Is ABA Therapy Covered by Insurance in Massachusetts? 

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Exploring ABA therapy for your child with Autism Spectrum Disorder (ASD) in Massachusetts naturally leads to an important question: Is the therapy covered by insurance in the state? As you seek to provide the best possible care for your child, understanding ABA therapy’s financial and insurance aspects is essential.  

Having a clear grasp of the insurance policies regarding ABA therapy in Massachusetts can potentially make your decision-making process smoother and more informed. Let’s examine how the insurance policies in the state handle ABA therapy. This can potentially simplify your transition from considering therapy to implementing it. 

How Much Does ABA Therapy Cost? 

Understanding the costs associated with ABA therapy can be pretty crucial for many families. Here, we break it down in simple terms with and without the support of insurance. 

Without Insurance 

The hourly rate for ABA therapy in the US is around $120. To illustrate, if a child requires an average of 22.3 hours of therapy each week, the family would be looking at a weekly expense of $2676, or $139,152 annually. 

On a smaller scale, 10 hours of therapy per week would cost $1200, amounting to $62,400 annually. However, in cases necessitating a comprehensive 40-hour therapy week, the costs skyrocket to $4800 weekly, or $249,600 annually. 

With Insurance 

Insurance can notably ease the financial burden, albeit the relief extent depends on the specific plan. Here’s a brief overview: 

1. Comprehensive Coverage: This covers most therapy costs, leaving families with minor co-pays, typically between $20 to $50 per session. 

2. Partial Coverage: This plan covers a portion of the therapy costs, with families shouldering the rest, possibly covering 30% to 50% of the total costs. 

3. High-Deductible Plans: Families initially cover a higher deductible, ranging from $1000 to $5000 annually, before the insurance completely takes over. 

At Circle Care Services insurance specialists can help families understand their coverage.

It’s beneficial for families to closely study their insurance policies to grasp the exact coverages. Although ABA therapy costs can be substantial, especially without insurance, informed choices and utilizing available resources can help make this vital therapy more financially accessible. 

Understanding Key Insurance Terms 

The therapeutic journey involves grappling with the language of insurance. Here are some of the essential terms you’ll encounter: 

Premium: The periodic payment, often monthly, that you make to your insurance company to keep your policy active. 

Deductible: The initial amount you are required to pay before your insurance starts covering the costs. 

Patient: Refers to the person receiving the services, which, in this context, would be your child undergoing ABA therapy. 

Co-pay: A predetermined amount you need to pay directly, usually at each service or appointment. 

Out-of-pocket: The total amount that you are required to pay personally in a year, which includes, deductibles, co-pays, and coinsurance. 

In-network: These are service providers with contractual agreements with your insurance company to provide services at a more affordable rate. 

By familiarizing yourself with these terms, you can confidently make informed decisions for your child’s therapy plan. 

Kinds of Insurance 

Insurance coverage falls into two main groups: public and private. Public insurance, such as MassHealth, is organized by the government and funded with state resources, offering essential health services. On the flip side, private insurance plans are created and run by insurance companies. Usually, either the individual or their employer covers the premiums for these plans. 

When looking into private insurance, it’s important to understand the two different plan structures: self-funded and fully-funded.  

In self-funded setups, employers have a bigger hand in shaping the plan’s details, giving them more control over the policy’s specifics. Meanwhile, fully funded plans are standardized packages crafted by the insurance company to accommodate various needs. Knowing the difference can help you choose a plan that fits your family’s unique requirements and budget. 

Is ABA Therapy Covered by Insurance? 

ABA therapy coverage can vary widely across the United States. The Affordable Care Act (ACA) generally requires commercial health insurance plans to include ABA therapy for children with ASD as an essential health benefit. Yet, the degree and details of the coverage can shift considerably depending on the state policies. 

Is ABA Therapy Covered by Insurance in Massachusetts? 

In Massachusetts, individuals diagnosed with Autism Spectrum Disorder (ASD) under the age of 21 can benefit from insurance coverage for Applied Behavior Analysis (ABA) therapy. Remember, securing pre-authorization from your insurer before commencing therapy can be a crucial step. 

Accessibility to ABA therapy took a positive turn in 2011, with private insurers extending coverage, a move reinforced by MassHealth in 2015. Eligibility primarily encompasses children below 21 diagnosed with autism through MassHealth Standard and CommonHealth programs. Getting covered is as simple as getting a recommendation from a pediatrician or neurologist and finding an approved provider. For a smooth process, start early, particularly if transitioning from Early Intervention services.  

Here are a few additional things to keep in mind: 

• The amount of coverage you receive will vary depending on your specific insurance plan. 
• Some insurance plans may limit the number of hours of ABA therapy covered per year. 
• You may be required to pay a co-pay or deductible for ABA therapy services. 
• Check with your insurance company for specific information about your coverage for ABA therapy. 

Should you find it challenging to secure insurance coverage for ABA therapy, contact the Autism Insurance Resource Center (AIRC). This organization can offer valuable guidance on the autism insurance regulations in Massachusetts. It can help you advocate for your child’s right to appropriate coverage. 

If You Need Help with Autism Services 

ABA therapy is a powerful tool for many families with children diagnosed with ASD. While the costs might seem overwhelming initially, acquainting yourself with the different insurance options available in Massachusetts can make the process significantly more manageable.  

Securing autism services in Massachusetts is not a task you must face alone. Circle Care Services can help you determine how much your insurance will cover for services. We offer a no-cost insurance eligibility check where our ABA insurance specialist will  

• Look into your Massachusetts insurance benefits 
• Let you know exactly what will and will not be covered by your specific plan. 
• Advise you on available options if there are options for better coverage.  

Circle Care is here to help families.  

Give us a call and find the help you need to help your child with autism begin to progress with ABA therapy.  

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