Advocacy efforts at the local and national level have led to many health insurance plans offering coverage for Applied Behavioral Analysis (ABA) under the Maryland Habilitative Services Mandate. However, it can be difficult to tell if your particular plan offers this coverage, since health insurance plans vary depending on many different factors, one of the most important being whether the plan is regulated by the state or federal government. This insurance guide from Pathfinders for Autism can help you to determine what coverage your plan offers. To learn more about the Maryland Habilitative Services Mandate, read on.
Coverage Plans in Maryland
The Maryland Habilitative Services Mandate has ensured that all health insurance plans sold in the state of Maryland include an autism treatment benefit for children up to age 19. Individual Plans and Employer Provided Plans are both covered. The mandate includes coverage for:
- Behavioral health treatment (including Applied Behavioral Analysis)
- Psychological care (including direct or consultative services and psychotherapy)
- Therapeutic care (including speech therapy, physical therapy, and occupational therapy)
Children from 18 months to 6 years old are covered for 25 hours of therapy per week, while children aged 6 years old to 19 years old are covered for 10 hours of therapy per week.
You may live and/or work in Maryland, but if the company you work for is not based in Maryland, your Employer Provided Plan may not offer coverage for Applied Behavioral Analysis. Be sure to talk with your employer to determine what your health plan covers.
Coverage under Federally-Regulated Plans
- Federal Employee Health Benefits: All FEHB plans will cover ABA benefits to children on the autism spectrum as of 2017.
- Military Health Plans: Beneficiaries diagnosed with ASD are provided limited coverage under the TRICARE Comprehensive Autism Care Demonstration (Autism Care Demo).
- Medicaid: As of 2017, the Maryland Medical Assistance program covers ABA therapy services that are medically necessary for enrolled members under the age of 21.
- Employer Self-Funded (Self Insured) Plans: Although employer self-funded plans are not mandated under federal law to provide autism benefits, many employers still choose to provide them. Review your plan options carefully during open enrollment. If your employer provided health care does not offer autism benefits, you may want to have a conversation with your employer. You may also decide to enroll in a Child Only Plan.
How to Qualify for Applied Behavioral Analysis
Just because you’re covered does not mean that you will automatically qualify for services. To qualify for services, you should be able to provide the following:
- A formal diagnosis in writing from a licensed professional
- A prescription for ABA outlining medical necessity
- A treatment plan outlining treatment goals
It’s also important to note that you must also find a service provider who is licensed, certified, or otherwise authorized under the Maryland Health Occupations Article in order for your insurance to pay for habilitative services. Find a licensed provider in Maryland here.
The Connections Therapy Center
The Connections Therapy Center serves families of children and adolescents with disabilities and special needs. We are a team of experts in the fields of pediatric speech, occupational therapy, speech-language pathology, and behavioral sciences. As a team, we offer intensive hands-on therapy for children and adolescents, as well as informative and useful resources for families. If you are interested in learning more about what we can do to help your family, visit us online or give us a call at (202) 561-1110 (Washington, D.C. office) or (301) 577-4333 (Lanham office). Want to get more information on how to help your child thrive? Follow us on Facebook, Twitter, LinkedIn, Google+, and Pinterest.