Key Highlights

• ABA therapy coverage varies by state and insurance provider, but is legally required in many cases.

• Parents should confirm diagnostic criteria, obtain a prescription, and understand pre-authorization steps.

• Knowing your state’s laws and required documentation increases the chance of approval.

• Denials can often be appealed successfully with the right evidence.

• Working with an experienced ABA provider simplifies the entire insurance process.

How to Get Insurance to Cover ABA Therapy

Applied Behavior Analysis (ABA) therapy is one of the most effective treatments for children with autism spectrum disorder (ASD). However, for many families, the question isn’t whether to start ABA—it’s how to afford it.

The good news is that most insurance plans in the U.S. now cover ABA therapy to some extent. Still, navigating the insurance process can feel overwhelming, especially with differing rules from state to state.

This guide breaks down, step-by-step, how to get insurance to cover ABA therapy—whether you’re in Georgia, Virginia, Tennessee, or North Carolina.

Step 1: Confirm Your Child’s Diagnosis

Before insurance companies will consider ABA therapy coverage, they typically require a formal autism diagnosis from a qualified professional.

Who can diagnose autism:

• Developmental pediatrician

• Child psychologist or psychiatrist

• Neurologist

• Licensed clinical psychologist

Make sure the diagnosis report includes:

• The DSM-5 criteria for autism spectrum disorder

• Your child’s developmental history

• Detailed behavioral assessments

• Recommended treatment (ABA therapy)

Tip: Always request a copy of the full diagnostic report—it’s crucial for insurance submissions.

Step 2: Check Your Insurance Coverage

Every insurance plan is different, even within the same state. Start by reviewing your Summary of Benefits and Coverage (SBC) or by contacting your insurance representative directly.

Ask these key questions:

Step 3: Understand State-Specific Coverage Laws

Each of the states where Blossom ABA Therapy operates has its own mandates for ABA therapy coverage. Here’s a quick breakdown:

Tip: If your employer’s insurance plan is self-funded (common in large companies), state laws may not apply—but many of these plans voluntarily include ABA benefits.

Step 4: Get a Prescription or Referral

Most insurance companies require a prescription or referral for ABA therapy. This usually comes from your child’s primary care doctor or diagnosing provider.

The referral should include:

• Autism diagnosis code (F84.0 in ICD-10)

• Recommended treatment: “Applied Behavior Analysis (ABA) therapy”

• Frequency or number of sessions per week (if known)

This document confirms medical necessity and helps speed up pre-authorization.

Step 5: Obtain Pre-Authorization

Before starting therapy, most insurers require pre-authorization—essentially, approval to begin treatment.

Your ABA provider usually helps with this process by submitting:

• Diagnostic evaluation

• Treatment plan

• Assessment results

• Proposed therapy hours and goals

Pro Tip: Keep communication open between your provider and your insurance company. Missing documentation is the #1 cause of pre-authorization delays.

Step 6: Start Services and Track Progress

Once approved, therapy can begin! But insurance coverage often depends on documented progress.

Most insurers require periodic progress reports, typically every 3–6 months, including:

• Measurable behavior changes

• Updated treatment goals

• Data tracking from ABA sessions

Staying consistent with therapy and documentation helps ensure continued coverage.

Step 7: Handle Denials or Appeals

Sometimes, claims are denied—even when families follow every step correctly. Common reasons include:

• Missing documentation

• Lack of “medical necessity” wording

• Incorrect billing codes

• Out-of-network provider use

If this happens, don’t panic—you can appeal.

Steps to appeal an insurance denial:

1. Review the denial letter to identify the reason.

2. Gather supporting documents (diagnostic report, treatment notes, progress data).

3. Write an appeal letter clearly explaining why ABA therapy is medically necessary.

4. Ask your ABA provider to submit additional documentation if needed.

5. Follow up regularly to track your appeal status.

Many families win on appeal—especially when they include data from their ABA team showing measurable improvement.

Step 8: Explore Additional Funding Options

If your insurance plan doesn’t fully cover ABA therapy, there may be other funding sources available:

Step 9: Keep Detailed Records

Organize everything in one place:

• Diagnostic reports

• Prescriptions and referrals

• Insurance authorizations

• Progress notes

• Communication logs with insurers

Having a record of all documentation helps if you ever need to reapply, appeal, or switch providers.

Step 10: Partner with a Knowledgeable ABA Provider

Experienced ABA providers understand insurance complexities and can help handle most of the administrative work for you. Many offer:

• Free insurance verification

• Pre-authorization assistance

• Direct communication with insurers

• Ongoing documentation and reporting

A good provider doesn’t just deliver therapy—they also advocate for your child’s access to care.

Final Thoughts

Getting insurance to cover ABA therapy can feel daunting, but understanding the process makes it much more manageable. From confirming your child’s diagnosis to navigating state laws and appealing denials, every step brings you closer to the support your child deserves.

Blossom ABA Therapy proudly serves families across Georgia, Virginia, Tennessee, and North Carolina, offering compassionate, individualized ABA services and expert insurance guidance to make the process easier every step of the way.

Frequently Asked Questions

1. How much does ABA therapy cost without insurance?

   The cost varies depending on location, therapist qualifications, and intensity, but it typically ranges between $120–$250 per hour. Comprehensive programs may exceed $30,000 annually without coverage.

2. Does Medicaid cover ABA therapy?

   Yes. In Georgia, Virginia, Tennessee, and North Carolina, Medicaid includes ABA therapy coverage for children diagnosed with autism.

3. What if my insurance doesn’t cover ABA therapy?

   You can appeal the denial, explore Medicaid waivers, or look into private grants and financial aid programs.

4. Can I switch ABA providers after authorization?

   Yes, but you may need to notify your insurance company and obtain new authorization for the new provider.

5. How long does it take to get insurance approval for ABA therapy?

   It varies, but most families receive approval within 2–6 weeks once all required documentation is submitted.

Sources:

• https://www.cdc.gov/autism/hcp/diagnosis/index.html

• https://www.autismspeaks.org/autism-diagnostic-criteria-dsm-5

• https://www.healthcare.gov/health-care-law-protections/summary-of-benefits-and-coverage/

• https://www.medicaid.gov/medicaid/benefits/autism-services