Insurance and Payment at The Helm ABA

At The Helm ABA, we believe every child should have access to high-quality Applied Behavior Analysis (ABA) therapy, regardless of financial or insurance complexities. Below, we’ve provided a detailed guide on how ABA therapy is covered, common insurance terms, potential funding options, and how we can help you navigate the process.

Understanding

Autism Insurance Coverage

ABA Therapy is widely recognized as a highly effective, research-backed treatment for children on the autism spectrum. While many insurance plans now include coverage for ABA therapy, each plan’s details can differ significantly. Here’s what you need to know:

  • State Mandates: Most states (including Texas) have laws requiring certain insurance policies to cover ABA therapy when there’s an autism diagnosis. However, each state has its own rules, including possible limitations on age, annual caps, or the total number of therapy hours.
  • Employer or Group Plans: These are typically “fully funded” plans regulated by state mandates—often providing meaningful ABA coverage.
  • Self-Funded Plans (ERISA): Some employers choose to self-fund. These plans can “opt out” of state mandates, meaning ABA coverage may vary or be excluded altogether.
  • Medicaid Plans: As of 2022, all states offer some degree of ABA coverage under Medicaid, though the requirements and benefits differ by state.
  • ACA/Marketplace Plans: Coverage for ABA therapy under marketplace policies can vary. Some cover it comprehensively; others may have limited or no ABA benefits at all.

Our Role: Before your child starts at The Helm ABA, we verify your insurance benefits so you know exactly what is—and isn’t—covered.

The Cost

of ABA Therapy

The cost of ABA therapy generally depends on:

  1. Your Insurance Coverage – This includes your deductible, co-pay or co-insurance, and any out-of-pocket maximums.
  2. Hours of Therapy – Following an initial assessment, your Board Certified Behavior Analyst (BCBA) will recommend a specific number of hours per week based on clinical need.

We can estimate your family’s out-of-pocket costs once we:

  1. Complete a diagnostic/psychological assessment (or review your existing diagnosis reports)
  2. Determine the recommended therapy hours
  3. Verify your insurance benefits with your specific plan
Insurance Authorization

1-2 Weeks

In most cases, your insurance provider requires pre-authorization for ABA therapy. This process generally includes:

Initial Diagnosis Documentation

A formal autism diagnosis from a qualified provider (MD or PhD).

Pre-Authorization for Assessment

Authorization for the initial ABA assessment, where we evaluate your child’s specific needs.

Pre-Authorization for Ongoing Therapy

Once the assessment is completed, we submit a formal treatment plan to insurance for approval of regular therapy hours.

Timeframe: On average, insurance authorization can take one to two weeks. Some plans are faster, while others may require additional documentation, taking several weeks or more.

Key Insurance Terminology

Navigating insurance jargon can be confusing. Here are the most common terms you’ll encounter:

  • Deductible: The amount you must pay out-of-pocket before your plan starts paying its share of covered services.
  • Co-pay: A fixed dollar amount you pay per service day or visit. Once you’ve paid your co-pay, insurance usually covers the remaining cost for that visit.
  • Co-insurance: A percentage-based split between you and your insurer. For example, if you have an 80/20 plan, the insurer pays 80% of the allowed amount, and you pay 20%, until you reach your out-of-pocket maximum.
  • Out-of-Pocket Maximum: The maximum amount you’re required to pay for covered services in a plan year. After you hit this limit, insurance pays 100% of eligible costs for the remainder of the year.
  • Exclusion of Benefits: If something is explicitly excluded from your plan (e.g., ABA therapy), the insurance will not cover it at all.
  • In-Network vs. Out-of-Network:
    • In-Network: We have a direct contract with your insurer, typically resulting in lower out-of-pocket costs.
    • Out-of-Network: You can still receive services, but you’ll likely pay higher costs or be responsible for submitting claims.
  • Pre-Authorization: Approval from your insurer for a specific service (like ABA therapy) before it begins.

Notification of Benefits (NOB): A summary from your insurer detailing your coverage, deductibles, co-pays, co-insurance, and any plan limitations.

An inclusive speech therapist works with a child with an autism spectrum disorder generative ai.
Beautiful psycologist and blond toddler girl doing therapy building tower using plastic blocks at kindergarten

Common Limitations & Exclusions

Even with mandates, some insurance plans or employer-funded programs may impose:

  • Age Caps: Coverage may be limited to children under a specific age.
  • Hour or Monetary Caps: A set number of therapy hours (e.g., 40 hours/year) or total dollar limit (e.g., $30,000/year).
  • Plan Limitations: Some plans won’t authorize more than a certain number of hours per week, requiring additional documentation or ongoing re-authorizations.

If your plan excludes ABA services altogether, it may show up as “Exclusion of Benefits.” In these cases, you might work with your employer or insurer to see if you can add coverage—or explore alternate funding (see Section 7).

Tips for Contacting Your Insurer

While we do much of the heavy lifting, it’s always wise for families to understand their coverage:

  • Ask Specifically About ABA Coverage
    • If they say “Autism is covered,” verify that includes ABA therapy for autism.
  • Document Everything
    • Write down reference numbers, the names of representatives, and any details shared during calls.
    • This helps resolve conflicts if you receive conflicting information.
  • Review Policy Changes Annually
    • Even if your plan seems the same, subtle changes can occur each year that affect coverage or costs.
  • Stay Proactive
    • Let us know if you change insurers or employers. New plans often require a fresh pre-authorization, and we’ll help reinitiate that process promptl
Boy playing with his therapist using a ball
Disclaimer

Coverage details are subject to change and depend on individual insurance plans. The Helm ABA staff provides general guidance but cannot guarantee payment. Please confirm final benefits directly with your insurance carrier.

In-Network Insurance

We offer comprehensive assistance with understanding insurance coverage and exploring grants and financial resources, so that financial constraints do not limit your child’s access to quality therapy. Contact us today to get started.

Getting Started

Our mission is to reduce stress and uncertainty around the financial aspects of ABA therapy so you can focus on what truly matters—your child’s growth and well-being. If you have additional questions or want us to verify your insurance benefits, reach out anytime.

Enroll Your Child Now