Is In-Home ABA Therapy Covered by Insurance?

If your child has been diagnosed with autism spectrum disorder (ASD), you are likely already searching for support and services that can specifically address the strengths and challenges that they face. In your search, you’ve probably come across applied behavior analysis, or ABA therapy, as it’s considered the gold standard treatment option for children on the autism spectrum.

There are many advantages to ABA therapy over other treatment plans, and one is the fact that it can be administered by trained professionals in your own home. Not only is this an extremely convenient option for parents, caregivers and other family members, it also ensures your child feels comfortable in an environment they’re familiar with and provides opportunities to learn in practical ways.

One thing you might be wondering, though, is whether in-home ABA therapy is covered by insurance. While the answer to that question will depend on a number of different factors, we’ll discuss it in more depth below.

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Do Insurance Companies Have to Provide Coverage for ABA Therapy?

A federal mandate was passed in 2014 that required all Medicaid programs across the country to provide children with ASD any treatment and diagnostic service that was deemed “medically necessary.”

It took seven more years, but by 2021, that insurance mandate was formally adopted by every U.S. state. What this means is that all Medicaid programs in the U.S. must provide some coverage for children with ASD, and that often includes ABA therapy.

What’s more, all states also have mandates in place that state that even private insurance companies must offer at least some coverage for treatment of ASD. That being said, there are no uniform standards that are set for these, as each state has a right to create whatever requirements, coverage limits and mandates are in place.

In addition, self-funded insurance plans that are provided through an employer must follow federal laws, but don’t necessarily have to provide the benefits that state law outlines.

What Are the Requirements to Have In-Home ABA Therapy Covered by Insurance?

Each insurance plan may vary in the specific requirements for qualifying for in-home ABA therapy coverage. This is true of Medicaid and private health insurance plans, as well as from one state to the next. Most insurance plans, though, will require that the patient must be under a certain age — 18 or 21 in most cases — have an official ASD diagnosis by a professional trained to do so and be recommended specifically for ABA therapy.

There is often a great onus on the parents to make sure they follow all the proper steps and have all the required documentation in order for their child’s in-home ABA therapy to be approved.
Once it is approved, what insurance will cover exactly will, again, vary from one plan to the next. Some will have a cap on the number of hours of ABA therapy per week that will be covered, while others will set a total dollar coverage limit.

That’s why it’s so important for parents of children with autism to fully understand their specific health insurance plan so they can be prepared for what’s ahead.

Does It Matter Where the ABA Therapy is Administered?

Typically speaking, ABA therapy is either administered in a clinical setting or directly in the child’s home. A common question parents have is whether the setting matters in terms of getting the therapy covered by insurance. Unfortunately, the answer to this question is — it depends on your specific insurance company.

Luckily, more insurance companies today are fully understanding the benefits of in-home ABA therapy and are including it as a covered option for children with autism. However, this isn’t true across the board.

Again, all of this emphasizes just how important it is to investigate your specific insurance plan to figure out what coverages are available to you, and contact the company directly if you have questions.

Blue Gems ABA Works with Many Insurance Companies

Having your child’s ABA therapy covered by your insurance plan is something that you’re very likely interested in. That’s why at Blue Gems ABA, we work with many insurance companies so we can serve our patients best. As mentioned above, what type of coverage your insurance plan will provide is very plan-specific. That’s why it’s always advisable to research the details of your plan so you can find out whether your child’s in-home ABA therapy will be covered. To learn more about what we do at Blue Gems ABA, and how we can help your child with autism grow, please contact us today.