The Struggle for ABA Coverage

When 2-year-old Tony Burke was diagnosed with autism, his parents like many in their shoes, wanted to get him the best services they could that would serve their child’s needs. After doing some research they decided to start him with applied behavioral analysis therapy or ABA therapy, which is considered to be one of the most effective treatment methods for those on the spectrum. After some time, Tony’s grunting noises turned into words and then smaller sentences—the therapy was working. But then something happened that slowed down all his hard work—his family’s insurance started to deny claims.

In Pennsylvania, health insurance laws require ABA therapy to be covered, though in Tony’s case, his therapy was not covered in school, where he needed the most help. His family all of a sudden could not afford o pay therapy costs—adding up to $80,000 a year. These autism coverage acts were passed since 2010 in states like Pennsylvania and New Jersey, but coverage for ABA therapy still remains hard to obtain.

The prevalence of complaints can be hard to assess since the law also requires Medicaid to cover autismservices leaving providers who don’t get paid by private insurance with the option to just bill Medicaid. Some insurers also avoid covering therapies a child can get at school, including ABA, by dumping cost onto public schools or other agencies.

Another major problem is delayed payments. Kara Matunas from New Jersey had her claims for her 2 year old autistic daughter repeatedly denied. Her daughter Reagan, was receiving early intervention, speech, developmental, and occupational therapy. Two of the denials were reportedly “incorrectly generated due to a manual handling error.”

“They’re just purposely delaying coverage,” Mrs. Matunas explains. Even when the claims are eventually paid, the family is left paying $400-$500 a month which can be especially hard on even middle-class families. Autism laws apply only to fully insured plans where companies have a contract with insurance companies to pay claims. However, as more and more large firms are converting to self-funded plans where they have to pay for care more directly from their own wallets, coverage seems harder to come by.

Shema Kolainu – Hear Our Voices is a non-profit school and center for children with autism that offer a variety of services at no cost to families all over New York City. They not only offer center-based services, including ABA, speech, art, occupational, therapies to name a few, but also home based services that reach hundreds of families. Organizations like Shema Kolainu have had great success in helping children on the autism spectrum from early intervention to school-age children, and hope to offer services to families like the Burke’s and Matunas who need these services to help their children succeed.