[USA ABA] Is ABA therapy 100% free in Massachusetts?

hello,

Today I'd like to share some information I've learned while working as a therapist in the Boston area.

Please note that these services vary greatly from state to state, city to city, and region to region, so I can only speak about Massachusetts, where I have experience.

Massachusetts Insurance and ABA Therapy

First, Massachusetts, like South Korea, mandated health insurance for all residents through health insurance reform, and its medical services are among the best in the United States. Furthermore, Massachusetts is one of the states with the highest coverage of autism-related services, particularly Applied Behavioral Analysis (ABA) therapy.

(For this reason, when talking to various health care providers, I can sense a high level of pride in Massachusetts' welfare system.)

Although autism-related treatments are widely covered, as in other states, ABA therapy is largely paid for through private insurance, government assistance, or private funding.

1) Application of private insurance

Under ARICA Law (Autism Insurance Act) **, most private health insurance plans are required to cover ABA therapy if it is deemed necessary for children diagnosed with Autism Spectrum Disorder (ASD).

Although there are exceptions, this law applies to both individual and group insurance.

How insurance applies

- Diagnosis : A licensed health care provider, such as a developmental pediatrician or psychologist, will diagnose your child's autism and recommend ABA therapy.

- Authorization : Insurance companies may require pre-approval for ABA services. Families typically work with their ABA provider to obtain this authorization.

- ABA Providers : Insurance companies have a network of ABA clinics and various providers (ABA therapists, OT therapists, speech therapists, etc.) who require you to submit claims for services provided.

- Cost sharing : Most insurance plans cover most of the costs, but you may incur deductibles, co-payments, and coinsurance.

> Coinsurance : Depending on your insurance plan, parents may be responsible for a co-payment (e.g., $25) or a co-pay (e.g., 20% of the service fee) per session.

> Deductibles: Some insurance plans have high deductibles, which may mean families have to pay thousands of dollars up front before the insurance begins to cover ABA therapy.

2) Government support

- MassHealth (Medicaid) : MassHealth, a Medicaid program, covers 100% of the cost of ABA therapy for eligible children with autism.

Fully Funded : For families enrolled in MassHealth Standard or MassHealth CommonHealth, ABA therapy is generally fully funded, meaning the state covers all medically necessary ABA services. It is available to children under 21 years of age and includes Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefits.

Medically Necessary Services : ABA therapy must be deemed necessary by a licensed healthcare provider, such as a developmental pediatrician or psychologist. The provider will submit a treatment plan and justification for ABA services.

- Certified Provider : ABA therapy must include a BCBA and RBT provided by MassHealth . Therapy can be provided in a clinic, at home, or in the community.

> Autism Waiver Program : Massachusetts has a special waiver program that provides free home- and community-based services, including Applied Behavioral Analysis (ABA) therapy, to children with autism. Eligibility is income-based, and while there may be a waiting list for these services, it varies by region, as shown in the image below.

3) Payment with private funds

There are many reasons why people seek out and pay for ABA therapists out of their own pocket, but the most common reasons are as follows:

1. If your insurance does not cover ABA

Depending on why you live in the United States, you may not have insurance, or your insurance may not cover ABA.

2. After receiving a diagnosis, it takes too long to get ABA treatment approved by the insurance company and to be assigned a therapist.

It can take 6-12 months to even see a doctor, and it can take a long time to even be assigned a therapist. So, those who cannot afford to waste this golden 6 months and want to proceed with treatment quickly turn to private clinics in the meantime.

3. I don't like the therapist provided by the insurance company.

Since you won't always get a therapist you like through your insurance company, in those cases you may have to hire a therapist out of your own pocket.

If you pay for it privately, of course there will be differences in the therapist's experience, region, etc., but it seems to cost around $80 to $150 per hour.

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As you know, what we're talking about today is separate from the IEP services provided at school. ABA, which is covered by insurance, is considered a medical treatment and is therefore covered by insurance.

ABA services may also be provided as part of an IEP, but only if they meet the criteria for medical necessity and follow insurance regulations requiring prior authorization.

In my case, ABA services, which are covered by insurance, are provided by the school . Next time, I'll share more about ABA services provided by the school.