Get Autism Treatments Covered By Health Insurance

Autism Coverage May Be More Generous Than You Think

Boy with Doctor
Boy with Doctor. John Howard

Can you get your health insurance to cover the costs of autism treatment? Of course, the answer will depend, in part, on the insurance coverage you have and on the types of treatment you're seeking. But even if your insurance doesn't cover anything called "autism treatment," there's a good chance you can get many important treatments covered.

What Is "Autism Treatment?"

There is really no such thing as "autism treatment." There are, however, a wide range of treatments available for and appropriate for people on the autism spectrum. Many, though not all, are covered by most major medical insurance.

Covered therapies are most likely to include medications and well-established therapies (speech, physical therapy, occupational therapy). Many insurance companies will also cover the cost of a psychiatrist (at least for some period of time). More autism-specific therapies, such as ABA (behavioral therapy), feeding therapy, or developmental therapies such as Floortime or sensory integration therapy, are less likely to be covered. The good news, however, is that many such therapies are provided, free of charge, through school districts.

Nine Steps to Insurance Coverage

Before settling on an insurer, therapy, or therapist, go through these nine important steps. If you find, after completing these steps, that certain therapies aren't covered, you have a few options. First, you can decide to self-insure (pay of pocket). Second, you can turn to your school district to ask for the therapies you want; in some cases they'll be able and willing to provide them (though you may have no choice about the provider or number of hours). Third, you can decide to change insurance companies based on what they cover. Finally, you can decide to either go without the therapies or (when possible) provide them yourself.

  1. Call your health insurance provider and ask these critical questions: 1) What are my individual and family out-of-pocket deductibles? What are my out-of-pocket maximums before 100% reimbursement begins? 2) How many visits per specialty (ie PT, OT, Speech) does my insurance plan allow per year for out-of-network providers? 3) Are there any limitations on diagnosis codes? 4) Does my plan have mental health coverage?
  2. Ideally, you will receive positive and helpful answers to the questions you pose in Step One. If you don't, it may be time to change insurance providers. According to Christina Peck, the ideal type of health insurance for the parent of a child with autism is a PPO or Preferred Provider Organization. If you are covered under an HMO and can make a switch through your employer or on your own, Peck recommends you do so.
  3. Get the details on coverage of specific therapies. Most children with autism will need physical, occupational and speech therapy. They may also need psychological, feeding, social and behavioral (ABA) therapy. Does your insurance company cover these therapies? If so, what are the deductibles? How much therapy is covered per year?
  1. Get the details on coverage of supplies and equipment. If your child with autism needs an augmentative speech device or other equipment, the cost may be covered.
  2. Know your insurance codes and units. Peck notes that all insurance companies use the same codes for the same diagnoses and therapies -- but there are different codes for different units of time spent on those therapies. For example, the code for one hour of speech therapy is different from the code for just 15 minutes of physical therapy. Be sure your therapists know which code is appropriate for their service, and how many units to charge for. Your physical therapist, for example, might need to charge for four units of therapy to cover the costs of a one-hour session.
  3. Get creative in your insurance claims. Most insurance companies limit therapies as they relate to autism per se, but Peck suggests that parents think outside the "autism box" when making their claims. For example, she says, "Is your child getting Occupational or Physical Therapy because they have autism? Or is it because of hypertonia (low muscle tone)? Why should your therapist use the code for autism instead of coding for the actual issue involved?"
  1. Organize your paperwork. Christina Peck, in her book Blessed with Autism, includes a set of worksheets you can use organize information about claims you've made, claims that are pending, and grievances you may have filed.
  2. If you feel you have the right to insurance coverage based on your policy, and you are running into problems getting that coverage, consider resubmitting, following up on your claim and even filing a grievance. Through a combination of knowledge and assertive follow-up, you may be able to save a great deal of money over time.
  3. Once you have a solid understanding of what your health insurance will cover, research your state's offerings. Some states require that insurance companies cover autism-related claims; others offer services through the Department of Mental Health and Retardation. By mixing and matching insurance and state-funded coverage, you may find that many of your child's services are covered.
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