Insurance & ABA: What You Need to Know
Navigating ABA therapy costs and insurance coverage for your autistic child or child with developmental delays can be incredibly stressful for families. Many find time-intensive behavioral services to be expensive out of pocket, and even with an autism diagnosis, not all health insurance policies provide comprehensive therapy coverage. Since this post was originally published, all remaining states have enacted autism mandates, requiring health insurers to provide some level of coverage for autism-related services, including Applied Behavior Analysis (ABA). However, the scope and comprehensiveness of these mandates vary significantly from state to state. While ABA is typically covered, the inclusion and extent of coverage for other essential services like physical therapy can still differ by state or even be excluded in some, though Kentucky and Ohio mandates generally include them. States can also set benefit caps and age limits, with Kentucky’s mandate generally covering individuals up to age 21, and Indiana’s mandate typically extending to ages 20 or 21 (though Indiana’s Medicaid specifically covers adults over 21).
Even in states with strong mandates, these vital protections don’t apply to every single plan. Many large employers self-fund their health plans, meaning they contract a health insurance company to administer benefits but pay for covered services themselves. Self-funded plans are regulated by federal law and are generally exempt from state mandates. For commercial or employer-sponsored plans that do cover ABA, you need to have a formal autism diagnosis for ABA, almost without exception.
Despite its foundation in learning, ABA is considered healthcare rather than education and as such it calls for medical diagnoses. Educational diagnoses from a school are not adequate for this purpose.
Medical autism diagnoses generally come from a psychologist or a multidisciplinary team, Arkansas’s Medicaid model outlines the two pathways. If an autism diagnosis is made, paperwork will include the associated diagnostic code from one of two coding systems in use in the United States, the Diagnostic and Statistical Manual (DSM), administered by the American Psychiatric Association, or the International Classification of Diseases (ICD) administered by the World Health Organization (WHO).
The diagnostic codes I see most are 299.00 (an older code from ICD-9 and adopted into the DSM); F84.0 (the primary code for Autism Spectrum Disorder in ICD-10); and F84.5 (Asperger’s Syndrome in ICD-10). These diagnostic codes accompany service codes (aka CPT codes) on the claim forms that providers submit to insurance companies for reimbursement. Incidentally, if your autism service provider submits claims to insurance, they almost necessarily report progress in terms of symptom reduction— even the diagnosis-affirming providers. If it is important to you that your provider fully celebrate neurodiversity, ask how they reconcile their approach with the medical model.
The Intersections of Autism Diagnosis, Insurance, and Individualized Support
The APA and WHO both review their diagnostic criteria at semi-regular intervals and their standards generally align. The APA’s last major revision in 2013 combined a number of diagnosis with similar features into “Autism Spectrum Disorder,” a new, expanded diagnosis meant to reflect the full range of autistic expression and experience. When rendering this diagnosis, the evaluator specifies the level of support the person needs up to the level of 3, “requiring very substantial support.” The F84.5 code mentioned above indicates Asperger’s syndrome, retired from DSM-5 as a separate diagnosis, but still present in ICD-10. Individuals who previously met criteria for Asperger’s typically align with Autism Spectrum Disorder, Level 1, requiring minimal support.” (And payers sometimes approve only minimal support.)
Because ABA providers very rarely diagnose, we use the codes provided in the diagnostic report when we request prior authorizations and make claims. Whether payers accept the F84.5 code depends on the specific insurance provider’s or healthcare program’s guidelines and medical necessity criteria. On that point, I have not found a diagnosis to “expire” and have treated teenagers on the basis of diagnoses made in early childhood, though your payer might want a follow-up evaluation. Requests for re-evaluations also come as the client approaches adulthood or there is a significant change in presentation of functional abilities. These reassess medical necessity and progress and/or reconfirm the diagnosis. Occasionally, re-evaluation finds that the person no longer meets diagnostic criteria. To the degree that this reflects improvement in the person’s quality of life and capacity to advocate for themselves, departure from a diagnosis can be a cause for celebration. But ABA is not “autism therapy” and behaviors or symptoms do not always cluster neatly into established criteria, so the loss of a diagnosis will complicate service delivery.
For ABA with diagnoses other than autism— in Kentucky I have had success billing MCOs, straight Medicaid, and Medicaid waivers for intellectual disabilities (codes F71-73) when there is medical justification. In some exceptional cases, payers have approved me to offer behavioral interventions for diagnoses like conduct disorders when other services had already failed to keep the client at the lowest possible level of care. In this context, level of care refers to the intensity and type of medical, psychiatric, or therapeutic services a patient requires based on the severity of their condition and their functional needs. It’s a way for healthcare providers and insurance companies to classify where a patient receives treatment and how intensive that treatment is. Higher levels of care cost more and payers can be very flexible when appropriately motivated.
Families who decline diagnoses entirely will forgo health benefits but can access ABA when paying out of pocket. The same applies for people who struggle with some of the deficits or behaviors inherent to autism without meeting criteria for a diagnosis. As a clinician, it’s up to me to determine the scope of my competency and the likelihood of a good outcome regardless of the diagnosis so there is no ethical barrier. Consultative services and parent training packages are cost-effective options but alternately, the family can pursue services in related or adjacent fields as best fits their needs. A person who is highly sensory-seeking will benefit from occupational therapy, another who is anxious will benefit from counseling, another who is minimally communicative will benefit from speech therapy. The methods of each respective discipline will vary but our training is comparably rigorous and we similarly want our clients to be happy and successful.
Beyond Labels: Behavior Science for Well-being and Growth
Payers and the public alike should remember that Applied Behavior Analysis (ABA) does not exist to eradicate autistic traits, or even address autism exclusively. Behavior science offers a remarkably broad framework. It provides actionable solutions for everything from navigating common parenting challenges and fostering positive behaviors in early education, to supporting child development and enhancing family dynamics. Behavioral methodology deeply respects individual differences, working to understand each person’s behavior from their unique perspective and context.
Curious how evidence-based strategies can benefit your family? Email us for a consultation today to explore customized solutions for your child’s well-being and growth.
Spectrum Behavioral Services of Kentuckiana 
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