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ABA Therapy, Autism and Insurance Coverage. What's Covered?

Advocating for Our Clients:  A look into the true ins-and-outs of insurance-funded ABA services and how to use the law in favor of our services. 

Reeling from the experience of the Autism Law Summit, surrounded by parents, advocates, and clinicians from all walks, the knowledge we gained from the presenting group of experts is a boon to our field. Considering the nature of insurance funding, here are the details that seem the most important in advocating for our clients and their right to effective treatment.  
Insurance-funded services, based in the principals of applied behavior analysis, can occur in any environment deemed necessary to decrease deficits and increase and maintain functioning. What does this mean? Services cannot be denied based on location. Services can be delivered in a variety of settings, such as  school-based, or as a behavior analyst prescribes. This was confirmed in a decision granted in Burke v. Independent Blue Cross (IBC); the services to be provided to a 6-year-old boy in his elementary school were identified as medically necessary and the family was granted their services in the decision of this case. This case sets precedent in the denial of services based on location. 

There are no arbitrary limits on the number of hours a patient can receive of services based in the principals of applied behavior analysis; unless the insurer applies the same cap to other services covered by the member’s plan, to deny a dosage of intervention because the insurance company has adopted a maximum number of hours it will cover, was found unlawful in Wit v. United Behavioral Health (UBH). An insurer cannot deny your client treatment based on caps on number of hours or caps on the age of the recipient of services. 

The laws have passed, the decisions have been made, it is now our job to ensure the information is used to enforce the laws and court decisions. All but two states in the United States have laws mandating insurance funding for Applied Behavior Analysis; the feat now is ensuring those laws work for our clients. 

​-Danielle Tibert, M.Ed, BCBA, Director of Family Services
References
Advances in Autism Law 2017. Autism Law Summit. (2017, October 27).