Is ABA Therapy Covered By Insurance in Tennessee?

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A young boy with autism playing with a sand filled sensory table next to his RBT
Published:  August 15, 2023

When it comes to accessing essential autism services, understanding your insurance coverage is crucial. For families impacted by autism, Applied Behavior Analysis (ABA) is often a critical component of their treatment plan. Understanding ABA therapy insurance coverage in Tennessee can help you get your child the support they need to reach their full potential.

Tennessee Autism Insurance Reform

Tennessee’s mandated ABA therapy coverage reflects a significant stride towards ensuring equitable access to healthcare programs for individuals with autism spectrum disorder (ASD). The enactment of the Autism Insurance Reform Act in 2019 underscores the state’s commitment to providing comprehensive care for children on the spectrum. This legislation requires private health insurance plans to cover medically necessary treatments, including ABA. This also applies to the state’s Medicaid program, TennCare.

As a result, families in Tennessee have the opportunity to access ABA therapy, an evidence-based intervention that fosters independence, communication, and social skills. This mandated coverage not only alleviates the financial burden on families but also empowers them to seek consistent and effective treatments that can greatly improve the quality of life for children with autism.

ABA Therapy Insurance Coverage in Tennessee

For children under the age of 21, TennCare provides an avenue for consistent and intensive therapy, covering up to 40 hours per week. This commitment to extensive coverage reflects the state’s recognition of the importance of early and intensive intervention for children with ASD. Moreover, private insurance options in Tennessee also contribute to the accessibility of ABA therapy. Children between the ages of 3 and 21, covered by fully-funded private insurers, can benefit from coverage of up to $60,000 per year for ABA therapy services.

Will Insurance Cover ABA Without An Autism Diagnosis?

When it comes to insurance coverage for ABA therapy, obtaining an autism diagnosis is typically the first requirement for eligibility. Insurance companies generally require a formal diagnosis of autism from a qualified medical professional to justify the medical necessity of ABA therapy. The diagnosis serves as a crucial basis for determining whether ABA therapy is appropriate and beneficial for a child’s specific needs. It’s essential that families seeking ABA therapy work closely with healthcare providers and their insurance company to ensure all necessary documentation and diagnostic criteria are met to maximize the chances of obtaining coverage.

How to Qualify for for ABA Therapy

The ABA insurance verification process involves a series of steps that families navigate to ensure access to essential care following a formal autism diagnosis. Once your child receives a diagnosis, the initial step is to verify insurance coverage for the preliminary ABA therapy assessment.

Verify Benefits

Check your qualifications by calling your insurance provider and share that your child has recieved an autism diagnosis. The payor should assist in understanding available resources. Wellspring Learning Centers will then verify benefits and explain coverage for your child, yet parents should additionally verify benefits in order to avoid any surprises and unforseen charges.

How to Get ABA Coverage

Here are the key steps for parents to advocate for ABA coverage on their insurance plan:

  • Research: Thoroughly research their insurance policy to understand coverage details.
  • Gather Documents: Collect relevant documents, including diagnosis, assessment reports, and ABA treatment recommendations.
  • Contact Provider: Initiate contact with the insurance provider to discuss their case and inquire about ABA coverage.
  • Maintain Communication: Keep clear and documented records of all conversations and correspondence with the insurance company.
  • Seek Professional Support: Enlist the support of healthcare professionals and ABA therapists who can provide expert opinions and advocate on their behalf.
  • Persistence and Collaboration: Remain persistent and collaborate with experts to ensure that their child receives the necessary ABA support and treatment.

Begin ABA Therapy Sessions

Once approval is granted, ABA therapy sessions can begin, offering valuable interventions to improve various functional areas in your child. It’s important to note that this process may be repeated if modifications are required in the treatment plan, ensuring that the therapy remains responsive to your child’s progress and evolving needs.

Understanding ABA Benefits with Insurance

At Wellspring Learning Centers, we aim to empower parents by clarifying the details of ABA insurance coverage. We’ll delve into the nuances of benefits, claims, billing codes, deductibles, copayments, and considerations for out-of-network providers below.

  • Benefits:
    • Contact your insurance provider or refer to your policy documentation to understand the specific benefits related to ABA therapy. This may include details on the maximum coverage amount, the number of sessions allowed, and any age or diagnosis restrictions.
    • Ensure you have a clear understanding of what ABA services are covered, such as assessments, therapy sessions, and associated services like speech or occupational therapy.
  • Claims:
    • Familiarize yourself with the claims submission process. Usually, this involves your ABA provider, such as Wellspring Learning Centers, submitting claims directly to the insurance company on your behalf.
    • Keep copies of all claims submitted and documentation for your records.
  • Billing Codes:
    • ABA therapy services are typically billed using specific Healthcare Common Procedure Coding System (HCPCS) codes. Common codes include:
      • 97153: Adaptive behavior treatment with protocol modification.
      • 97155: Adaptive behavior treatment by protocol, each 15 minutes.
      • 97156: Family adaptive behavior treatment guidance.
  • Deductibles:
    • Understand your insurance plan’s deductible, which is the amount you must pay out of pocket before your insurance coverage begins.
    • Determine if your ABA therapy expenses count toward your deductible.
  • Copayments:
    • Check your insurance policy to find out the copayment amount you are responsible for per ABA therapy session.
    • Be aware of any requirements regarding copayments, such as whether they must be paid in advance or after the session.
  • Out-of-Network Providers:
    • If you choose an ABA provider who is not in-network with your insurance, your coverage may differ.
    • Inquire about the out-of-network coverage, including any reimbursement rates and whether you need to submit claims on your own.
  • Preauthorization:
    • Some insurance plans may require preauthorization before starting ABA therapy. Contact your insurance company to check if this is necessary and follow the preauthorization process if required.
  • Appeals:
    • If your insurance denies coverage or claims, be aware of your right to appeal their decision. This may involve providing additional documentation and making a case for the necessity of ABA therapy.
  • Documentation:
    • Maintain meticulous records of all communications with your insurance provider, including names, dates, and details of conversations.
    • Keep copies of bills, claims, and any letters or documents related to ABA therapy.

Using the Katie Beckett Waiver for Autism Treatment

The Katie Beckett Medicaid Waiver is a Medicaid program in the United States designed to provide healthcare coverage for children with significant medical needs or disabilities, including those who may benefit from ABA therapy. This program is named after Katie Beckett, a young girl with severe disabilities whose case led to the development of this waiver.

To benefit from the Katie Beckett Medicaid Waiver, families typically need to apply through their state’s Medicaid agency, as the program operates at the state level and eligibility criteria can vary. It’s essential for families to understand the specific requirements and application process in their state to determine if their child qualifies and how to access ABA therapy and other needed services. This program has provided critical support for many families, making it more feasible for children with disabilities to access essential treatments like ABA therapy.

ABA Therapy with Insurance at Wellspring Learning Centers

At Wellspring Learning Centers we accept most major health insurance plans and are proud to accept Medicaid. We are committed to making the ABA insurance coverage verification process as seamless as possible. We will provide you with guidance and all necessary information to help your child with autism get access to this effective treatment. Contact us to learn more about our ABA therapy programs or get started today.

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