Due to the tireless efforts of parents of those on the Autism Spectrum along with countless others advocating reform, several states now mandate insurance coverage for Applied Behavior Analysis (ABA) services. For well over a quarter of a century, ABA treatment has provided undeniable, empirical results and data that demonstrate its effectiveness, particularly within the Autism population. Utilizing Applied Behavior Analysis (ABA) as a teaching technology and treatment model for individuals with Autism has been validated by The U. S. Surgeon General and the New York State Department of Health. ABA is the ONLY behavioral therapy covered by insurance companies in the 15 states, including Texas, that have passed insurance legislation mandating coverage for Autism.
State legislation that requires medical insurance companies to cover Autism is very promising for many parents of those on the spectrum, but not all insurance plans are the same. There are loop holes and hoops to jump through depending on the size of the organization that funds the insurance, whether it is a pre-existing condition, and multiple other nuances. Knowledge, persistence and patience are your best weapons in fighting the battles that will result in benefits for your Child.
There are two major and important categories of insurance policies that exist in the US that account for almost all policy holders in Texas. Fully-funded policies are regulated by the Texas Department of Insurance and self-funded policies by the U.S. Department of Labor. Simply stated, with a fully-funded policy, the insurance company is the entity that assumes all of the risk for a claim and then pays the claim. With a self-funded policy, the employer assumes the risk for claims and pays claims out of their own pocket. In this instance, the insurance company is only hired in order to manage the policy.
All of the Autism insurance legislation passed in Texas pertains to fully-funded policies only and requires insurance companies providing these policies to help fund ABA treatment for Children diagnosed with Autism or Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS). In Texas, this coverage is mandated from the time of diagnosis until the day your Child turns ten years old and no limits are placed on the number of visits per year a Child may access therapy. Self-funded policies may offer help paying for ABA services at their own discretion, but may limit the coverage and number of visits per year.
One of the most important things to know when looking into coverage for your Child is that insurance companies are still learning the ropes when it comes to understanding and implementing what it is they are supposed to be covering. Many times you, the Parent, must educate the person from the insurance company on what they should be covering and why. It can be frustrating, but a little research goes a long way. Don’t ever hesitate to ask to speak with a supervisor if the person you are dealing with doesn’t understand or know what you are talking about. Don’t give up until the battle is won!
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