Autism Coverage Limitations
Age
ABA therapy is only required for individuals under the age of 8, but some insurance companies have voluntarily waived this limit (Blue Cross Blue Shield of Mississippi, Magnolia Health, and UnitedHealthcare of Mississippi).
Preauthorization
Insurance companies may require preauthorization or pre-certification prior to covering these services, just as they can for medical, surgical, and mental health benefits.
Duration
ABA therapy is limited to 25 hours/week, and no more than 10 hours/week may be for services from a licensed behavior analyst.
Deductibles and Co-Pays
For these services, insurance companies may not have a higher deductible, co-insurance, or co-payment than other physical health care services (other policy provisions may apply, such as in-network vs. out-of-network, but the amount cannot be higher just because it is treatment for ASD).
Medical Necessity
Like treatment for other conditions, coverage for autism or ASD services is subject to a determination of medical necessity. Even though coverage cannot be denied because of an autism or ASD diagnosis, an insurance company may deny coverage for a treatment or service that it determines is not medically necessary.
- Who decides necessity?
- The provider who develops the treatment plan specifies what services they believe are medically necessary. The insurance company then reviews that information under its criteria for medical necessity (its “medical policy”). Services that are deemed medically necessary according to the company’s medical policy will be covered.
- What can I do if my claim or treatment is denied based on medical necessity?
- Appeal the denial. Mississippi law requires that insurance companies have an appeals or grievance process. If it is still denied, you can file a complaint with MID to have an external review of the denial.
- What if someone needs more ABA therapy than what’s required?
- Coverage may be extended if medically necessary, and individuals can always appeal as outlined in their health plan.
