible. It is never too early to get on the phone to your insurance company and discuss coverage options, even before an autism diagnosis has been obtained. Doing this can make future planning easier and your ABA therapy journey less stressful.

References

Autism Spectrum Disorders – Medical Clinical Policy Bulletins | Aetna

Autism Mandates by US state – You can check whether your state’s mandate includes ABA therapy on this page

Related Articles

Does Cigna Cover ABA Therapy? What You Need to Know Indiana ABA Therapy & Insurance: What Parents Should Know Yes, ABA Therapy is Covered by Insurance in Arizona, But… ABA Therapy Coverage by Insurance in Texas (In Plain Language)