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By Athena Mandros

The rising prevalence of autism (see U.S. Child Autism Prevalence Up To 1 In 45 and Increase In Autism Prevalence Attributed To Better Detection) and states’ decisions to mandate health plan coverage of treatment for autism spectrum disorders (ASD) has been a big issue for the health and human service field. It has also brought a new look at applied behavioral analysis (ABA), the often preferred treatment modality for individuals with ASD.

Applied Behavior Analysis (ABA) is an evidence-based treatment used since the 1960s to improve cognitive skills and language skills for individuals with autism spectrum disorder (ASD). Drawing from the field of behavioral analysis, ABA uses positive reinforcement to modify behavior. Importantly, ABA is considered an umbrella term and there are a variety of autism treatments – discrete trial training and pivotal response training – that can be considered a type of ABA treatment.

Who can deliver ABA services is dependent upon state regulations. Most states require ABA to be delivered by applied behavior analyst or an applied behavior analyst paraprofessional who is licensed through the Behavioral Analyst Certification Board, Behavioral Sciences Regulatory Board, Allied Mental Health and Human Services Professionals or the state licensure board (see Overview of State Laws to License or Otherwise Regulate Practitioners of Applied Behavior Analysis). Generally becoming an applied behavior analyst requires either an advanced degree or bachelor’s degree, but in some states others may be able to obtain certification to provide ABA services.

What states require commercial health plans to provide ABA? The past year has brought major changes to the field of autism insurance mandates with five new states requiring coverage of treatment for autism spectrum disorder (ASD). Those states include:

  1. Georgia – Georgia Requires Commercial Health Plans To Cover Autism Diagnosis & Treatment, Effective July 2015
  2. North Carolina – North Carolina To Implement Autism Insurance Coverage Mandate Effective July 1, 2016
  3. South Dakota – Daugaard Signs Autism Therapy Coverage Compromise Measure
  4. Hawaii – Hawaii 42nd state to pass autism insurance reform
  5. Mississippi – Mississippi 40th State to Enact Autism Insurance Reform

With the inclusion of the five states that passed autism insurance mandates this year, there are now 43 states that require the coverage of ABA. Of course, these mandates have a number of catches:

Application to a subset of health plans – The autism insurance mandates only apply to commercial health plans and then often a subset of health plans. For example, the mandate may only require the coverage of autism spectrum disorder for large group plans, excluding health insurance marketplace plans and individual policies.

Age restrictions – Most states restrict how long an individual can receive treatment services for autism spectrum disorder. In some states such as Georgia and Virginia, this age limit can be as low as age six. However, the majority of states (23) set the age limit at 18 or 21.

Dollar restrictions – Most states place an annual limit on the amount of services a health plan has to provide. The limit can either be a restriction on the number of hours provided or the total cost of care. In some states these limits specifically apply to ABA while in a few states (10) these limits apply to all benefits related to the treatment of autism spectrum disorder. States set the annual benefit limit for ABA at 25,000 to 50,000 with most states capping the benefit at $36,000. The Centers for Disease Control and Prevention (CDC) states that the cost of intensive ABA treatment (25-40 hours a week) on average costs in between $40,000 and $60,000 (see Autism Spectrum Disorder: Data & Statistics).

OPEN MINDS Senior Associate Lora Perry, Board Certified Behavior Analyst, noted:

Lora Perry

While the scope of mandates is different from state to state, this is certainly a step forward for children who do not have Medicaid. Medicaid covers applied behavior analysis for children who have autism under specific state Medicaid benefits, or under EPSDT. Given that $176 -196 billion dollars a year are spent annually on services for adults with autism, effective treatment for children on the spectrum is a critical investment in managing to future costs of the disorder over an individual’s lifetime (see Autism Facts and Statistics).

For more on this topic see: What States Mandate ABA Benefits For Autism Spectrum Disorder?: An OPEN MINDS Market Intelligence Report. The report provides a state-by-state analysis of autism insurance mandates including age limits, excluded health plans, limitations on services, and answers a number of key questions:

  1. What Is Applied Behavior Analysis?
  2. How Are ABA Services Covered?
  3. What States Require Health Plans To Cover ABA Services For Autism Spectrum Disorder?
  4. What States Require Health Insurance Marketplace Plans To Cover ABA For Autism Spectrum Disorder?

The report is free to all OPEN MINDS Circle premium members, and can be purchased in the OPEN MINDS e-Store for $495. And for even more, check out, An Autism Reality Check, which provides great insight into how provider organizations can tailor their services and organizations to better service individuals with ASD.


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