Does Cigna Insurance Cover Autism Testing & Therapy Treatment?

Does Cigna Cover Autism Testing & Treatment?

Yes, Cigna insurance may be able to cover autism testing and treatments in Tennessee, depending on the specifics of your insurance plan. The Tennessee Department of Commerce and Insurance published a bulletin in 2019 requiring insurance providers to cover medically necessary care for Autism Spectrum Disorder (ASD).¹

Jump to Section

• Does Cigna Cover Autism Testing & Treatment?
• How to Verify Cigna Autism Coverage
• What is Autism?
• Is Autism Testing Covered by Cigna?
• Are Autism Treatments & Medications Covered by Cigna?
• How To Find Cigna Autism Testing & Treatment Clinics Near Me?
• How Much Does Autism Testing & Treatment Cost Without Insurance?
• Can Autism Affect My Insurance Coverage?

How to Verify Cigna Autism Coverage

Athena Care is in-network with most major insurance plans. To learn more about your Cigna autism benefits, call your insurance company or contact us below. One of our care coordinators can help you navigate your insurance coverage and help you get the care you need.

What is Autism?

Autism Spectrum Disorder (ASD) is a developmental disease that can lead to significant social, communicative, and behavioral difficulties. People with autism can have a broad range of cognitive, reasoning, and problem-solving abilities and disabilities, ranging from gifted to severely impaired.²

Types of Autism

There are five types of autism:³

• Asperger’s Syndrome
• Rett Syndrome
• Childhood Disintegrative Disorder (CDD)
• Kanner’s Syndrome
• Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS)

Signs & Symptoms of Autism

Although there is typically nothing about people with autism that distinguishes them from others in terms of appearance, they may communicate, engage, conduct, and learn in unique ways. The signs of autism include but are not limited to the following:⁴

• Difficulty developing social communication and interpersonal skills
  • Example – Does not respond to name by nine months of age
• Restricted or repetitive interests or behaviors
  • Example – Becomes upset by minor changes in routine
• Delayed cognitive, learning, language, and movement skills
• Hyperactive, impulsive, and/or inattentive
• Epilepsy or seizures
• Unusual sleeping and eating patterns
• Gastrointestinal issues (i.e., constipation)
• Mood swings or emotional reactions that are out of the ordinary
• Anxiety, tension, or excessive worry
• Fearlessness or greater than expected fear

Is Autism Testing Covered by Cigna?

Cigna autism testing and diagnosis are covered according to the Tennessee Department of Commerce and Insurance bulletin of 2019. In addition, the Mental Health Parity Act (MHPA) states that major health plans are not allowed to have lower annual or lifetime dollar limits on mental health benefits than they would for medical/surgical benefits.⁵ However, the specifics of coverage will vary by each plan, and you may be required to pay out of pocket expenses such as co-pays and deductibles.

It might be challenging to diagnose Autism Spectrum Disorder because there is no blood test or other medical test for the condition. Instead, doctors examine the child’s behavior and developmental history to make a diagnosis.

Developmental monitoring looks at how your child grows and changes and if they reach milestones in activities like playing, learning, speaking, acting, and moving. Parents, grandparents, early childhood professionals, and other caregivers can conduct developmental monitoring.

Developmental screening looks more closely at your child’s growth. Your child will take a brief test, or you’ll answer some questions about your child. Doctors, nurses, and other healthcare, community, or educational professionals can conduct developmental screening.

It’s possible to detect autism in children as young as 18 months. Therefore, a diagnosis made by a qualified practitioner by age two is reliable. Unfortunately, many people do not receive a conclusive diagnosis until they are older.⁶

Are Autism Treatments & Medications Covered by Cigna?

Yes, Cigna may cover autism treatments and medications if a patient meets all of the following criteria:

• The person diagnosed complies with the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition’s ASD criteria (DSM-5).
• An appropriate mental health care practitioner is treating patients.
• Services are appropriate in terms of type, frequency, extent, site, and duration.
• Meaningful and measurable change is anticipated from the therapy.

Specific drugs can help regulate symptoms but cannot alter the primary symptoms of autism spectrum disorder.⁷ For instance, antipsychotic meds, like risperidone, can treat severe behavioral issues,⁸ and antidepressants can treat anxiety. It’s essential to keep all medical professionals informed about any prescription drugs or dietary supplements your child is taking. Some drug-supplement interactions can result in harmful side effects.

According to research, medication is most effective when combined with evidence based psychotherapy such as Applied Behavioral Analysis (ABA). Cigna health insurance requires additional criteria to be met when part of treatment involves ABA⁹ or a speech generating device.¹⁰

ABA treatment applies what we know about behavior to real-life settings. The goal is to encourage positive behaviors while reducing detrimental or learning-inhibiting behaviors. ABA therapy can help improve language and communication skills, attention, focus, social skills, memory, and academics.¹¹

Your plan’s benefits will determine your eligibility and the details of your Cigna insurance autism coverage for treatments and medications.

How To Find Cigna Autism Testing & Treatment Clinics Near Me?

Athena Care’s multiple locations across Tennessee make gaining access to autism testing and treatment simple. A care coordinator can assist you with any questions or concerns about Cigna autism coverage Monday through Friday, 7:00 a.m. to 6:00 p.m.

Here, you’ll find a list of practitioners organized by city and information about their backgrounds and specialties. When choosing autism specialists, it’s important to keep the following in mind:

• Education, training, license, and years of experience
• Specialties and services offered
• Treatment methods and philosophies
• Insurance companies they work with
• Office hours
• Pricing
• Session length

Also, don’t be afraid to ask lots of questions.

How Much Does Autism Testing & Treatment Cost Without Insurance?

The following are average costs, though they may vary by location and other factors. Therefore, these costs may not reflect the actual cost of what you’ll pay for autism testing or treatment in Tennessee without Cigna autism coverage.

Doctor’s visits alone can range from a few hundred dollars to more than $2,700. In the United States, the typical cost of psychotherapy ranges from $100 to $200¹² a session, dependent upon the state and the length of the session.

The cost of a supply of 30 risperidone 1 mg oral tablets is around $18,¹³ and the average price of Applied Behavior Analysis (ABA) is $120 an hour. Some children require up to 40 hours of ABA therapy every week to reach their full potential, which comes to $4,800 per week or $249,600 per year.¹⁴

Can Autism Affect My Insurance Coverage?

Under Tenn. Code Ann. 56-7-2367 (2006), contracts and insurance policies that offer benefits for neurological illnesses must also provide benefits and coverage for the treatment of autistic children under the age of 12.¹⁵ According to the law, neurological disorders include autism spectrum disorder.

In addition, the Affordable Care Act states that most health insurance policies are no longer permitted to exclude, limit, or increase the cost of coverage for anyone due to a pre-existing condition, including autism.¹⁶

Sources

1. “Tennessee State-Regulated Insurance Coverage.” Autism Speaks, Autism Speaks, www.autismspeaks.org/tennessee-state-regulated-insurance-coverage. Accessed 8 July 2022.
2. “What is Autism Spectrum Disorder?” U.S. Department of Health & Human Services, 2020, https://www.cdc.gov/ncbddd/autism/facts.html
3. “What Are the 5 Types of Autism?” Integrity, Inc., 2021, https://www.integrityinc.org/what-are-the-5-types-of-autism/
4. “Signs and Symptoms of Autism Spectrum Disorders.” U.S. Department of Health & Human Services, 2021, https://www.cdc.gov/ncbddd/autism/signs.html
5. “The Mental Health Parity and Addiction Equity Act (MHPAEA) | CMS.” Centers for Medicare and Medicaid Services, www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet. Accessed 8 July 2022.
6. “Screening and Diagnosis of Autism Spectrum Disorder.” U.S. Department of Health & Human Services, 2020, https://www.cdc.gov/ncbddd/autism/screening.html
7. Mayo Clinic Staff. “Autism Spectrum Disorder – Diagnosis and Treatment – Mayo Clinic.” Mayo Clinic, Mayo Foundation for Medical Education and Research (MFMER), 6 Jan. 2018, www.mayoclinic.org/diseases-conditions/autism-spectrum-disorder/diagnosis-treatment/drc-20352934.
8. “Medication Treatment for Autism.” NIH, 2021, https://www.nichd.nih.gov/health/topics/autism/conditioninfo/treatments/medication-treatment
9. Intensive Behavioral Interventions. Cigna, 15 Dec. 2021, https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf.
10. Cigna. “Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment.” Cigna, 15 Dec. 2021, static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/mm_0447_coveragepositioncriteria_autism_pervasive_developmental_disorders.pdf.
11. “Applied Behavior Analysis.” Autism Speaks Inc., 2022, https://www.autismspeaks.org/applied-behavior-analysis
12. “Risperidone Prices, Coupons and Patient Assistance Programs.” IBM Watson Micromedex, Cerner Multum™, ASHP, 2022, https://www.drugs.com/price-guide/risperidone
13. Tatom, Carol RBT. Autism Parenting Magazine, 2022, “How Much Does ABA Therapy for Autism Cost?” https://www.autismparentingmagazine.com/aba-therapy-autism-cost/
14. “Autism and Insurance Coverage State Laws.” National Conference of State Legislatures, NCSL, 24 Aug. 2021, www.ncsl.org/research/health/autism-and-insurance-coverage-state-laws.aspx.
15. Digital Communications Division (DCD). “The Affordable Care Act and Autism and Related Conditions.” HHS.Gov, U.S. Department of Health and Human Services, 1 Feb. 2021, www.hhs.gov/programs/topic-sites/autism/aca-and-autism/index.html.