Medicaid and ABA

It has been a year now since Medicaid and a handful of private insurers began covering Applied Behavior Analysis (ABA) services for their clients in Washington State.  As expected with an endeavor of this size, there have been challenges with implementation. We have been tracking some of the more common issues that have arisen and offer this blog to help provide guidance for those seeking ABA services for their child.

While parents haven’t reported much difficulty in getting the order needed for insurers, getting approval from some insurers and then accessing services have been problematic for many. The sheer volume of referrals that has been generated for the pool of contracted ABA providers has led to long waiting lists.

“that kind of ABA”

Some parents have reported that after a long wait, they have been told during their intake evaluation that the ABA provider doesn’t provide “that kind of ABA” they are asking for. The issue seems to be the distinction between the application of ABA in addressing disruptive behavior and in its application in skill acquisition using discrete trial training (DTT).

Some have even been told that help with behavioral challenges is “not ABA”.  It is – but what the provider is saying is that he or she doesn’t provide ABA to treat disruptive behavior, only ABA for skill acquisition. That’s important information to know ahead of time! And parents can’t count on insurers to know this distinction when receiving a list of their contracted ABA providers.

The end result is that parents wait on the “wrong list” thereby prolonging the wait even further when finally getting on the “right list”. It is important then for parents to know exactly what it is they are asking for and to confirm with their insurer’s contracted ABA providers as soon as possible that they provide the ABA service your child needs.  If you have an ABA order for help with challenging behavior, call the ABA providers on your list and ask if they offer this service. If not, go back to your insurer and ask for more providers to call.

“it must be right for my child…”

Another issue that we hear about seems to stem from so many jumping on the ABA bandwagon. “If it’s a covered service, then it must be right for my child”, seems to be the thinking.  Parents have told me they are waiting for ABA but don’t even know what it is or how it might help their child. It’s important to keep in mind that there is no one, definitive treatment for all with autism spectrum disorder. Not every child with autism needs ABA.  Being clear about what behavior(s) are to be addressed and what your expectations are will help direct the focus and prevent confusion and disappointment.

Katrina Davis, Family Resource Coordinator at Seattle Children’s Autism Center offers the following tips on accessing ABA services:

  • If ABA has been recommended for your child by a medical or mental health provider, obtain an order for ABA therapy from this provider.  This may come if the form of a letter ordering ABA services or the provider may put his or her request for ABA services in the summary/recommendation notes or evaluation report. Regardless, request a copy.
  • Submit this ABA order to your insurance for pre-authorization.
  • Keep in mind, in WA State, ABA is covered by Medicaid, Group Health, TriCare, Uniform Medical, Microsoft, and Amazon plans and a handful of other plans.  Other plans may deny ABA services.
  • If ABA services are approved, ask for a list of ABA providers contracted with your plan and proceed with securing services. Determine the type of ABA you need (skill acquisition and/or challenging behaviors) and find the service provider who is the best fit for your child. Be prepared for long wait times.
  • If ABA therapy is denied by your insurer, request a letter of medical necessity from your medical or mental health provider and connect with WAAA (see below) for advocacy and information on how to proceed with the appeal process.   Many families have secured ABA therapy through the appeals process. Don’t give up if you are denied services.

For more information about what ABA is, we offer the following links:

Story of Hope: Arthur

Disruptive Behavior and Autism Spectrum Disorder

For information on how to access ABA services in Washington, see:

Washington Autism Alliance and Advocacy (WAAA)

Health Care Authority (HCA)