Autism Spectrum Disorder (ASD) presents unique challenges for families. Applied Behavior Analysis (ABA) therapy has emerged as a scientifically supported treatment model that remediates the functional impairments typically found in individuals with autism. However, understanding the medical necessity of ABA therapy, navigating insurance coverage, and advocating for necessary care can be daunting. This blog aims to unravel these complexities.
Understanding ABA Therapy and Its Medical Necessity
ABA is a therapeutic approach that uses techniques and principles to bring about positive changes in behavior. For children with autism, ABA therapy plays a critical role in improving social interactions, learning new skills, and reducing behaviors that impede learning.
Medical necessity refers to healthcare services that a physician deems clinically necessary to prevent, diagnose, or treat a patient's condition. ABA therapy is not merely beneficial; it is essential for children diagnosed with ASD. The improvement in behaviors and skills brought about by ABA therapy substantiates its medical necessity.
Continuity of Care and the Impact of Insurance Denials
Continuity of care is vital in managing autism effectively. Any disruption in therapy due to insurance denials can hinder progress and negatively impact a child's development. Unfortunately, insurance companies sometimes deny claims for ABA therapy. These denials can create barriers to receiving consistent, effective treatment. However, both federal and Arizona state laws have provided provisions to protect and ensure coverage for ABA treatment.
Federal and Arizona State Laws Supporting ABA Therapy
The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 mandates health insurance issuers to make mental health benefits comparable to general medical and surgical coverage.
In Arizona, HB 2847, also known as Steven's Law, requires state-regulated plans to include coverage for autism. Importantly, Steven’s Law does not allow limitations of coverage based on hours of therapy, ensuring children receive the therapy they need. However, it does permit reasonable copayments, coinsurance, and deductibles. Additionally, Arizona Revised Statutes § 20-1057.11 prohibits insurance companies from denying coverage based solely on an autism spectrum disorder diagnosis.
The Role of a Healthcare Disability Advocate
A healthcare disability advocate is a professional who assists families in understanding their insurance policy, helps file appeals, and even represents the family in negotiations with the insurance company.
They guide families through the process, citing relevant federal and state laws to strengthen their case. Advocates are not lawyers or attorneys but are equipped with the knowledge and skills to navigate the complexities of healthcare systems and insurance coverage.
For instance, when an insurance company wrongfully denies Arizona ABA therapy services, an advocate may use strategies such as filing an appeal citing medical necessity, referencing applicable laws, and leveraging real-life examples from court cases, news, and history of successful advocacy in action.
Real-Life Advocacy in Action
One compelling example of successful advocacy is the landmark case of Doe vs East Lyme Board of Education. Owing to strong advocacy, the court ruled in favor of providing ABA services within public schools, setting a precedent for future cases.
Sami’s Angels ABA Services: Your Partner in Advocacy
Understanding ABA therapy, autism laws, and healthcare advocacy can be overwhelming. But remember, you don't have to navigate this journey alone.
If you believe you or a loved one could benefit from having an ABA Healthcare Advocate, reach out to Sami’s Angels ABA Services for more information. Our dedicated team is here to help you navigate the complexities of ABA therapy, autism laws, and healthcare advocacy.
Knowledge is power, and with the right information and support, you can ensure that your child receives the best possible care.
Footnotes
https://www.aetna.com/content/dam/aetna/pdfs/health-care-professionals/applied-behavioral-analysis.pdf ↩
https://www.autismspeaks.org/applied-behavior-analysis-aba-0 ↩ ↩2
https://tuftshealthplan.com/documents/providers/guidelines/medical-necessity-guidelines/behavioral-health-aba-therapy-autism-masshealth ↩
https://www.premera.com/medicalpolicies/3.01.510.pdf ↩
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3614070/ ↩
https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet ↩
https://www.autismspeaks.org/arizona-state-regulated-insurance-coverage ↩
https://www.azleg.gov/legtext/49leg/2r/laws/0243.htm ↩ ↩2
https://law.justia.com/codes/arizona/2018/title-20/section-20-1057.11/ ↩
https://www.appliedbehavioranalysisedu.org/state-by-state-guide-to-autism-insurance-laws/ ↩
https://caselaw.findlaw.com/us-2nd-circuit/1609737.html ↩
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