DISCLAIMER: While many Blue Cross Blue Shield plans cover ABA therapy, eligibility and approval are not guaranteed. For specific information about your own eligibility, call BCBS with the number listed on the back of your BCBS ID card, or check the website for your specific state. BCBS in most states has a webpage like this one, for Texas, that explains their behavioral health coverage. Some also have FAQs specific to ABA therapy like this one, which can be helpful.
In short, many Blue Cross Blue Shield policies cover Applied Behavior Analysis (ABA) therapy; however, coverage varies widely by state, including the level of coverage, conditions for coverage, and other factors.
If you have health insurance with BCBS and are wondering whether ABA therapy is covered for your child, this article will provide general guidance, and, at least, show you how to find out quickly.
We’ll also discuss the process of establishing ABA therapy through your insurance generally, so you’re better prepared for what comes next.
Does BCBS cover ABA Therapy for autism treatment?
As of 2024, over 40 states in the US have enacted laws requiring insurance coverage for ABA therapy for individuals diagnosed with autism spectrum disorder (ASD). Consequently, numerous private health insurance plans, including those offered by Blue Cross Blue Shield, now include ABA therapy as a covered service. However, policies vary from state to state, and state laws vary regarding specific coverage.
For policies including ABA services as a standard benefit, coverage is contingent upon meeting medical necessity criteria defined by BCBS policy, physician prescription, and a medical diagnosis of F84.0, autism spectrum disorder.
Prior authorization is typically necessary, requiring approval from BCBS for both the initial assessment and the commencement of ABA services, usually conducted by a credentialed and licensed provider.
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Requirements and Eligibility for BCBS ABA Coverage
While specifics of laws vary from state to state, the following is a list of states in the United States that have laws mandating insurance coverage for ABA therapy for individuals with autism spectrum disorder (ASD):
Although the general requirements and eligibility criteria for BCBS of ABA therapy still varies depending on state regulations and specific policy details, some common requirements include meeting medical necessity (meaning a qualified healthcare provider (QHP), typically a Board Certified Behavior Analyst (BCBA)) recommends ABA therapy stating that it is appropriate and effective for the patient’s diagnosis and needs.
Verifying and Accessing BCBS ABA Therapy Coverage
How to Verify BCBS ABA Therapy Insurance Coverage
Navigating insurance coverage for Applied Behavior Analysis (ABA) therapy can seem daunting, but there are several avenues individuals can explore to determine if their Blue Cross Blue Shield (BCBS) insurance plan covers such services.
- Online Verification:
BCBS provides an online platform accessible through the website listed on the back of the insurance card. - Phone Inquiry:
Calling the number on the back of the BCBS insurance card is another option to connect directly with a representative. - Requesting a QOB/VOB through an ABA provider:
Many individuals opt to engage with a company that provides ABA services to conduct a Quote of Benefits (QOB) or Verification of Benefits (VOB). Though the terminology may vary across different companies (e.g., quote of benefits, view of benefits), the essence remains the same: a report outlining what ABA services their policy covers.
A complete VOB/QOB will give information on whether ABA is covered under the policy, what environments services are allowed to be provided in (i.e., school, community, home, clinic) if prior authorization is required, as well as financial information including copays, co-insurance, and where the family is at on their deductibles and out of pocket maximums.
How to Get BCBS Coverage for ABA Therapy
If ABA is not covered by your current BCBS plan, families can advocate for insurance coverage by reaching out to their insurance company, employer, or elected representatives. Individual companies typically have a significant degree of influence over the benefits included in their insurance policies for their employees.
Additional Insights into BCBS Coverage for ABA Therapy
Blue Cross Blue Shield Family Assistance
Many Blue Cross Blue Shield plans offer case management or care coordination to the families following a diagnosis of autism spectrum disorder. Case managers can provide caregiver support, assist with locating in-network providers, and help interpret medical policies. Contacting BCBS directly through a phone inquiry is the best way to determine if this is a covered service on your policy.
Pre-Requisite Process: Mandatory Prior Authorization for ABA Services
For ABA services, including those covered by insurance providers like BCBS, prior authorization is a required step. This involves the submission of requests by qualified health professionals (QHPs) or ABA organizations for both the initial assessment and subsequent direct ABA services. Approval from BCBS typically takes up to 14 business days for the initial assessment and an additional 14 days for the authorization of direct services. This process ensures that necessary documentation is provided and reviewed before therapy commences and that the provider has approval for ABA services.
Diagnostic Mandate: Essential DSM Diagnosis for ABA Services
Additionally, BCBS mandates a DSM diagnosis of F84.0, autism spectrum disorder, as a prerequisite for the approval of ABA services. Without the F84.0 diagnosis, authorizations for ABA assessments or direct ABA services cannot be granted.
Summary
While Blue Cross Blue Shield (BCBS) does offer coverage for Applied Behavior Analysis (ABA) services within many of its plans, the specifics of this coverage can differ significantly. Therefore, families need to begin the process by conducting a thorough verification of their private policy. By taking this initial step to understand the coverage, families can navigate the process of initiating services with confidence and make informed decisions regarding the access and utilization of ABA therapy for their loved ones. This proactive approach empowers families to effectively advocate for the necessary support and resources, ensuring that individuals with autism spectrum disorder receive the vital care they require to thrive and reach their full potential.
Further Reading
In case they’re useful, here are the information pages at a few state level BCBS websites on ABA therapy.
BCBS Vermont Guide on ABA Therapy
