Special Education Insurance Coverage Guide & Tips in the US

View Table of Contents

Trying to understand healthcare systems and whether their children have special needs or not can get complicated for most families. Understanding the healthcare system and how it works becomes more intimidating and costly, especially if it is essential for the children to see a professional, continuously receive therapy, or use a medical instrument. The necessity of seeing a professional and the constant need for therapy could pose several problems for parents of children with special needs. Many insurance companies demand referrals , a written command from a family doctor indicating that seeing a professional or therapist is needed. They do not include reimbursement for all types of therapies. However, parents whose children have special needs could derive the maximum out of their insurance plan and diminish the out-of-pocket expenses ( Out-of-pocket expenses are known as the charges where individuals pay the expenses from their own pockets and cash reserves) if they can figure out the detailed information on their insurance policy.

Understand What Kind of Health Insurance Plan You Have

There are many healthcare benefits that an insurance plan may cover; however, what healthcare benefits are provided within an insurance plan often depends on the kind of insurance plan you have. There are two types of healthcare plans :

Private insurance plans that can be purchased by you or your employer.
Healthcare plans known as government programs are provided by governments.

Also, the type of healthcare plan you have impacts the advocacy process if you try to change the healthcare benefits of your plan. Moreover, suppose you need to submit a complaint when you are unsatisfied with the benefits of your plan or appeal to the denial of coverage. In that case, it is essential to know your insurance plan type so you can contact the relevant authorities directly.

Some Helpful Tips to Know For Any Healthcare Benefits

Become educated and knowledgeable about your family’s insurance plan and its benefits. This step is important because your insurance plan and the features it provides will be a guideline for you to afford and pay for the essential services. In addition, your insurance plan is a report because it informs you what services are included and not included within your plan. You can usually obtain this report online from your health insurance company or when you enroll to get your insurance plan.
Health coverage can be complicated; however, case managers could help advise and guide you about your insurance plan. First, though, you have to contact your insurance plan to see whether they have case management or not. Even so, having a case manager is not essential. You still have the right to call and ask your insurance company about any questions regarding your plan.
Do your search and consider all alternatives. Before signing up, think carefully about what this plan will include. Are doctors, prescriptions, therapies, or services that your child needs covered? If you are indecisive about what plan to choose, make a comparison between each plan about its advantages, benefits, and disadvantages before enrolling in a plan.
It is okay to appeal a decision, and there is no need to be afraid of it. Sometimes your insurance or Medicaid plan may deny a service that is essential for your child. Usually, when a parent requests an appeal, several insurance companies reverse the decision. So, know that it is your right to appeal a decision.

Insurance

Autism and Insurance Coverage State Laws Across the USA

There are many intervention treatment programs for autism. These include behavioral and educational interventions, complementary and alternative medicine, changes in diet or medicines to regulate and alleviate the symptoms of autism spectrum disorder. Unfortunately, these treatments may be highly costly for parents. Therefore, the insurers in some states in the USA are obligated to cover expenses for the treatments of autism. You can find the information about insurance coverage for autism for each state below .

Alabama

This state necessitates that a health benefit plan offers coverage for insured children with autism who are nine years of age or under. The coverage should include screening, diagnosis, and the treatment of autism spectrum disorder. However, for an insurance plan to cover services, the treatment must be prescribed by the child’s attending physician or psychologist with a treatment plan. This treatment plan may include behavioral health treatment (involving applied behavior analysis), pharmacy care, psychiatric, psychological, and therapeutic care,however, behavioral therapy services are limited to $36,000 per year.

Alaska

Necessitates coverage for the treatment and the diagnosis of autism spectrum disorders for people who are under the age of 21. The treatments covered by the insurance plan include medically necessary pharmacy care, psychiatric, psychological, habilitative, or rehabilitative care (involving applied behavior analysis), and therapeutic care. Also, there might be no limitation regarding the number of visits to a provider for autism services. However, coverage is dependent on copayment and deductible.

Copayment is an arranged amount that the receiver pays for the covered services, where the receiver’s insurance company pays the remaining amount.
A deductible is an arranged amount that patients must pay annually before their health insurance benefits to cover the expenses.

Arizona

Here, health insurance companies must ensure coverage for both the treatment and the diagnosis of autism spectrum disorders, although it has some limitations. Deductible and the amount of money that your insurance company pays cannot be determined based merely on the diagnosis of autism spectrum disorder. Essential behavioral therapy services are covered up to $50,000 in a year for eligible individuals nine years of age or younger. The amount is $25,000 for eligible individuals between the ages of nine and 16.

Arkansas

Health benefit plans are required to cover the treatment and the diagnosis of autism spectrum disorder. Treatment coverage includes applied behavior analysis, pharmacy, psychiatric, psychological, therapeutic services, essential equipment needed for evidence-based treatment, and any service that is deemed necessary by a qualified physician. Eligible children under 18 can benefit from applied behavior analysis services limited to $50,000 per year. Also, there are no visit limits that an individual can make to providers of autism services every year.

California

Health insurance plans must cover the diagnosis and the proper medical treatment for autism, including hospital and surgical expenses, regardless of their age. Every health insurance policy is required to provide coverage for behavioral health treatment for autism. Moreover, the law specifies that this provision does not make it necessary that the benefits provided should exceed the essential health benefits specified by the federal Patient Protection and Affordable Care Act.

Colorado

Health benefit plans are required to ensure coverage for the assessment, diagnosis, and treatment of autism spectrum disorder for children. Treatment for autism spectrum disorder is specified as medically necessary, appropriate, efficient, or beneficial. Also, treatment should include services for evaluation and assessment, such as behavior management and training, applied behavior analysis, habilitative, rehabilitative care, ergotherapy, speech therapy, pharmacy, psychiatric, psychological, and therapeutic care.

Connecticut

Some specified group health insurance policies ( Group insurance health plans ensure coverage to a group of members consisting of office workers or to the members of an organization) are required to cover the diagnosis and treatment of autism spectrum disorder. Treatments are supposed to be determined and ordered by a qualified physician, psychologist, or clinical social worker who deem it medically necessary. Treatments for autism can be behavioral therapy, prescription medicines, psychiatric or psychological services, physiotherapy, ergotherapy speech and language pathology services. Behavioral therapy services might be limited to $50,000 annually for an eligible child under nine, $35,000 for an eligible child between the ages of nine and 13, and $25,000 for an eligible child between 13 and 15. It is important to note that the coverage may not impose visit limits to the provider of autism services.

District of Columbia

Requires health insurance companies to cover speech, occupational, and physical therapy as treatments for children with congenital or genetic congenital disabilities to improve the children’s ability to function well. Congenital or genetic congenital disabilities are innate, inherent, hereditary defects, including autism spectrum disorder. To be eligible, individuals must be under the age of 21. If the services required for the children with autism are provided by school services or through early intervention, health insurance companies are not required to deliver repayment.

Delaware

Individual health benefit plans are required to cover the services for autism spectrum disorder including screening, diagnosis, and the treatment of autism for eligible individuals who are under the age of 21. However, there are yearly coverage limits for applied behavior analysis. Still, the law requires that any coverage limit put on autism spectrum disorders shall not be lower than the coverage limit put on any physical illness. Also, the state requires that insurance companies are allowed to demand the evaluation of the treatment.

Florida

Health service contracts and insurance plans are required to cover the expenses for qualified individuals. The coverage includes well-baby and well-child screening to diagnose whether the children have autism spectrum disorder or not. Also, applied behavior analysis, speech, occupational, and physical therapy services are covered as the treatment methods for autism spectrum disorder. The coverage is subject to some limitations, such as the prescription of the treatment must be done by a physician and should be in line with a treatment plan with a cost limit of $36,000 per year. Also, the total amount of money reimbursed by the insurance plan shall not be more than $200,000 in maximum lifetime benefits.

Georgia

Requires health insurance companies to cover the expenses for screening, diagnostic examination, and treatment for autism spectrum disorder.

Illinois

All individual and group health insurance plans are required to cover the expenses for the diagnosis and treatment of autism spectrum disorders for eligible individuals who are under 21. Applied behavior analysis and any other treatments are covered by the insurance plans, where the most significant benefit per year is limited to $36,000. Insurance coverage should be provided for children under the age of 19 who have a congenital, genetic, or early acquired disorder, together with autism spectrum disorder. Also, the law requires that insurance companies should cover habilitative services (Speech therapy, occupational therapy, and physical therapy) to improve the child’s function who has congenital, genetic, or early acquired disorders.

Indiana

Accident and sickness insurance policies that are compiled on a group basis and a group contract with a healthcare organization are required to cover the expenses for the treatment of a pervasive developmental disorder. The treatment should be prescribed by a qualified physician, where the coverage is limited to the treatment plan created by the physician.

Iowa

State employee health care plans are required to cover the expenses of the diagnosis and treatment for autism spectrum disorders for eligible individuals under 21. The treatment includes pharmacy, psychiatric, psychological, rehabilitative, and therapeutic care. Also, the maximum benefit that an eligible child could receive per year is limited to $36,000. In addition, coverage does not have any visit limits to the provider of autism spectrum disorder services.

Come along with 200k+ families!

Explore the endless possibilities of learning!

Download for Free.

More than 100 games designed by
psychologists and specialists.

Otsimo Special Education

Download for Free

Kansas

State employee health care plans are required to cover the diagnosis and treatment expenses for autism spectrum disorders for eligible individuals up to 19. Evidence-based services and applied behavior analysis services are included in the treatment. The maximum benefit for children under seven could be $36,000 per year and $27,000 for children between the ages of seven and 19.

Kentucky

Large group, individual, and small market healthcare plans are obliged to cover the expenses of the diagnosis and treatment for autism spectrum disorder for eligible children under the age of 21. However, the coverage is limited to $50,000 per year for eligible children under seven years of age. Thus, for children between the ages of seven and 21, the maximum benefit that an individual could receive is $1,000 in a month. There are also no constraints on the number of visits made to the providers of autism services. Treatment includes medical, pharmacy, psychiatric, psychological, therapeutic care, applied behavior analysis, and rehabilitative and habilitative services.

Louisiana

Insurance companies and health maintenance organizations must cover the expenses of the diagnosis and treatment of autism spectrum disorder for qualified individuals under the age of 21. The maximum benefits that an eligible individual could receive are set to $36,000. The treatment includes habilitative, rehabilitative, pharmacy, psychiatric, psychological, therapeutic care, and applied behavior analysis.

Maine

All individual and group insurance policies, group and individual health maintenance organizations are required to cover the diagnosis and treatment expenses for autism spectrum disorders for eligible children who are five years old or under. The services included in the treatment are habilitative or rehabilitative care, applied behavior analysis, counseling, therapy services (speech, occupational, and physical therapy). Although there may not be any visit limits made to the services, the maximum benefit for applied behavior analysis is $36,000 annually. Also, another law states that specified group contrasts are obliged to cover the expenses regarding pervasive developmental disorders, including autism.

Massachusetts

Specified individual, group, and state employee health plans and health maintenance contracts are required to cover the diagnosis and treatment expenses for autism spectrum disorders in an unprejudiced way. Habilitative, rehabilitative, pharmacy, psychiatric, psychological, and therapeutic services are included in the treatment. Also, accident and sickness individual and group insurance plans and health maintenance contracts that provide surgical and hospital insurance are required to cover the expenses regarding mental health for the diagnosis and treatment of specified biologically-based mental disorders and autism. Additionally, there may not be limits on the maximum benefit that individuals could receive per year for autism.

Michigan

Individual insurance policies and health maintenance organization groups are obliged to cover the expenses of the diagnosis and treatment for autism spectrum disorders. The coverage limitation is $50,000 for children who are up to the age of six, $40,000 for children between the ages of seven and 12, and $30,000 for those between the ages of 13 and 18. In addition, behavioral health treatment like applied behavior analysis, psychiatric, pharmacy, psychological, and therapeutic care are included in the treatment services.

Minnesota

finances the costs of Early Intensive Developmental and Behavioral Intervention (EIDBI) services for eligible individuals who are up to the age of 21 and need medical assistance (MA) with autism spectrum disorders and associated conditions.

Missouri

All group health benefit plans are obliged to provide coverage for the treatment and diagnosis of autism spectrum disorders; however, coverage is only legitimate for medically necessary services prescribed by a licensed physician in line with a treatment plan. Psychiatric, psychological, habilitative, or rehabilitative care, applied behavior analysis, therapeutic, and pharmacy care are included in the treatment services. Applied behavior analysis has an annual dollar limit of $40,000 for eligible children who are up to the age of 18. However, if the insurance companies see that applied behavior analysis is needed for the child, they may allow this limitation to go beyond $40,000. Also, there may not be any limitations on the number of visits made to the provider of autism services.

Montana

Specified disability policies, insurance plans, and membership contracts are required to cover the expenses of the diagnosis and treatment for autism spectrum disorders for eligible individuals who are either 18 years old or under. Habilitative or rehabilitative care, medicines, psychiatric, psychological, therapeutic care, and other specified care are included in the covered services. For children who are eight years or younger, the maximum benefits received per year are $50,000, and it is $20,000 per year for those between the ages of eight and 19.

Nebraska

Any individual or group health insurance plans are required to cover the expenses of the diagnosis and treatment for autism spectrum disorders.

Nevada

Individual health benefit plans are obliged to offer an option to cover the expenses of the diagnosis and treatment for autism spectrum disorder for individuals under 18 of age; however, if they registered the insurance plan during high school, the age limit for the coverage goes up to 22. Health insurance for small employers, group and blank health insurance benefit plans, and health care plans which a health maintenance organization issues are required to follow the same law as individual health benefit plans. Medically necessary habilitative or rehabilitative care, medication, psychiatric, psychological care, or behavior therapy might be included in the treatment services, which must be recognized in a treatment plan prescribed by a physician.

New Hampshire

Insurance plans are required to cover professional and treatment services for autism spectrum disorders for eligible individuals. The treatment services include applied behavior analysis, prescribed medications, direct or consultative services provided by qualified licensed professionals, and services provided by accredited speech, occupational, or physical therapists. The maximum benefit for applied behavior analysis is $36,000 annually for children who are up to 12, and $27,000 for children between the ages of 13 and 21. Also, some insurers who deliver benefits for disease and sickness to children who have biologically-based disorders are required to cover the treatment expenses and the diagnosis for pervasive developmental disorders and autism spectrum disorders.

New Jersey

Specified health insurance plans are obliged to cover the expenses of the diagnosis and treatment for autism spectrum disorder or other developmental disorders. When the qualified individual’s primary diagnosis is made, the coverage is supposed to be provided for the costs related to medically necessary occupational, physical, or speech therapy, in line with a prescribed treatment plan. Suppose the person is under the age of 21 with a primary diagnosis of autism. In that case, coverage should be provided for the costs of behavioral intervention and relevant programs, such as applied behavior analysis, which should be in line with a prescribed treatment plan. Also, the state obligates that insurance plans that provide benefits for hospital and medical expenses should cover the costs for people who have biologically-based mental illnesses, including autism spectrum disorder.

New Mexico

Health care plans, specified insurance plans, certificates of health insurance, and contracts are required to cover the expenses of the diagnosis and treatment of autism spectrum disorders. Eligible individuals are 22 years old or younger and registered in high school for well-baby and well-child screening for autism spectrum disorders. The treatment program includes applied behavior analysis, speech, physical, and occupational therapy. The maximum benefit that an eligible individual could receive in a year is $36,000, and it must not exceed $200,000 in the full lifetime benefits.

New York

Specified health insurance plans and contracts that ensure hospital and surgical expenses coverage are obliged to cover the diagnosis and treatment of health conditions for autism spectrum disorders. In addition, other insurance plans that ensure coverage for physician services, medical, major medical, or similar broad type coverage plans are required to cover the expenses of the diagnosis and treatment for autism spectrum disorders. Also, the law requires that there* shall not be any limitations on the number of visits* made to the provider of autism services. The treatment for autism spectrum disorder includes behavioral health treatments, applied behavior analysis, psychiatric, psychological, medical, therapeutic, and pharmacy care. However, the maximum benefit that eligible individuals could receive per year is $45,000 for applied behavior analysis.

North Carolina

All insurance plans are required to cover the expenses of the diagnosis and treatment for autism spectrum disorders. Also, the law states that no insurance plans are allowed to either refuse or cancel coverage for autism spectrum disorders.

Oklahoma

The state laws require insurance plans to ensure coverage for autism spectrum disorders in certain circumstances. Also, insurance plans are obliged to put no limitations on the number of visits made to the provider of autism services. In addition, the maximum benefit one could receive per year is adjusted each year.

Ohio

Insurance plans are required to ensure coverage of the diagnosis, screening, and treatment for autism spectrum disorders.

Oregon

Health benefit plans, Public Employees’ Benefit Board, and Oregon Educators Benefit Board are required to ensure coverage for autism spectrum disorders.

Pennsylvania

All insurance plans and government programs are obliged to ensure coverage for eligible individuals younger than 21 to diagnose and treat autism spectrum disorders. The maximum benefit an eligible individual could receive annually is $36,000.

Rhode Island

Specified health insurance plans and contracts are required to ensure coverage for autism spectrum disorders. Coverage includes applied behavior analysis, occupational, physical, speech therapy, psychology, psychiatric, and pharmaceutical services for eligible individuals up to 15. The maximum benefit an individual could receive for applied behavior analysis per year is $32,000.

South Carolina

Health insurance plans are obliged to ensure coverage for the treatment of autism spectrum disorders. Insurance plans only cover the treatment determined by the child’s physician and in line with a treatment plan. To be qualified for the coverage, an individual should get diagnosed at the age of eight or younger and must be under 16 years old.

South Dakota

Health insurance plans must provide coverage for children with autism spectrum disorders for applied behavior analysis services. However, coverage might depend on prior permission and approval, requirements of care management, particularly the limits on the number of visits, deductibles and copayment, and limits on maximum benefits that eligible individuals could get per year. These rules also apply to other insurance plans that cover medical and surgical services for autism spectrum disorders.

Tennessee

Here, autism spectrum disorder is included in the category of neurological disorders. Therefore, health insurance plans and contracts are obliged to ensure coverage for the treatment of neurological disorders for eligible individuals who are less than the age of 12 with autism spectrum disorders.

Texas

Health insurance plans are required to ensure coverage for prescribed services to children with autism spectrum disorders. A licensed physician should make the primary diagnosis and recommend a treatment plan to the eligible child. The prescribed services include applied behavior analysis, speech, occupational, physical therapy, medicines or nutritional supplementation, and any other treatments recommended by a physician. However, coverage might be dependent on yearly deductibles, copayments, and coinsurance. The state law also obligates that the child should be provided with coverage from the day of the diagnosis until nine years of age.

Utah

Health benefit plans are required to ensure coverage for the treatment of autism spectrum disorders.

Vermont

Health insurance plans are required to ensure coverage for the evidence-based diagnosis and treatment of early childhood developmental disorders, including autism spectrum disorders, but not learning disabilities. Eligible individuals are those who are up to the age of 21. The treatment services include applied behavior analysis and evidence-based care, requiring essential equipment, psychological, psychiatric, pharmacy, therapeutic care, and behavioral health treatment. The insurance plan may not limit the number of visits made to the provider of autism services.From January 1, 2014, the law states that the insurance plans are not required to cover the special needs benefits if they exceed the essential benefits provided by The Federal patient protection and affordable care act.

Virginia

Health insurance plans, health care subscription plans, and health maintenance organizations are obliged to ensure coverage for the treatment and diagnosis of autism spectrum disorders for eligible individuals between the ages of two to six. Local choice health programs and the state employees’ health plans are included in the requirement as well. However, if the expenses covered in the insurance plans go above 1% of insurance premiums, which is the money individuals pay to the insurance policy for that insurance plan that is charged over the experience period, these requirements shall not apply. The treatment service includes applied behavior analysis, behavioral health treatment, psychiatric, psychology, pharmacy, and therapeutic care. If the person does not choose a greater insurance plan, where the maximum dollar limit of benefits is higher, usually the coverage is limited to $35,000 per year for applied behavior analysis. Also, there may not be any limitations in the number of visits made to the treatment services provider. Additionally, the state requires that specified insurance plans, who provide health care services, must ensure coverage for children with biologically-based mental illnesses, including autism.

West Virginia

Specified health insurance plans, and the state’s Children Health Insurance Program (CHIP), are required to ensure coverage for the diagnosis and treatment of autism spectrum disorders for eligible individuals at 18 months and up to the age of 18 years. However, to be qualified for the coverage,__ the child must get diagnosed at the age of 8 or younger__. The treatment service includes medically necessary programs and applied behavior analysis prescribed by a qualified physician or a psychologist. The coverage has some limitations; for instance, the maximum benefit that an individual could receive per year is $30,000, enduring for three years after the treatment begins. The limitation is $2,000 per month after three years of treatment.

Wisconsin

Self-insured health plans and specified disability insurance plans are obliged to ensure coverage for the treatment of autism spectrum disorders, where the treatment must be prescribed either by a licensed physician including specified therapies. Here, the state includes autism spectrum disorder in the category of developmental disabilities. It states that* no insurance may refuse coverage based on the individuals’ developmental disability or physical condition severity*.

special education insurance

Financial Support and Health Care Plans For Special Needs

You can benefit from two types of insurance coverage for your children’s special needs expenses. These are primarily private health insurance plans and government programs. Below, you can find the information for government programs and insurance programs;

Medicaid is a state program where medical services are provided to eligible individuals who satisfy the disability requirements and have a certain income.
Children’s Health Insurance Programs (CHIP) is an insurance program that ensures low-cost coverage for eligible individuals at the age of 18 or younger depending on family income.
Children with Special Care Needs (CSHCN) is a government program that provides healthcare benefits for eligible individuals younger than 21 years old with either disability, needs special care, or has cystic fibrosis.
Medicare is a state program that ensures coverage for people who are 65 years or older and for eligible individuals at the age of 18 if they satisfy the requirements, such as having a disability or special health care needs.
Health Insurance Premium Payment (HIPP) program enables families to pay their health insurance if one of the family members receives benefits from Medicaid and if one of the other family members can get a private health insurance plan over their job.
Supplemental Security Income (SSI) is a state program founded on financial needs and assists in the payment of living and the health care costs for eligible individuals who have disabilities and special health care needs. If you are allowed to get Medicaid, then you may be eligible for SSI as well.
Social Security Disability Insurance (SSDI) is a benefit that an adult child could receive if social security taxes are paid either by the child or the parents, and in the program, the child can get a monthly payment from the insurance, based on either the child’s or the parents’ earnings.
Waivers allow the states to use Medicaid funds to provide lasting home and community-based services for eligible individuals with disabilities, special health care needs, and the elderly to assist them in living with a community. Waivers are not a type of insurance. In contrast to other insurance plans, many Waivers rely on the child’s earnings rather than his or her parents’ earnings. However, the waiting period for getting waivers is too long, so it could be better if you register at the earliest time possible.

Insurance Coverage for Applied Behavior Analysis Therapy

Applied behavior analysis is an intense therapy where weekly 40 hours of therapy might be needed according to the child’s situation with autism spectrum disorders. Therefore, it is not surprising that applied behavior analysis (ABA) therapy is known as the absolute standard for autism spectrum disorders. Because of this, many people believe that their insurance plan always covers ABA services. Nevertheless, insurance coverage rules vary from state to state in the USA, as explained above, so you may want to check what is and what is not covered in your state’s regulations. Also, the changes could be seen not only in states but in different coverage plans as well. While some insurance companies are willing to cover ABA, others are still hesitant and doubtful about it. Below, you can find information about several insurance plans and what kind of services they provide in their coverage plans.

Cigna Applied behavior analysis is covered by some plans in Cigna; however, to receive the essential ABA therapy services, your doctor’s paperwork of autism spectrum disorders should be submitted so that your child could start receiving the services.
Blue Cross Blue Shield insurance plans vary in Blue Cross Blue Shield. For instance, in Michigan, ABA services are covered for eligible children younger than 18. However, as it is in Cigna, some of the plans obligate preauthorization and paperwork to start ABA therapy.
Aetna Here, you may need to contact your insurance company to learn whether ABA is covered by your insurance plan or not because ABA services are not explicitly stated to be covered. At the same time, some may provide coverage for it. Therefore, talk to your insurance company about the details.
Kaiser Permanente, the first insurance company in Oregon, announced that they would voluntarily ensure coverage for ABA services. However, you should know that not all insurance companies voluntarily provide coverage for ABA services in each state.

Since every insurance plan has a brochure about what is and is not covered, it may give you the essential information about what you are looking for.

Come along with 200k+ families!

Let's communicate better!

Download for Free.

Certified speech therapy app
designed with SLPs.

Otsimo Speech Therapy

Download for Free

The Cost of ABA Therapy in Each State in the USA

It is well-known that children who receive ABA therapy highly benefit from this therapy service . With ABA, the patient is objectively measured in terms of the change in their behavior, which indicates whether they show some improvement with the therapy in social, communication, and learning aspects. Moreover, it is widely known that ABA therapists can work in various settings, including one-on-one meetings with their patients either at their homes, in large health clinics, schools, and workplaces. However, there are costs for everything, and ABA therapy is no different, and it is a pretty challenging task for the parents to pay for the treatment services from their pocket. Luckily, because several states have some regulations that ABA should be covered by the insurance plans, this could help families to compensate for the costs. However, the amount of coverage usually varies depending on the insurance plan you have. Also, The Centers for Disease Control and Prevention (CDC) states that the cost of care for children with autism is $17,000 more than children who do not have autism spectrum disorders. However, it should be noted that the amount could go up depending on the severity of children’s autism spectrum disorders. That being said, you can find the information below for each type of care that children with autism could receive in line with the degree of their disability.

Community-based services where all-day nursing services are available could cost $43,000 or over annually.
The price for daycare programs could be over $11,000 annually.
Substitute care, which is known as out-of-home care, could cost over $5,200 yearly.
Homecare programs could cost approximately $3,000 yearly.
Employment support programs, where educational and skills training is included, could cost approximately $5,000 per year.
Other than that, behavioral treatment services, crisis management, agency services for home health are likely to cost around $13,500 annually.

However, the cost of the ABA therapy is also dependent on the skills, certification, and how much experience the therapist has. Usually, the education level of the provider also affects the cost. For instance, therapists with a doctoral-level degree have the highest rates of cost compared to those who do not have doctoral-level degrees.

What to Do If your Coverage is Denied?

Sometimes insurance companies deny covering the essential services that your child needs; however, there are some tips that you can follow that could turn the decision around.

Appealing the Decision you can write a letter of medical reasons for why your child needs required services with the help of your doctor. Also, it would be good to learn by asking your doctor whether he or she was successful in collaborating with your insurance company before in similar situations.
Scheduling a Conference Call If it is a higher-level appeal ( Higher-level appeals are reviewed by the seniors, where the employee from the insurance company denies the initial claim.), then usually a sit-down meeting becomes necessary. You could ask your doctor to speak on the phone to the insurance company or attend the meeting in person. Sometimes, the presence of the doctor usually increases the families ‘ coverage requests’ reliability.
Learn the Law Every state has its regulations for insurance coverage, so if you know the laws for your state, then your conflict with the insurance company could become easier for you because you know what is offered in your state. Also, communicating with other parents and asking them what they have done during the process could be valuable for you to follow the essential steps during the path.
Knowing the Goal, many parents think that the Individualized Education Plan (IEP) is where the child’s services are planned for the subsequent year, where it is not the case. However, IDEA (Individuals with Disabilities Education Act) aims to guarantee that children with disabilities are provided with free public education with a specific focus on special education and services to address their particular needs and train them for an independent future life. Therefore, it would be better for parents to form the habit of asking the school to explain to them how the plan for the current period helps the child through his or her future independent life, employment, and education. This helps them change their conversation with the school because of assuming wrongly that IEP is a place for the children to plan their future special needs services.
Be Ready to Require a Written Document for Denials Sometimes a member from the IEP could let you know that the service for your child cannot be covered, so you have the right to require a written document from them that explains why the service is denied. Under the statements of IDEA, parents have the right to ask for a denial letter, so do not be afraid.
Ask for a Recess You should know that you are not obliged to sign anything at the end of your meeting with the IEP. You could spend your time thinking about it for a while and tell them that you need a break to consider some things, discuss with an expert, do some search about the law, or anything else you want to. Therefore, you can just say that you are not ready to sign the papers now and set a time to meet with the IEP team again, and remember that the school is still required to cover your child’s services during your decision-making process.

Some Tips to Get Your Therapy Expenses Covered by Your Insurance Plan

Each state requires that the insurance companies cover essential benefits; however, these benefits depend on the state you live in, as there are different regulations in each state. Below, you will find five tips that could help you get the coverage for the services your child needs to be by your insurance company.

Understand what is required and be determined.

If you aim to get your insurance company to cover the expenses for therapy that your child needs, then be determined and persistent through the process to understand what is required by the insurance company to ensure coverage for the therapy services.

Acquire a medical diagnosis.

When you acquire a medical diagnosis, it indicates that the therapy for the child is due to medical reasons and not developmental, which could ease getting approval for coverage. Carefully read what your insurance plan excludes and does not cover in terms of services, and make sure that your doctor or therapist does not use such words which implies that the diagnosis is not medical.

Add a personal letter

This tip is up to you. As a parent of your child, you could write a letter highlighting the importance of the services that your child needs due to his or her medical condition.

Rejection of coverage

It is not rare for insurance companies to deny coverage; however, this is not their definite answer. At this point, it is crucial that you are determined. When you receive a denial, make sure to look at the letter of denial or other insurance documents where the diagnostic code is written. Also, you should check whether the diagnostic code is neurological rather than one showing a developmental delay. Ask your speech therapist whether he or she could help you. If you realize an inconsistency between the diagnostic code given to deny the coverage and your child’s actual diagnosis, it allows you to appeal that decision.

The process for appealing the decision

If you think that the denial of coverage was an error in the first place, then you should ask the insurance company about how their appeal process works and get ready to take action afterwards. Although there might be some differences in the working system of appeals processes, generally, individuals are required to provide everything in written documentation. Also, you should be determined throughout the whole process, and do not forget to keep careful records of the communication between you and the insurance company. If you would like to appeal the decision, the first thing you should do is to carefully review the specific reason that caused the insurance company to deny coverage. Moreover, it is good to require a copy of the insurance company’s master policy and any exceptions to the coverage. Finally, cautiously make comparisons between the copied documents you have and the medical report that you have provided before. This will create the basis of the best argument for why your child’s services need to be covered.

Therefore, being prepared and determined are the key characteristics to get the coverage you need for your child’s special needs.

young boy in therapy

Last Updated: December 2021

Save Your Money with These 4 Insurance Tips

You can use some strategies to save your wallet when looking for insurance plans for your child’s special needs. Below, you can find some tips that could help you pay less money while searching for the most suitable plan for your child.

Keep Medicaid in your Mind

Medicaid is a government-funded health insurance program. If your income and state regulations match Medicaid requirements, you might be eligible for it. However, note that in some states, the name of the program varies. For instance, Medicaid is called MediCal in California, whereas it is TennCare in Tennessee. Nevertheless, if your income is too high to be eligible for Medicaid, but in that case, your child could be eligible for another government program called Children’s Health Insurance Program (CHIP). Therefore, these are good options to consider before buying a private health insurance plan.

Consider Child-Only Health Plans

Sometimes, you get denied by government-funded healthcare programs, or you do not have access to one through your employer, there are still individual healthcare plans for you that could cover your child’s needs. Although some states have child-only health insurance plans, this is not the case for every state. However, due to states’ regulations for insurance plans, children cannot be denied coverage for the services if one of the child’s eligible parents applies to get coverage for special needs.

If you plan to enroll in an individual plan for your family or your employer provides you with an HSA-based health plan, you can consider enrolling in it. An HSA-based insurance plan enables you to control your healthcare expenses because it allows you to choose where to spend your healthcare dollars. You should take HSA-based healthcare plans into account, which could be useful when considering the best insurance plan for your child.

Consider All Your Options

Looking for the best insurance plan could be complicated, however, it is essential for you to consider all of the options before you make a decision. Hiring an advisor or participating in a state-sponsored program to learn insurance plans would make you better understand what to choose or not to choose.

Medicaid as a Government Program for Special Education

Medicare special needs plans are under the category of Medicare advantage plans. Only people with certain characteristics and specific diseases could be a member of Medicare SNPs. Also, Medicare SNPs offer customized benefits according to the needs to get the most out of a plan. In addition, there are some commonly asked questions about Medicare SNP, and these include;

Can I get treatment from any doctor, healthcare provider, or hospital?

Usually, members of Medicare SNP should get their healthcare and treatment services from doctors and hospitals in the Medicare network. Nevertheless, suppose you need to see a doctor for an emergency or care, an unexpected injury that needs to be treated immediately. In that case, you could see a doctor or go to a hospital out of Medicare SNP’s network.

Do Medicare SNPs cover prescription drugs?

Prescription drugs are covered by all Medicare SNPs.

Do I need to select a primary care doctor?

Usually, you are required to have a primary care doctor for SNPs, and if you do not have one, a care coordinator could help you choose a primary care doctor.

Is getting a referral necessary to consult a specialist?

Usually, getting a referral is required to see a specialist, however, for particular services, getting a referral is not required. For instance, annually screening mammograms, an in-network pap test, and a pelvic exam.

Other Things You Should Know About Medicare

Medicare SNPs are limited to people who live in established institutions, like a nursing home, or people who need medical assistance at their home, people who are both qualified for Medicaid and Medicare, people who have specific and disabling conditions (like chronic mental health conditions or diabetes, etc.)
SNPs try to coordinate treatment services and providers for you to keep you healthy and follow the orders of the healthcare providers or doctors.
If you have Medicare and Medicaid, Your SNP must ensure that all plan doctors or healthcare providers you see could accept Medicaid.
However, if you live in a certain organization, the providers of the SNP provide services for where you stay.

What to Do If You Do Not Have an Insurance Plan for Special Needs?

Insurance plans usually help parents of children with special needs by covering the expenses related to special education; however, some families may not have insurance for these kinds of services. Fortunately, there are some ways to get your child’s treatment services covered. If your child’s age is below three, then your state programs might get involved in covering your child’s special needs expenses . If your child is above three years old, then your child’s school may provide your child with some forms of treatment for autism spectrum disorders. Also, many states are willing to help children under the age of three, and some states even have programs for older children. Therefore, every state has its own rules regarding eligibility, what to cover, etc. If your state provides you with good and decent benefits, then you are more likely to receive the assistance your child needs. For instance, in Nevada, there is a program called The Autism Treatment Assistance Program (ATAP), which provides financial support to children under 20. Although they might not cover all the expenses, it provides families some relief with the payment. On the other hand, New Mexico offers a program called The Developmental Disabilities Supports Division, where many family services are covered except Applied Behavior Analysis. Also, you can communicate with your state office with the help of The Early Childhood Technical Assistance Center . Communication with your state office could happen in many ways including arranging a phone call, e-mailing, or visiting the state office so that you could learn how the system operates. Also, you may not know how the system works in your state; therefore, talking with your child’s doctor or child’s school counselor and administrator could provide you with the essential information you need.

Could Your Child’s School Help?

Every child has the right to access education in the USA. Therefore, children with autism spectrum disorders could receive treatment during their class time every day. Unfortunately, though, the treatment may not be as strong as families may expect it to be. Also, to receive these special needs services, your children first may need to complete:

Diagnostic Play Sessions.
An evaluation to measure the child’s development.
Speech-Language evaluations.
Behavioral Assessments.

Fortunately, the tests are conducted in some schools by the school district; however, the problem is usually other children are waiting to be tested, which could cause long waiting times. Also, in other school districts, the test expenses should be paid by the parents, and also test time scheduling is necessary. Therefore, some parents may not be able to pay for these expenses. You can communicate with other families who have been through the same procedure before for their children and ask them what the school district requires so that they may help you. Also, some schools may have special education teachers in their schools; therefore, you can ask for some advice about signing up for the program. However, keep in mind that even if you provide all the necessary paperwork, it is not guaranteed that your child will get the therapy for their needs.

Other Funding Opportunities

If you already tried the tips mentioned above, there are still options available to you. For instance, some treatment providers offer you services and set the price in line with the family income so that the services are accessible and reasonably priced. Also, other treatment providers could offer you a payment plan, where your child could get the essential services now, which requires you to pay back the bill later that is extended to a longer time. Usually, these payments are set to a low price, making the payment procedure easier, even for a long time. You can contact the potential providers to learn more about what options you have. Besides, you can benefit from scholarships and grants which are for children with autism spectrum disorders. Many of the scholarships and grant programs cover particular needs. Also, eligibility for many grant programs are different. For instance, some of the grant programs provide funding to active-duty military families and vice versa. If you do not belong to any of the grants, you can search for more general grants. For example, the CARE grant program offers many treatment services related to autism spectrum disorders. Other than that, more grant and scholarships programs include :

ACT today! Grants
Adonis Autism Assistance Foundation
Anchor of Hope Foundation
Autism Cares
Autism Family Resources Grants
Autism Now State Support Grants and Cash Subsidies
Disabled Children’s Relief Fund
The Ezra B. Smith Foundation for Autism Therapy and Education
Family First Program: National Autism Association
First Hand Foundation
Fund it Forward
Heal Autism Now
Maggie Welby Foundation Scholarships
Modest Needs Foundation
Small Steps in Speech

Therefore, enrolling in an insurance plan is not the only solution to get your child’s services covered. There are still many options that you could benefit from that are more affordable than an insurance plan may be.

For Insurance Tips in Other Countries

Visit this link for Special Education Insurance Guide and Tips in the UK.

Visit this link for Special Education Insurance Guide and Tips in Canada.