Does ABA fall under speech as far as insurance purposes?

ash2 · May 2012

We are looking into programs for our DS, but have been told by one of the clinics that ABA may not be covered by insurance. I called our insurance provider and they said they didn't know. We are covered for speech therapy and developmental delays, but it doesn't list ABA specifically. The insurance company told me that the clinic would have to submit a letter of medical necessity to them with diagnosis and CPT codes and then they would know for sure. Is it typically covered?

redtulip · May 2012

No, not that I am aware of. Your insurance policy must state ABA therapy coverage or you live in a state that has a law mandating coverage for fully funded policies.

lite-bright · May 2012

I'm pretty sure that ABA does not equal speech therapy in the eyes of insurance. If your insurance covers therapy for developmental delays, that's your best bet that ABA is covered.

And I think it's pretty common for it NOT to be covered, unfortunately. It's good that the clinic gave you a heads up on that. Our insurance -- which is a self-insured group plan through a Fortune 100 company -- does not cover any therapies for autism, period. They specifically exclude autism as a covered dx, in fact, which was an ugly thing to find out when you need that therapy for your child.

Despite the fact that CO has a law that mandates that insurance companies cover autism treatment, the fact that our plan is self-insured means that they don't have to obey state law on what they cover.

I would call the clinic and either get their billing codes for ABA and cross-check them with your insurance company, or talk with the clinic's finance/insurance person and give them permission to call your insurance company to check the details of your coverage. They deal with this stuff all the time and IME have been very helpful. "I don't know" if you're covered is not an acceptable answer from your insurer when you're talking about hundreds or thousands of dollars a week in therapy costs that you could be on the hook for if they decide to deny coverage at any point.

GL!

st.augbride · May 2012

No, it's typically its own thing for insurance purposes, often through programs specific for autism or developmental delay coverage. The latter is how we qualified.

erkie · May 2012

ABA is not performed by a Speech & Language Therapist; it is performed by a Psychologist or Behavior Specialist. So, no, it would not be automatically covered even if Speech Therapy is covered. A good therapist will supply you with the ammunition needed to (hopefully) get it covered by your insurance. Good luck!

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Does ABA fall under speech as far as insurance purposes?

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