Covering ABA Costs
Tex. Insurance Code § 1355.015 (2007 Tex. Gen. Laws, Chap. 877; HB 1919 of 2007:, Fiscal Note)
Texas requires a health benefit plan to provide coverage for all generally recognized services prescribed in relation to autism spectrum disorder by the enrollee’s primary care physician in the treatment plan recommended by the physician. The law defines “generally recognized services” to include applied behavior analysis; speech, occupational and physical therapy; medications or nutritional supplements; and other treatments. This coverage may be subject to annual deductibles, copayments and coinsurance that are consistent with annual deductibles, copayments and coinsurance required for other coverage under the health benefit plan. 2009 Tex. Gen. Laws, Chap. 1107 (House Bill 451) amended the law to specify that a health benefit plan must provide coverage to an enrollee who is diagnosed with autism spectrum disorder from the date of diagnosis until the enrollee completes nine years of age (the law previously required coverage to an enrollee older than two years of age and younger than six years of age). If an enrollee who is being treated for autism spectrum disorder becomes 10 years of age or older and continues to need treatment, this does not preclude coverage of treatment and services.
Where do I begin?
Getting your health insurance to reimburse/cover ABA therapy can range from as easy as submitting a claim or as hard as taking your insurance company to court. There are many variables that affect how much your particular health plan will cover in your child’s particular case: type of plan, child’s diagnosis, type of provider, etc.. However, take heart in that there are more people getting reimbursement for ABA therapy every day. Filing claims with the insurance company can become overwhelming—especially if you have several young children at home. You may wish to hire a claims specialist. This is someone who can file the claims on your behalf and charges you a fee. There are two national organizations through which you can find a professional who may help you.
- First your child must have a diagnosis from doctor, and the doctor must prescribe Applied Behavior Analysis and specify that ABA is “medically necessary”.
- Next you need to know what type of health plan you have: fully funded, self-funded, individual, etc. Knowing the name of your insurance company does not tell you what kind of plan you have. Blue Cross Blue Shield, for example, can administer a self-funded plan for one company and offer fully funded plans to another. (NOTE: You cannot compare the benefits that your insurance company, say Blue Cross Blue Shield, offers you to the benefits of another person at another company that uses Blue Cross Blue Shield. Each employer buys a unique set of benefits to offer their employees based on the cost of the benefits to the company.)
- Use your employer’s HR department as a resource to learn what coverage your child has access to. Ask to see the Summary Plan Document for your company’s insurance program.
- You may want to request a case manager from the insurance company so that you are not speaking with a new person each time you contact them.
- Keep a log of your conversations with the insurance company. Try to get as much in writing as possible.
About half the people in Texas are insured through self-funded plans. This term describes plans in which the company directly pays for the health care costs and contracts with an insurance company, like Aetna or Blue Cross Blue Shield, to administer its health plan, keeping track of the claims and paying them, for example. The good news is that your company is the one who decides which benefits to include or exclude in the contract that they sign with the administering insurance company. The first health plans that reimbursed for ABA programs were self-funded plans. They did this after employees advocated to secure reimbursement for ABA programs. The amount of advocacy required has varied significantly from company to company—from a written request to the human resources department (HR) of the company to years of appeals within the company to a full blown lawsuit– but it has been done. If your self-funded plan does not currently cover ABA, you, as an employee, can appeal directly to those decision makers within your company. You may wish to download the PowerPoint presentation available at
Autism Votes under Resources that helps educate companies with self-funded plans about autism and its treatment.
This link will provide you with detailed information about self-funded plans including what the appeal process looks like:
Another bright spot is that in 2008, as a part of the economic bailout package, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008” was passed to close the previously existing loopholes in mental health coverage that allowed limitations on the number of visits and dollar amounts for therapy. The number of therapy visits has been one of the largest barriers for getting coverage of ABA because ABA differs significantly in intensity and duration from other mental health therapy models for other conditions. If a company offers a mental health benefit, the benefits, copays and financial limits must match those offered under the plan’s medical/surgical coverages.
Fully funded plans are regulated by the Texas Department of Insurance (TDI)
Texas Department of Insurance. As of January 1, 2010, state funded plans were mandated to provide coverage to children up to age 10 years old with autism in Texas. The legislation in the 2009 session and the 2007 sessions of the Texas Legislature:
- redefined autism as a medical, neurobiological disorder
- mandated that if a physician prescribes evaluations and assessments, ABA, speech, behavior training and management, occupational therapy, physical therapy, medications or nutritional supplements for a child with autism ages 3 – 10, they must be paid for out of surgical and medical benefits rather than mental health benefits.
- provided definitions or criteria that allow board certified behavior analysts and board certified associate behavior analysts to be considered approved providers for reimbursement.
- included language that the mandated age range cannot be used as an excuse to stop benefits just because a child turns 11 years old.
FEAT-Houston lauds the work that Sen. Eddie Lucio Jr., Rep. John Davis, Rep. Juan Garcia, and Rep. Todd Smith have done to obtain better insurance coverage for children with autism in Texas. The bills that accomplished this passed only as the result of grassroots advocacy throughout the state of Texas. It is one of a series of mandate bills that have been passed in various states. For a complete up-to-date list on state initiative throughout the country please go to
Clearly, more work needs to be done so that all persons with autism spectrum disorder can have appropriate services reimbursed through their insurance plan as well.
Please note that plans that are fully funded by the company or organization providing them (self-funded plans) are NOT governed by ERISA, and so are NOT affected by the passage of the “Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008”
If you find yourself in a dispute with your insurance company, please contact TDI
Texas Department of Insurance. It is also wise to “cc” all your correspondence with your state representative and state senator as well so that your case can be resolved quickly. You can find out who represents you here:
Federal Medicaid requires that all reimbursable services be provided by a “licensed practitioner of the healing arts”. At this time, there are only a few states in the US which offer licensure for board certified behavior analysts (BCBAs). Texas is not one of them, and therefore does not cover ABA therapy. Most states do not have income or asset tests for Medicaid eligibility for children who have disabilities. However, a check for services called “Behavioral Health Rehabilitation Services” is recommended. Medicaid Waivers may also be available under the “Katie Beckett Waiver”. A child with special needs often qualifies when the parents’ income exceeds normal Medicaid guidelines. The following link has more information:
Other Funding Resources
Behavioral services may be accessed in a variety of ways. Behavioral services can be paid for with funds available through insurance, grants, federal and state agencies, and through private means. In addition, behavioral services can be provided by school, Early Childhood Intervention services, and local Service and MHMR centers.
Early Intervention Services: Birth to 3
For children under the age of 3, each state provides services under the Individuals with Disabilities Education Improvement Act (IDEIA). Each state must assess your child to determine if your child meets the eligibility criteria. In most states, the child must have an identified disability such as Down syndrome or they must qualify based on a developmental delay.
If your child is eligible, then you and the specialists will develop an Individualized Family Service Plan (IFSP). That plan will determine what services your child needs and how often they are needed. In most states, these services are free. However, in some states, the services are provided on a sliding scale. Further information about Early Intervention can be found at NICHY.org (
If you think your child has a behavioral need, contact your provider to request an assessment. In Texas call 1-866-581-9328.
Public School Provision of Behavioral Services; Students Age Three to 21
For children who are 3 years up to age 21, behavioral services are provided by the school district. If you think your child has a behavioral need, you will need to request an assessment from the district to determine if your child has a disability or if special behavioral supports are needed.
If your child has an Individualized Education Program (IEP), then you will need to request additional services for your child’s IEP. Usually a request for a functional behavioral assessment will be sufficient to start the process. Further information about behavioral service provision and public schools can be found at the US Department of Education (
Individuals with Disabilities Education Act (IDEA). For information on schools, discipline and behavior, Wrightslaw carries a number of relevant articles and links (
Individuals with Disabilities Over 21
Behavioral services and supports are provided by a state agency. In Texas, the services are provided by the Department of Aging and Disabilities. In Connecticut they are provided by the Department of Developmental Services. You will need to complete various applications to be approved for funding.
In Texas: Contact the Department of Aging and Disability Services (webpage:
United Healthcare Children’s Foundation:
United Healthcare Children’s Foundation
What are the grants? The grants provide financial relief for families who have children with medical needs not covered or not fully covered by their commercial health benefit plan. The Foundation aims to fill the gap between what medical services/items your child needs and what your commercial health benefit plan will pay for.
How does the grant work? If a grant is approved by the Regional Board of Directors for your child, the grant will help pay for approved medical services/items after your commercial health benefit plan submits payment, if any. The grant funds are not paid to you or the child outright – you work with the Foundation on submitting invoices/bills for approved medical services/items after your commercial health benefit plan submits initial payment (if any) to the health care provider.
USA armed services:
“TRICARE”, the military insurance, is authorizing ABA as an educational benefit to be cost-shared under the Program for Persons With Disabilities (PFPWD). Families in the military should contact their local Tricare office to obtain a case manager under the PFPWD.” (Benefits may be limited to $1000/month.)
Health and Behavioral Health Insurance
Many states now have mandated health insurance coverage for ABA services for children with autism. However, these laws apply to certain insurance companies. Self-funded insurance companies do not have to abide by these laws. These laws only pertain to children with autism and do not include ABA services for children with other types of disabilities. (See Richard Saffran’s webpage on Autism: http://rsaffran.tripod.com/aba.html. It has a lot of very helpful information.)
Services in Texas Only
DARS grant programs
Autism spectrum disorder (ASD) is the fastest-growing serious developmental disability in the United States, affecting an estimated 1 percent of children.1 It incorporates diagnoses of Autistic Disorder, Pervasive Developmental Disorder – Not Otherwise Specified, Rett’s Disorder, Asperger’s Disorder, and Childhood Disintegrative Disorder. In 2008, there were approximately 50,100 Texas children under age 21 with ASD.2 With this number growing at a significant rate, there continues to be an unmet need for services. The DARS Autism Program was developed as an attempt to mitigate this need.
In August 2007, the Legislative Budget Board, in conjunction with the Office of the Governor, instructed the Health and Human Services Commission to transfer $5 million in general revenue for the biennium to DARS to fund services, such as applied behavior analysis (ABA), for children ages three through eight with an autism spectrum disorder. Current providers listed below:
1. Child Study Center, Ft. Worth, TX
2. Easter Seals-North Texas, Carrollton, TX
3. MHMRA-Harris County, UH-CL, Houston, TX
4. Texana Center, Rosenberg (Houston), TX
5. Any Baby Can + TSU, San Antonio, TX
6. Center for Autism and Related Disorders (CARD), Austin, TX
Insurance Coverage Information Courtesy of Families for Effective Autism Treatment (FEAT)-Houston