Does Aetna Cover ABA Therapy?

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Does Aetna Insurance Cover ABA Therapy?

Yes, Aetna insurance covers the cost of Applied Behavior Analysis therapy (ABA) when specific requirements are met.¹ However, complete coverage might not always be available. Aetna also notes that ABA therapy may have evidence-based deficiencies concerning Autistic Spectrum Disorder (ASD).

Aetna members pay for behavioral therapy under their behavioral health insurance coverage. The variables and out-of-pocket expenses for Aetna ABA therapy coverage change from plan to plan and from provider to provider. Furthermore, what you pay in one location in Tennessee might not be what you pay in another.

ABA therapy is founded on the science of learning and behavior. Typically, it is used for autism treatment and other developmental disabilities. It teaches actions that will make patients’ lives safer and more satisfying.² ABA therapy is part of many evidence based therapies that focus on a behavioral approach.

Qualified therapists help autistic individuals develop abilities such as:

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

How to Verify Aetna ABA Therapy Insurance Coverage

Aetna Insurance may be able to help cover the cost of ABA therapy.

Athena Care is in-network with most major insurance plans. Find out more about your insurance coverage by calling your insurance company or contacting Athena Care at 877-641-1155.

Requirements, Eligibility & Process for Aetna ABA Coverage

According to Tennessee state law, contracts and plans that offer benefits for neurological illnesses must also provide health insurance benefits for treating children with autism under the age of 12.³

ABA therapy is covered by Aetna plans as medically necessary when specific criteria are met. For example, when developmental delays or multiple persistent deficits in social communication and interaction have been identified, and when the evaluation is performed by a certified/licensed Aetna ABA therapist, Aetna considers the assessment and diagnosis of ASD medically necessary.

The majority of Aetna plans don’t cover educational services. For instance, these plans would not cover speech therapy or ABA services provided during class.

If ABA therapy is delivered in a hospital setting (inpatient, residential, or partial hospitalization), specific permission for ABA therapy coverage and any appropriate medical need for coverage at that level of care is used. In that case, authorization is unnecessary.

All of the following are Aetna’s medical necessity standards for using Applied Behavior Analysis (ABA) and must be met:⁴

• Essential elements are all met.
• Functional impairment has been demonstrated in the past twelve months on a standardized scale. For instance, the Adaptive Behavior Scales Vineland Adaptive Behavior Scales 3 (VABS-3), ABLLS, VB-MAPP, or Assessment Scale (ABAS). There must be at least one standard of impairment deviation that is below the population mean OR that poses a serious risk to oneself or others.
• Parents (or guardians) will receive the support and instruction they need to support interventions and generalize gains.
• The amount of impairment justifies the proposed number of hours. For example, treatment sessions may last 1-20 hours a week and 1-4 years with focused ABA therapy for all ages.

Every six months, a member’s progress has to be assessed. A patient not making progress will be switched to suitable alternative services.

Because there is inadequate support in the peer-reviewed literature for all other non-ASD purposes, Aetna views ABA as experimental and exploratory. Therefore, Aetna ABA therapy coverage does not apply unless a patient is diagnosed with autism.⁵

How Much Does ABA Therapy Cost Without Insurance?

According to Forbes, ABA therapy costs roughly $17,000 yearly without insurance. For some children, it might be between $45,000 and $100,000 annually.⁶

The CDC estimates that average annual medical costs for a child with ASD are $4,110 to $6,200 higher than for children without the condition.⁷