Does United Healthcare Cover ABA Therapy?

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Does United Healthcare Cover ABA Therapy?

United Healthcare covers medically essential evidence based therapy based on Applied Behavior Analysis (ABA) principles. However, costs may vary depending on the details of your United Healthcare behavioral health insurance coverage and your particular plan.

ABA therapy is founded on the science of learning and behavior. Typically, it is used as part of autism therapy and treatment and other developmental disabilities. ABA principles employ contextual elements, motivational operations, positive reinforcement, and other techniques to assist in acquiring new behaviors, modifying current behaviors, and emitting behaviors in response to various environmental situations.¹

Licensed psychologists help autistic individuals develop abilities pertaining to the following:

• Language and communication skills
• Social skills
• Hygiene and self-care practices
• Leisure and play abilities
• Motor skills

In addition, some of the goals of ABA therapy include:

• Reducing problematic conduct such as extreme disruptive behavior, physical/verbal aggression, self-inflicted injury, and property destruction
• Increasing reciprocity and other socially acceptable actions
• Acquiring the ability to accept changes in one’s surroundings and activities
• Reduction of repetitive or stereotypical behaviors

How to Verify United Healthcare ABA Therapy Insurance Coverage

Insurance may be able to help cover the cost of therapy. Call your insurance provider to learn more about the details of your United Healthcare ABA therapy coverage.

While Athena Care does not offer ABA therapy, we do provide comprehensive mental and behavioral health services in Tennessee, including autism assessment, psychotherapy and counseling, medication management, TMS, Spravato and more. We’re also in-network with most major insurance companies. Contact us below, and one of our care coordinators will help you navigate your insurance coverage and get the care you need.

Requirements, Eligibility & Process for United Healthcare ABA Coverage

According to Tennessee state law, contracts and plans that offer benefits for neurological illnesses must also provide autism benefits for treating children under the age of 12.²

Conditions for the initiation of ABA therapy United Healthcare coverage:

• The member (up to 21 years of age) has been given a DSM-5 diagnosis, such as Autism Spectrum Disorder (ASD), for which ABA may be a useful and appropriate clinical intervention. In addition, a thorough clinical evaluation by a Tennessee-licensed clinician establishing the medical necessity for ABA accompanies the diagnosis.

AND

• ABA services must be located in Tennessee and provided by or supervised by a Tennessee Board Certified Behavior Analyst (BCBA) or a United Healthcare ABA therapist, permissible under Tennessee state law.

AND

• The member’s family and/or support network is actively involved and eager to help with their participation in ABA treatment.

AND

• It is possible to assess the member’s current status safely, effectively, and efficiently in this setting since there are acute changes in the member’s symptoms and psychosocial and/or environmental factors.

Prior authorization is necessary for United Healthcare ABA coverage. The initial authorization may be limited to an evaluation and plan development. Ongoing ABA interventions may be authorized for up to 6 months (or at various intervals based on the patient’s specific requirements, behavior/maintenance plan, skill support plan, and treatment progress).

The number of hours the service provider suggests is needed each week to address the problematic behaviors effectively. These hours should be included in the initial treatment plan, even though the primary care physician or specialist may have ordered the initial exam.

After each authorized period, the patient must be reevaluated. Measurable changes in the frequency, intensity, and duration of the particular behavior of interest must also be observed.

After three months of receiving the best care possible, if the patient has not undergone noticeable changes, ABA may no longer be considered medically necessary.

How Much Does ABA Therapy Cost Without Insurance?

The average cost of ABA is $120 per hour. Some children with autism require up to 40 hours of ABA therapy each week to reach their full potential, which costs $4,800 per week or $249,600 annually.³

Forbes estimates that the annual cost of ABA therapy without health insurance benefits is about $17,000. However, it might range from $45,000 to $100,000 annually for some children.⁴ The CDC estimates that average yearly medical costs for a child with ASD are $4,110 to $6,200 higher than for children without the condition.⁵