Insurance-Based Services
Tricia Moss, PhD, BCBA-D
ABA Psychological Services, P.C.
[email protected]
(516) 294-5000
In November 2011, New York State passed a law that mandates private health insurance to pay for ABA services for individuals with Autism Spectrum Disorder (ASD). Additionally, this health insurance mandate covers many medical and behavioral services through insurance including: screening, diagnosis, behavioral health treatment, pharmacy care, psychiatric care, psychological care, augmentative communication devices, and therapeutic care provided by licensed or certified speech therapists, occupational therapists, physical therapists, and social workers. There is no age cap or lifetime cap for ABA services. This insurance mandate pertains to private health insurance plans that are regulated by New York State. Plans that are regulated out of state or self-funded plans may not cover services.
Below is a list of links to information on insurance-based services and guidelines for ABA services.
https://www.autismspeaks.org/sites/default/files/docs/gr/ny_law_one_page_summary.pdf
http://www.nysaba.org/Downloads/NY%202014%20COMMUNITY.pptx.pdf
http://bacb.com/asd-practice-document/
http://www.apbahome.net/downloads/AutGuidelines.pdf
https://www.autismspeaks.org/docs/sciencedocs/atn/atn_air-p_applied_behavior_analysis.pdf
Written by Tricia Moss, PhD, BCBA-D
ABA Psychological Services, P.C.
[email protected]
(516) 294-5000
In November 2011, New York State passed a law that mandates private health insurance to pay for ABA services for individuals with Autism Spectrum Disorder (ASD). Additionally, this health insurance mandate covers many medical and behavioral services through insurance including: screening, diagnosis, behavioral health treatment, pharmacy care, psychiatric care, psychological care, augmentative communication devices, and therapeutic care provided by licensed or certified speech therapists, occupational therapists, physical therapists, and social workers. There is no age cap or lifetime cap for ABA services. This insurance mandate pertains to private health insurance plans that are regulated by New York State. Plans that are regulated out of state or self-funded plans may not cover services.
- What to know before you start
- ABA services must be supplemental to any services that the individual is receiving through an Individual Education Plan.
- Anyone with an ASD diagnosis can receive services regardless of age or functioning level. Many caregivers or adults with ASD don’t realize that ABA can be used with all types of functioning levels.
- How Does My Child Start Receiving ABA Services?
- (S)he must have a diagnosis and prescription from a medical professional (e.g. pediatrician, neurologist, developmental pediatrician, etc.) for ABA. To get the authorization, the ABA provider will need to submit proof of diagnosis and a prescription for ABA services from a medical professional.
- Once you decide on an agency that you will use to provide the services, the insurance company will provide an authorization for an initial assessment by a BCBA/LBA.
- If your plan does not cover ABA services, you can speak to Human Resources at your company and try to get self-funded plans to cover these services. Some self-funded insurance plans have chosen to provide ABA for their employees.
- To begin ABA services: 1) Call your insurance company directly to determine if you have the benefit. 2) Call the provider/agency directly and give them your insurance information, and they can call your insurance company to determine if you have the benefit.
- (S)he must have a diagnosis and prescription from a medical professional (e.g. pediatrician, neurologist, developmental pediatrician, etc.) for ABA. To get the authorization, the ABA provider will need to submit proof of diagnosis and a prescription for ABA services from a medical professional.
- How do these services work?
- A BCBA/LBA will conduct an initial assessment. Typically, the number of hours are limited to 6-8 hours including record review and report write-up, but you should expect to see the BCBA/LBA for at least 3-4 hours. The BCBA/LBA will develop treatment goals and write a report indicating the treatment goals, how they will be addressed, and request a certain number of hours of ABA services. Once the report is submitted to the insurance company, you will need to wait for an authorization for treatment to begin services.
- In most cases, a paraprofessional will be the one working several hours a week with your child (i.e. will provide the direct services) under the supervision of a BCBA/LBA. The BCBA/LBA will provide training for the paraprofessional to implement the procedures that he/she has developed to teach new skills and decrease challenging behavior. In addition, the paraprofessional will collect data and graph these data.
- The BCBA/LBA should provide supervision for the paraprofessional for 1 hour for every 10 hours of service (may be 2 hours for 20 or 3 for 30, but the ratio should be 1 in 10). This supervision is extremely important to the progress of the individual receiving ABA services because this is when the person with the expertise in ABA is directing the paraprofessional to implement new procedures, make any modifications to procedures, or continue with the previous procedures.
- A BCBA/LBA will conduct an initial assessment. Typically, the number of hours are limited to 6-8 hours including record review and report write-up, but you should expect to see the BCBA/LBA for at least 3-4 hours. The BCBA/LBA will develop treatment goals and write a report indicating the treatment goals, how they will be addressed, and request a certain number of hours of ABA services. Once the report is submitted to the insurance company, you will need to wait for an authorization for treatment to begin services.
- Questions for the BCBA
- How do you develop treatment goals?
- Have you worked with individuals with similar needs as my child (be specific)? Have you worked on behaviors similar to my child’s behavior before, and how (be specific)?
- How do you plan to help my child catch up to the skill level of his/her neurotypical peers?
- This will probably require working in real world situations. If the provider is not able to or not willing to work in real world settings, you may need to find another provider. Many agencies have a policy that a caregiver needs to be present during community outings, but the provider should be able to accompany the caregiver and child in the community to generalize skills they are working on in the home or community.
- What type of approach do you use? Do you use only discrete trial teaching, or do you implement more naturalistic teaching as well?
- What are the qualifications of the paraprofessional?
- How frequently should I expect to see the BCBA/LBA? How frequently will we be in contact? What is the best way to communicate with the BCBA/LBA?
- How do you handle cancellations or rescheduling sessions?
- What are the parents’ responsibilities?
- How does billing work?
- It is important that you find an ABA provider who can work best with your child, and has the training and qualifications to work with your child. For a list of qualifications for a BCBA/LBA to oversee ABA services see: http://www.apbahome.net/downloads/AutGuidelines.pdf
- Materials you may want to have
- This will depend on your child and the programs the team will be working on. For example, if you are working on turn-taking, you should have a variety of board games and other games available. If you are working on independent play skills, you should have a variety of preferred toys. If you are working on drinking from an open cup, you should have a variety of cups and liquids for your child to drink.
- The team should have some way of collecting data and graphing data. This may be a computer program, or by paper and pencil.
- Data collection
- Data are used to determine whether or not the treatment plan is effective or not. If the procedures are not effective, the BCBA/LBA will change the procedures.
- Data should be collected on all targets of the treatment plan. Data should be collected on behaviors you would like to decrease, as well as behaviors you would like to increase.
- The way in which data are collected and the forms used to take data will depend on the behaviors that are being targeted for increase or decrease.
- Caregivers may be asked to collect data. The BCBA/LBA should work with the caregivers to develop a data collection system that will work for them. See the paper on Data Collection for more detailed information.
- What to expect
- What services should look like
- A BCBA/LBA conducts an initial assessment that, most likely, will be 6-8 hours including report writing. He/she may observe the child or work directly with the child for 3-5 hours.
- Caregivers, and the patient, as much as possible, should be involved in the development of the ABA program goals.
- BCBA/LBA should provide supervision of the paraprofessional for 1 hour for every 10 hours of service.
- The paraprofessional should be following the treatment plan as instructed by the BCBA/LBA, collecting data, and graphing data every session.
- It is extremely important to collect data, and have the BCBA/LBA review those data to determine what is working and what is not working. If a treatment plan is not working, the BCBA/LBA should make changes to the treatment plan.
- A parent should be able to review his/her child’s data with the BCBA/LBA on request, and should have access to those data/graphs.
- ABA can address a wide variety of goals related to the symptoms of ASD. Some examples of targets of ABA services are: decreasing challenging behavior, increasing appropriate behavior, increasing communication, social skills, play skills, self-help skills, community living skills, and work skills.
- The BCBA/LBA should collaborate with caregivers and other providers who work with your child. This may be through phone calls, emails, school visits, etc.
- BCBA/LBA should provide supervision of the paraprofessional for 1 hour for every 10 hours of service.
- What to look for in a company?
- Conducts background checks, reference checks, etc.
- Can explain the billing process and how services are provided.
- Employees are knowledgeable, courteous, and polite.
- Data are collected throughout sessions, and these data are graphed.
- BCBA/LBA is present for 1 hour in 10.
- BCBA/LBA should be available to answer questions and collaborate with caregivers and other providers including schools.
- Employees show up on time, stay the entire time they are supposed to be there, and are consistent in providing services
- Conducts background checks, reference checks, etc.
- Parent responsibilities
- Caregiver involvement is essential for success with any ABA program. Caregivers should participate in identifying ABA program goals, and should receive training on how to work on each of the ABA programs. ABA will be most successful if caregivers are following through with therapy when the ABA team is not present.
- Question practices that you may not feel comfortable with or do not understand. If you do not understand what is being done or how to do something yourself, speak with your BCBA/LBA.
- Make a list of things you would like to work on (e.g. communication, social skills, going out to dinner, playing with siblings, decreasing problem behavior, following directions, etc.) and ask that they be incorporated into the treatment goals.
- Caregiver involvement is essential for success with any ABA program. Caregivers should participate in identifying ABA program goals, and should receive training on how to work on each of the ABA programs. ABA will be most successful if caregivers are following through with therapy when the ABA team is not present.
- Books and resources
- A BCBA/LBA conducts an initial assessment that, most likely, will be 6-8 hours including report writing. He/she may observe the child or work directly with the child for 3-5 hours.
Below is a list of links to information on insurance-based services and guidelines for ABA services.
https://www.autismspeaks.org/sites/default/files/docs/gr/ny_law_one_page_summary.pdf
http://www.nysaba.org/Downloads/NY%202014%20COMMUNITY.pptx.pdf
http://bacb.com/asd-practice-document/
http://www.apbahome.net/downloads/AutGuidelines.pdf
https://www.autismspeaks.org/docs/sciencedocs/atn/atn_air-p_applied_behavior_analysis.pdf
Written by Tricia Moss, PhD, BCBA-D
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