Applied behavior analysis (ABA therapy) is typically prescribed for children who are diagnosed with autism spectrum disorder (ASD). As the leading treatment plan for children on the autism spectrum, it’s an evidence-based approach to learning and behavior that helps patients build social, communication and daily life skills with which they may struggle.

ABA therapy can be quite intensive, from both a time and monetary perspective. Some children are prescribed up to 40 hours per week of treatment, based on their specific needs and challenges. Not only can that cause a strain on time management in a family, but it can also present a financial strain as well.

Luckily, many health insurance plans in Missouri provide coverage for ABA therapy and autism-related services. In this article, we’ll explore whether Aetna covers ABA therapy in Missouri.

Does Missouri Mandate Coverage for ABA Therapy?

Missouri has required state-regulated health insurance plans to provide coverage for autism-related services for more than a decade, following the passage of landmark autism insurance legislation (HB 1311 and HB 1341), which was later expanded under SB 514.

Under state law, fully insured large group plans, fully insured small group plans and individual non-grandfathered health plans that comply with the Affordable Care Act (ACA) are required to provide meaningful coverage for the diagnosis and treatment of autism spectrum disorder.

The law states that coverage for ABA therapy must be given to individuals who are 18 years of age and younger.

While the original statute established a baseline cap of $40,000 per year for ABA therapy, Missouri law requires this limit to be adjusted regularly for inflation. As of recent regulatory updates, that annual benefit cap has adjusted upward to over $57,000 per year.

The law also specifies that this cap can be exceeded if the health plan determines that additional ABA services are medically necessary for the child.

Services that fall under the umbrella of Missouri’s autism mandate include diagnosis, habilitative or rehabilitative care (such as ABA therapy), psychiatric care, psychological care, pharmacy care and therapeutic care, which includes speech, occupational and physical therapy.

Does Aetna Cover ABA Therapy in Missouri?

Many of Aetna’s insurance plans provide coverage for ABA therapy in Missouri. It’s very important that you check the specific insurance plan you have, though, to not only make sure that it provides this coverage but what the limits are.

While Missouri has outlined the coverage that state-regulated insurance plans must provide, these are only minimum levels. In other words, your insurance plan may provide services above and beyond these levels if they choose.

There are some Aetna insurance plans that do just this, and even some self-insured employer plans (which are governed by federal ERISA laws rather than state mandates) that still choose to opt-in and provide robust autism-related coverage.

So, investigate what your plan specifically provides if your child has ASD.

How Do You Get ABA Therapy Covered in Missouri?

Every insurance plan is different, so it’s best to check what the rules, regulations and procedures are for getting your child’s ABA therapy services covered by Aetna. That being said, there are some general rules that you should keep in mind.

First, Aetna will require that you provide them with an official ASD diagnosis from a certified professional such as a developmental pediatrician, child psychologist or pediatric neurologist. In addition to the diagnosis, they must provide a letter of medical necessity that states your child requires ABA therapy as a result of their neurodevelopmental disorder.

Once those have been approved, you can search for an ABA therapy provider that is in your Aetna plan’s network. You probably will need to have the services pre-certified, which usually entails providing Aetna with your child’s detailed treatment plan designed by a Board Certified Behavior Analyst (BCBA).

After it’s fully approved, your child can begin ABA therapy services.

Under Missouri law, health carriers have the right to review the ABA treatment plan no more than once every six months, unless the provider and Aetna agree otherwise. Therefore, it’s likely that Aetna will need to re-approve your child’s ABA therapy on a periodic basis.

Blue Gems ABA Works with Most Insurance Companies in Missouri

ABA therapy can be expensive for families who have a child with ASD. Luckily, many insurance plans in Missouri, such as Aetna, provide coverage for ABA therapy and related autism services.

At Blue Gems ABA, we work with Aetna and most insurance companies in Missouri. Our team is experienced doing so, and we can help you navigate the intake process and get your child’s treatment plans approved so they are covered by insurance, taking a huge weight off your shoulders.

To learn more, please contact us today.