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Medicaid Now Covers ABA Therapy! So, How Do I Get It?

picture of an ABA Therapy Gym at Westside's Willowbrook Clinic , as a main picture for the Medicaid and ABA Therapy blog

Illinois Medicaid ABA Therapy Coverage

In 2008 the State of Illinois passed the “autism mandate”. This law required insurance companies to provide coverage for the diagnosis and treatment services for children with autism. Even though private insurers began covering these services, Illinois Medicaid did not do so. Ever since, families of children with autism who have Medicaid have struggled to find services for their child.

In October 2020 it was announced that Illinois Medicaid will finally begin covering ABA services. On a certain level, this announcement is a reason to celebrate. It showed that our legislators were open to listening to the calls for help. At the same time, it proved that a lot of work remains. A particular provision in this law will continue to make access to ABA services challenging for families with Medicaid.

Awkward Licensure Provision Limiting Access

What many do not realize with the 2020 coverage announcement is that there is a provision in the law that will hinder access to services. Families on Medicaid who now finally have the approval to get ABA will find that there are not many providers that meet the licensure requirements in the law.
Typically, ABA Therapy is provided under the guidance of a Board Certified Behavior Analyst (BCBA). The provision in the law states that a BCBA providing ABA services to children with Medicaid must not only be a BCBA but also be licensed in (1) Clinical Psychology or (2) Social Work.

To become a BCBA, one must focus on a specific career path. They undergo thousands of hours of training. The large majority of these BCBAs spend so much time becoming one that they do not seek out additional careers. Both Clinical Psychology and Social Work are distinctly separate career paths from becoming a BCBA. It is very unlikely that a BCBA would also have one of these licenses.

The coverage announcement is going to lead to many new families looking for services. At the same time, there will be only a small number of providers that meet this criteria. The result will be long waitlists and low access to services. So, what can be done?

How Children With Medicaid Can Access ABA

The most effective path for a family on Medicaid to receive ABA Therapy for their child with autism remains purchasing a private insurance plan during open enrollment. This can be done by connecting with a personal insurance broker. They will help you find an insurance plan.

If you are looking for the best insurance plan to cover ABA, it is likely that the broker will point you to the Blue Cross Blue Shield (BCBS) PPO Bronze Plan. The BCBS Bronze plan has the lowest premium of the BCBS Bronze/Silver/Gold PPO plans. For a single child, the Bronze plan costs $245 per month, whereas the Gold costs $378 per month. More importantly, the Bronze plan has the same exact out of pocket max amount as the other plans ($8,550 for 2021).

image of a table Costs of Blue Cross Blue Shield Plans for ABA therapy as a supplementary visual to explain medicaid and insurance coverages

When you get ABA Therapy, you almost always will meet your plan’s out of pocket max amount. This amount is likely what you will owe for services for the year. In the case of BCBS’s PPO plans, a year of ABA would likely cost $8,550 whether you are on the Bronze, Silver, or Gold plans. If you get the same services for the same cost no matter the plan, it would make sense to buy the one with the lowest monthly premium amount: the Bronze Plan. If you are looking to get an insurance plan for ABA, and someone is recommending the Silver or Gold plan, this should raise questions. It is possible you will be overpaying for the same exact service.

Making the Cost of ABA Affordable

Costs of a Private Insurance Plan

When getting a private insurance plan, you will owe (1) your monthly premiums to the insurance company and (2) your out of pocket expenses to the company providing ABA services. On a Bronze plan, the premium costs will total $3,050 per year, and the out of pocket costs will likely be $8,550 per year. Before your jaw hits the floor, there are ways to get these costs covered!

(1) Getting Help With the Premiums
There are autism non-profits that exist to help families cover their premium costs for ABA Therapy. The organization Autism Hero Project is an example of one. Families can complete their quick online application to be considered for a stipend that covers some or all of their premium costs. Applying to such organizations in advance of open enrollment in November can help families secure funding for premiums in advance.

 (2) Getting Help With the Out of Pocket Costs
Covering premium costs is only one part of the equation. The out of pocket cost is the bigger challenge. This is where picking the right therapy provider makes sense. Providers like Westside Children’s Therapy will allow families to apply for sponsorship. If a family demonstrates economic hardship, Westside provides grants to help these kids get the support they need. When calling providers, asking about hardship programs could save you in the long run and make ABA therapy much more accessible until the Medicaid law is adjusted to include more providers.

Similar to premium cost support, there are also many autism-focused nonprofits that offer grants to families. Autism Speaks has a resource list that can get you started.

Have ABA Cost Questions?

This is not straightforward stuff! But don’t worry – we have experts that can help. If you have questions around getting ABA while on Medicaid, or about ABA costs in general, Westside can help. We can run a financial analysis on your insurance plan (or one that you are looking to buy) to tell you what your weekly costs for ABA therapy will be for the year. If you need some help, contact our Insurance Specialists.