If you’re a parent of a child with autism, you’ve probably heard about ABA therapy’s life-changing benefits.
Before you dive into what could be months or years of treatment, you need to know if Blue Cross Blue Shield will actually cover your ABA therapy treatment.
Understanding your insurance coverage upfront can save you thousands of dollars and prevent devastating surprises down the road.
Our team here at Aviation ABA in Salt Lake City has helped many families navigate BCBS coverage successfully.
In this guide, we’ll break down exactly how BCBS handles ABA therapy claims, what documentation you’ll need, and the steps to get approval. Let’s get started!
Does Blue Cross Blue Shield Cover ABA Therapy?
Yes, BCBS does cover ABA therapy for autism treatment in most cases. However, coverage depends on individual plans and geographic location. Our clinic, Aviation ABA, which is located in Salt Lake City, Utah, currently takes BCBS to cover autism therapy treatment.
All 50 states have laws requiring insurance companies to cover applied behavior analysis services, which means most families can get help paying for these essential interventions.
If you have BCBS and are interested in Aviation ABA’s process, we start with an intake call to gather all the necessary information. From there, we’ll take care of everything else: submitting all required documentation, completing your assessment, and preparing a personalized treatment plan.
But, Coverage Does Vary by Plan and State
Not all BCBS plans work the same way. With a Fully Insured Plan, state laws determine required benefits.
But when employers have an Administrative Services Only plan, they might choose different benefits that could affect therapy coverage.
State regulations play a significant role in determining what insurance companies must pay for, and some employers can customize their benefits packages.
Two families with BCBS might have different coverage levels depending on their plan type and state regulations.
Medical Necessity Requirements
For BCBS to approve applied behavior analysis services, a doctor must prove medical necessity.
A qualified healthcare provider, such as a developmental pediatrician or psychologist, needs to evaluate the patient and create a treatment plan that matches their autism diagnosis and individual needs.
The insurance company will review documentation to ensure the therapy is appropriate and necessary before approving benefits.
Requirements and Eligibility for BCBS ABA Therapy Coverage
To get ABA therapy covered by Blue Cross Blue Shield, families must meet standard requirements across plans.
The primary requirement is getting a recommendation from a licensed healthcare provider, such as a developmental pediatrician, psychiatrist, or psychologist.
The clinician needs to explain why the patient needs applied behavior analysis services and how it will help them.
Keep in mind that coverage requirements can differ by state and BCBS plan type, so what works for one family might not be exactly the same for another.
Autism Spectrum Disorder Diagnosis Requirement
Patients must have an official autism spectrum disorder diagnosis with the code F84.0 from the DSM (Diagnostic and Statistical Manual) to qualify for benefits.
The autism diagnosis should specify the tool the doctor used to evaluate and diagnose the child with ASD (F84.0). Common tools used include the Childhood Autism Rating Scale (CARS-2), the Autism Diagnostic Observation Schedule (ADOS-2), the Social Responsiveness Scale (SRS-2), and the Autism Diagnostic Interview-Revised (ADI-R).
Only licensed professionals can provide this diagnosis, including developmental pediatricians, child psychiatrists, or psychologists who specialize in autism.
Without this diagnosis code in medical records, BCBS will not approve coverage for applied behavior analysis services, making this step absolutely essential.
Age and Treatment Limitations
Most BCBS plans only cover applied behavior analysis for individuals under 18 years old, though some plans might have different age limits.
Plans might also have caps on how many therapy sessions patients can have per week, month, or year.
The amount and length of treatment depend on individual needs, autism symptom severity, and what the insurance plan allows.
Healthcare providers will work with the insurance company to determine the right amount of therapy hours for each situation.
How to Verify Your BCBS ABA Therapy Coverage
Before starting applied behavior analysis services, families must verify benefits to avoid expensive surprises later.
ABA therapy’s costs have a very wide range, going anywhere between $17,000 $249,600 per year without insurance, depending on the type of therapy required, so understanding plan benefits and limitations can save thousands of dollars.
Some families have learned the hard way that their plan doesn’t cover particular providers or has strict session limits, which is why checking benefits first is so crucial.
Online and Phone Verification Methods
Check ABA therapy benefits by logging into the BCBS website or app, where you’ll find your benefits summary under “covered services” or “behavioral health.”
If you prefer talking to someone, call the customer service number on your insurance card and ask these questions:
- Does my plan cover applied behavior analysis?
- What’s my deductible and copay?
- Do I need prior authorization?
- Are there any session limits per week or year?
- Is my preferred provider in-network?
The representative should be able to give you clear answers about benefit details.
Verification of Benefits (VOB) Through ABA Providers
Many applied behavior analysis providers will do a Verification of Benefits (VOB) for families, which takes the guesswork out of understanding benefits.
A complete VOB report should tell you exactly what environments are covered (clinic, home, school), whether you need prior authorization, what out-of-pocket costs will be, and any session limits the plan has.
Having the provider handle this verification is often the best option because they know exactly what questions to ask and can spot potential issues that families might miss when checking on their own.
Prior Authorization Process for ABA Services
Most BCBS plans require prior authorization before starting applied behavior analysis services, and this applies to both the initial assessment and ongoing interventions.
The approval process usually takes 10-14 business days for each step, so families need to plan ahead and be patient.
The patient’s doctor or provider will submit the authorization request, but it’s essential to understand that only licensed health professionals can do this. Families can’t submit the request themselves.
Required Documentation
To get prior authorization approved, several documents are needed.
The patient’s official autism diagnosis, doctor referral or service order, recent medical records, and a detailed treatment plan from the provider are all required.
The treatment plan must explain the individual’s needs, what goals the therapy will work toward, how many hours of therapy per week are needed, and how long the treatment is expected to last.
BCBS will review all documentation to make sure the therapy is medically necessary for the patient’s condition.
Working with In-Network Providers
Finding an in-network provider can save families substantial money and make the authorization process much smoother.
Search for providers using the BCBS website or app, or call the customer service number on your insurance card to get a list of covered providers in your area.
Using an out-of-network provider will cost significantly more. Sometimes, families pay 50% to 70% of the total cost instead of just their regular copay.
Aviation ABA is proud to be an in-network provider with most BCBS plans in Utah, which means lower out-of-pocket costs for families.
In-network providers also know exactly how to work with BCBS requirements, which means fewer delays and denials.
Understanding Your Out-of-Pocket Costs
Even with BCBS benefits, families will likely have some out-of-pocket expenses for applied behavior analysis services.
These might include copayments (a fixed amount paid for each session), deductibles (the amount paid before insurance kicks in), and coinsurance (a percentage of the total cost the family is responsible for).
For example, one family might pay a $25 copay per session, while another might have a $3,000 deductible to meet first, then pay 20% of each session’s cost. Until they meet their yearly out-of-pocket. Then the therapy would be covered at 100%, until the plan renews.
These expenses can vary dramatically between different BCBS plans, so it’s essential to understand the plan details and budget accordingly. Some families spend $200 per month, while others might pay $800 or more.
Additional BCBS Support Services
BCBS often provides case management or care coordination services to help families navigate applied behavior analysis benefits.
These representatives can help you find in-network providers in your area, understand policy details, and even assist with the prior authorization process.
If you’re feeling overwhelmed by insurance paperwork or confused about your benefits, don’t hesitate to call the customer service number on your card and ask to speak with someone who specializes in behavioral health or autism services.
They’re there to help make the process easier for families.
What to Do If ABA Therapy Isn’t Covered
If your BCBS plan doesn’t cover applied behavior analysis services, families still have options for benefits.
Start by filing a formal appeal with your insurance company, providing additional medical documentation that shows why the patient needs this therapy.
If you get insurance through your employer, talk to your human resources department about adding ABA benefits to the company’s package.
Sometimes, employers don’t realize this benefit isn’t included. You can also contact your state representatives and ask them to support insurance mandate laws for autism treatments. These regulations are effective at increasing access to autism treatment and shifting health care spending from families to insurers.
Getting Your BCBS ABA Coverage Right
Wondering whether BCBS will cover applied behavior analysis services can feel overwhelming, especially when you’re already dealing with an autism diagnosis and trying to figure out the best treatment options.
Now you know that BCBS does cover these services in the majority of cases, but the details depend entirely on individual plans, state laws, and provider networks.
The key to success is being proactive about understanding benefits before starting therapy.
Don’t wait until after treatment begins to discover surprise costs or benefit gaps. Take the time to verify your benefits, check if your preferred providers are in-network, and understand out-of-pocket expenses upfront.
If you’re in the Salt Lake City area and ready to move forward with ABA therapy, Aviation ABA is here to guide you through every step of the BCBS coverage process.