Does Medicare Cover Autism Testing & Therapy Treatment?

Does Medicare Cover Autism Testing & Treatment?

Depending on your specific health insurance plan, Medicare insurance may cover autism testing and treatment in Tennessee. In addition, if your provider offers the Psychiatric Collaborative Care Model, Medicare may pay to help you manage a behavioral health condition.¹

The Psychiatric Collaborative Care Model is a collection of integrated behavioral health treatments that includes care management support such as the following:

• Care planning for behavioral health conditions
• A doctor will monitor your condition regularly.
• Medication assistance
• Counseling
• Other therapies suggested by your doctor

To be eligible for Medicare, you must be a United States citizen 65 years or older. If you’re younger with a disability or End Stage Renal Disease, you may also be eligible for Medicare.

Jump to Section

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

How to Verify Medicare Autism Coverage

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.

Let our highly experienced, expert care coordinators handle the difficulties of contacting your insurance carrier for more information about Medicare coverage for autism treatment.

What is Autism?

Autism Spectrum Disorder (ASD) is a developmental disability caused by changes in the brain that impair communication and behavior. As a result, people with ASD may speak, conduct, engage, and learn differently than most people.

Autism is a “spectrum” disorder because people with ASD have a wide range of talents. Some people require a lot of assistance with daily tasks, while others can work and live independently.

ASD usually appears before the age of three and can remain for the rest of a person’s life. However, symptoms may improve over time. Some children exhibit symptoms before the age of twelve months, while others may not show symptoms until the age of 24 months or later.²

Some children with ASD learn new skills and achieve developmental milestones until they are 18-24 months old, at which point they cease learning new skills or lose the ones they already have.

Because their symptoms are modest or because they can “hide” their symptoms, some with high-functioning autism may not obtain a diagnosis of ASD until later in life.

Types of Autism

The following are the 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 spectrum disorder 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 Medicare?

Medicare may cover autism assessments depending on your specific insurance plan’s benefits.

Because there is no medical test for autism spectrum disorder (ASD), such as a blood test, diagnosing the illness can be difficult. Autism doctors look at the child’s developmental history and behavior in order to diagnose.

A comprehensive developmental evaluation can determine whether or not a person meets the criteria for an autism diagnosis. It can also help identify the best treatment options. Observation, standardized tests, interviews, and questionnaires are common components of this evaluation. A doctor or nurse and other specialists from the healthcare, community, or educational sectors can perform developmental screening.

Autism can be discovered as early as 18 months of age. Therefore, a diagnosis by an experienced professional by age two can be considered reliable. Many, however, do not obtain a definitive diagnosis until they are considerably older.⁵

Are Autism Treatments & Medications Covered by Medicare?

Yes, Medicare may cover autism treatments and medications. Your plan’s benefits will determine your eligibility and the details of Medicare autism coverage.

There is no specific medication for autism or any of its symptoms. Some medications, on the other hand, can help alleviate autism symptoms, particularly certain behaviors. They can help with depression, anxiety, hostility, repetitive behavior, hyperactivity, and concentration problems. For example, some antipsychotic medications, such as risperidone and aripiprazole, have been approved by the FDA for treating irritability associated with autism in children of certain ages.⁶

Medication is most beneficial when paired with evidence based psychotherapy, such as Applied Behavior Analysis (ABA), according to research. ABA applies what we know about behavior to real-life settings. The idea is to promote positive behaviors while minimizing negative or learning-inhibiting ones. Language and communication skills, attention, focus, social skills, memory, and academics can all benefit from this form of therapy.⁷

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

With Athena Care, autism services are a phone call away. Open Monday through Friday, 7:00 a.m. to 6:00 p.m., Athena Care’s autism testing clinics in Tennessee provide superior care for many of your behavioral and mental health needs.

When choosing care providers, it’s important to ask many questions and 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

Here, you’ll find a list of practitioners organized by city and information about their backgrounds and specialties.

A care coordinator can also assist you with any questions or concerns about Medicare and autism at one of our multiple locations throughout Tennessee.

How Much Does Autism Testing & Treatment Cost Without Insurance?

The following are average costs, though they may vary by location and other factors. Therefore, they may not reflect the actual cost of what you’ll pay for testing or treatment services in Tennessee.

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 $200⁸ 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 roughly $18,⁹ and the average price of ABA is $120 an hour. Some children require up to 40 hours of ABA therapy every week to reach their full potential, which amounts to $4,800 per week or $249,600 per year.¹⁰

Sources

1. “Integrated Behavioral Health Coverage.” Medicare.Gov, U.S. Centers for Medicare and Medicaid Services., www.medicare.gov/coverage/behavioral-health-integration-services. Accessed 19 June 2022.
2. “Basics About Autism Spectrum Disorder (ASD) | NCBDDD | CDC.” Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 31 Mar. 2022, 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. “Screening and Diagnosis of Autism Spectrum Disorder.” U.S. Department of Health & Human Services, 2020,  https://www.cdc.gov/ncbddd/autism/screening.html
6. “Medication Treatment for Autism.” NIH, 2021, https://www.nichd.nih.gov/health/topics/autism/conditioninfo/treatments/medication-treatment
7. “Applied Behavior Analysis.” Autism Speaks Inc., 2022, https://www.autismspeaks.org/applied-behavior-analysis
8. Lauretta, Ashley. “How Much Does Therapy Cost?” Forbes Health, Forbes Media LLC, 19 Oct. 2021, www.forbes.com/health/mind/how-much-does-therapy-cost.
9. “Risperidone Prices, Coupons and Patient Assistance Programs.” Drugs.Com, www.drugs.com/price-guide/risperidone. Accessed 19 June 2022.
10. Tatom, Carol Rbt. “How Much Does ABA Therapy for Autism Cost?” Autism Parenting Magazine, 2 Feb. 2022, www.autismparentingmagazine.com/aba-therapy-autism-cost.