Accessing Applied Behavior Analysis (ABA) therapy—a medically necessary, evidence-based treatment for Autism Spectrum Disorder (ASD)—can be a critical part of a child with autism’s development. However, the path to coverage is often complex and varies significantly based on your state and your specific insurance plan.

Understanding what your insurance covers is crucial because the cost of intensive ABA therapy without coverage can vary substantially. Knowledge is your most important tool in advocating for the care your child needs.

Understanding Your Health Insurance Plan

The first step in securing coverage is understanding your plan’s structure. State mandates generally apply to fully-insured plans (purchased by individuals or small businesses) but may not apply to self-funded plans (large employers that pay for employee care directly). Federal laws like the Mental Health Parity and Addiction Equity Act (MHPAEA) can also provide important protections.

Different Plan Types

HMO (Health Maintenance Organization): Typically limits coverage to care from doctors who work for or contract with the HMO. You usually need a Primary Care Physician (PCP) and a referral to see a specialist, and there’s often no coverage for out-of-network care (except emergencies).
PPO (Preferred Provider Organization): Offers a network of “preferred” providers. You pay less if you use providers in the network but can still see out-of-network providers for a higher cost. You generally don’t need a PCP or referrals.
EPO (Exclusive Provider Organization): A hybrid plan. It only covers in-network providers (like an HMO), but usually doesn’t require referrals to see specialists (like a PPO).
POS (Point-of-Service): Combines HMO and PPO features. You can go out-of-network, but you must usually get a referral from your PCP first, and you’ll pay more for the out-of-network care.

Key Cost-Sharing Terms

Deductible: The amount you must pay out-of-pocket each year before your insurance starts to pay for covered services.
Copayment (Copay): A fixed amount you pay for a covered service, like a daily flat fee for therapy.
Coinsurance: Your share of the costs of a covered service, calculated as a percentage (e.g., you pay 20%, the insurer pays 80%) after you meet your deductible.
Out-of-Pocket Maximum (OOP Max): The most you will have to pay for covered services in a plan year. Once you hit this limit, the insurance company pays 100% of covered costs for the rest of the year.

State-Specific ABA Coverage and Providers

All 50 states have some form of law ensuring ABA therapy coverage. The specifics—like age caps, dollar limits, and required services—vary widely. The general insurance providers listed below often have networks of ABA providers in the respective states, but coverage is always plan-specific and requires prior authorization.

Disclaimer: This information is a general overview. Always contact your specific insurance provider for a Verification of Benefits (VOB).

Arizona (AZ)

Mandate for coverage in state-regulated plans and included as an Essential Health Benefit (EHB) in Marketplace plans.