autism treatments covered by health insurance

Are Autism Treatments Covered by Health Insurance?

Autism treatments covered by health insurance vary by state and plan. Fortunately, the Affordable Care Act contains important provisions for individuals with autism and related conditions and their families.

>Most health insurance plans are no longer allowed to deny, limit, exclude, or charge more for coverage to anyone based on a pre-existing condition—including autism and related conditions.

>New health plans sold in the individual and small group markets, including the Marketplace, must cover “essential health benefits.” This includes hospitalizations, preventive services and prescription drugs. Health insurers will also have annual out-of-pocket limits to protect families’ incomes against the high cost of health care services.

ABA (behavioral therapy) is included in the “Essential Health Benefits” package and required to be covered in Marketplace plans in the following 33 states and the District of Columbia: Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Georgia, Hawaii, Idaho, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, South Dakota, Tennessee, Texas, Vermont, Washington, West Virginia, Wisconsin, and Wyoming.

In these states, ABA must also be covered in non-grandfathered small group and individual plans sold outside the Marketplace. 

ABA is not currently a covered benefit in Marketplace plans in Alabama, Florida, Iowa, Kansas, Minnesota, Mississippi, North Carolina, Nebraska, Oklahoma, Pennsylvania, Rhode Island, South Carolina, or Virginia.

>All Marketplace health plans and most other private insurance plans must cover preventive services for children without charging a copayment or coinsurance. This includes autism screening for children at 18 and 24 months.

>Health plans cannot put a lifetime dollar limit on most benefits you receive. The law also does away with annual dollar limits a health plan can place on most of your benefits. Before the Affordable Care Act, many plans set a dollar limit on what they would spend for covered benefits during the time individuals were enrolled in the plan, leaving individuals on the autism spectrum and their families to pay the cost of all care exceeding that limit.

>Young adults can remain covered under their parents’ insurance up to the age of 26. For a young adult with autism or related conditions and their family, that means more flexibility, more options and greater peace of mind.

>Individuals on the autism spectrum and families of children on the autism spectrum now have expanded access to affordable insurance options through the new Health Insurance Marketplace and expansion in Medicaid.

Child-Only Insurance Plans for Children With Autism

A child-only policy is an individual health plan available to children under age 21 with no parent or guardian covered on the same policy. Financial assistance may also be available to help pay monthly premiums. Financial help will be determined based on the income of the parent who claims the child as a dependent on their federal tax return.

A child-only policy may be a good option if

  • The child lives with grandparents who do not have private insurance because they are eligible for Medicare, and the child is not eligible for Medicaid or the Children’s Health Insurance Program.
  • The parents are divorced or live in different states.
  • Job-based coverage does not include ABA for families affected by autism.

If your child has access to an employer-sponsored plan, you will not be eligible for a discounted Marketplace plan. However, you can still purchase a non-discounted child-only Marketplace plan. Some plans allow you to carry more than one policy while others do not.

Get the Coverage You Need

The time and energy often needed to ensure that prescribed treatments are covered can complicate what may already be a stressful time for families faced with a diagnosis of autism. I am here to help.

I can help you determine if your health benefit plan provides meaningful coverage for the treatment of autism. I can also assist with getting the best health insurance plan to fit your family’s needs. Contact me today for a no-cost, no-obligation appointment.

I am licensed in Georgia, South Carolina, Florida, Pennsylvania, and Alabama.