INSURANCE

What steps need to be taken prior to starting services? Once it is determined that ABA services are covered by your insurer we will submit authorization for your child’s initial assessment. Once the initial assessment is completed, the BCBA/LABA will develop your child’s treatment plan which will detail skills to be targeted during sessions as well as include the recommended number of weekly hours.

Are social skills groups covered?

Yes, subject to medical necessity criteria. If your health plan includes ABA coverage, it also includes social skills group coverage.

Is there an age limit for covered treatment?

In Massachusetts, there is no age limit for covered treatment under ARICA however MassHealth only covers ABA until age 21. Out of state plans may have different coverage and limitations as well.

If I receive services through another source (e.g. school district or Early Intervention), can I still receive services through insurance?

Yes. Children receiving ABA services through EI may still be able to receive additional services through insurance based on medical necessity and insurance company guidelines. Educational services delivered at school should not limit services your child can receive through insurance based on medical necessity.

Are there a maximum number of hours that can be authorized?

Insurers typically authorize hours based on medical necessity and their insurance company guidelines. After your child’s assessment, our LABA/BCBA will make recommendations for service delivery based on medical necessity and will work with your insurer to provide any additional documentation to support the rationale for their recommendation.

What are my options if I have a self-funded plan or private insurance that doesn’t cover ABA?

You can contact your employer to request an exemption or you can enroll in MassHealth.

Can a person have both private insurance and MassHealth?

Yes, people can have private insurance and MassHealth. Private insurance will always be considered your primary insurance and is billed first.

Can the insurance company reduce hours and if so, how does this happen?

Insurance companies typically require a re-authorization process every 3-6 months. Your LABA/BCBA will submit a treatment plan with progress updates and will propose any new goals or objectives for your child. At this point, if an insurer determines that a decrease in hours is warranted, a lesser amount may be approved. If this happens, your LABA/BCBA will work with your insurer and provide further rationale for the recommended service delivery.

Are there any insurance plans exempt from the ARICA Law?

Yes, self-funded plans are mandated by ERISA, which is federal law and therefore not subject to state laws.

For more information, please email our Admissions team at admissions@rcsconsultingne.com