How Insurance Plays a Role in Your Child’s Program

At Autism Learning Partners, we are here to make sure your child and family receive the care that you need. The beginning of that journey starts with your insurance coverage. Understanding and navigating coverage can be difficult, and at times, overwhelming. Our knowledgeable team of experts will advocate for you and determine the appropriate steps for your child to begin their program.

In the United States, there isn’t a one-size-fits-all response to insurance coverage, however, steps have been taken in recent years to ensure that those who need it, can receive autism-related care. The Affordable Care Act, enacted in 2010, outlines provisions for autism and other related conditions for children and their families. This includes preventative autism screenings for children at 18 and 24 months without a copayment or coinsurance. As of 2019, all 50 states and Washington, D.C. require some level of insurance coverage for the treatment of Autism Spectrum Disorder. While there are mandates in place, coverage for Applied Behavior Analysis (ABA) services varies from state to state. 

To better understand the role insurance plays in your child’s program, we’ve outlined the significance and impact in each step you’ll take.

ASD Evaluation Process

If your child is referred for an Autism Spectrum Disorder diagnosis, Autism Learning Partners’ Intake Care Coordinators will provide you with a list of partnered diagnosticians in your area. In select states, such as New York and Texas, we have diagnosticians onsite at our centers. 

Next Steps After Receiving an ASD Diagnosis 

During the intake process, one of our Intake Care Coordinators will verify your child’s insurance benefits and discuss them with you to ensure you understand the benefits covered. Our team works to obtain the authorization for services to begin in addition to a copy of the diagnostic evaluation. 

In some states, there are exceptions for bypassing a formal diagnostic evaluation: 

• In Colorado, if you have Medicaid, your child can get Applied Behavior Analysis services by providing the screening results conducted during your child’s latest well child visit and a letter from your child’s doctor. The letter needs to confirm if your child is medically stable to receive ABA therapy and if your child needs 24-hour monitoring or procedures provided in a hospital or intermediate care facility. 
• In North Carolina, if you have Medicaid, your child can receive Applied Behavior Analysis services through a provisional diagnosis if they are five years old and under. You will need to provide a copy of the Modified Checklist for Autism in Toddlers, Revised (M-CHAT) neuropsychologist or developmental pediatrician’s report showing the initial testing signed by an M.D. or Ph.D. level doctor that was done to determine a diagnosis. You will also need an Research Based Behavioral Health Treatment (RB-BHT) service order letter of recommendation for ABA therapy or a prescription signed and dated from an M.D., D.O. or Ph.D. doctor for ABA therapy.
• In California, regional centers will cover Applied Behavior Analysis services, Speech Therapy, Physical Therapy, and Occupational Therapy for children five years old and under. 

Benefit Coverage

Parents should be aware of the type of insurance plan that they have – a Fully Funded Plan, PPO, or HMO. Each plan will determine their benefit coverage, including which healthcare providers are contracted with their plan, covered and non-covered benefits, authorization requirements, and cost share information such as deductibles, coinsurance, and copayments. 

Your patient responsibility portion depends on your insurance coverage. During the intake process, Autism Learning Partners staff will verify the insurance information you provide as well as the copayment, coinsurance, and deductible related to your plan and provide these details to you. Your patient responsibility portion will be charged or billed to you after your insurance adjudicates your claim to ensure the correct amount. Please contact your insurance company or refer to your benefit plan for more information about what your out-of-pocket costs may be in relation to your care.

In order to ensure an accurate and timely client billing process for families, Autism Learning Partners automates credit card charging for rendered services at the point when your claim is processed by your insurance company. In order to automate this process, we ask clients to keep their credit card on file for the duration of care. Please keep in mind that there will be no charges made to your card until your treatment begins. 

Secondary Insurance

Autism Learning Partners will not initially charge your card for patient responsibility if you have a secondary insurance on file. We will bill your secondary insurance for any outstanding balances, following your primary. You will be billed for any patient responsibility balance remaining after all insurance plans adjudicate your claims. If you do not have a secondary insurance during your initial intake process but add one later,  you may inform an ALP staff member at that time so we can verify your coverage and add it to our system.

If your insurance ever changes throughout your child’s treatment plan, please notify an ALP staff member to navigate a smooth transition and ensure that services are not disrupted. ALP will also work with you to verify your new benefits.

If you have any questions about our insurance coverage, please visit our website or call our Intake Care Coordinators at (855) 291-3623 ext. 276. Our team is eager to assist so you can prioritize the health of your child and your family.

**Many self-advocates from the autism community have indicated a preference for the phrase “autistic person” rather than “person with autism,” as they consider autism to be a core component of their identity; as part of ALP’s commitment to providing neurodiversity-affirming care that uplifts the lived experiences and preferences of those we serve, we have used the phrase “autistic person” throughout this blog post.