Mass Health ABA Coverage
Frequently Asked Questions
Applied Behavior Analysis (ABA) is one of the frequently prescribed therapies for people with autism. Private insurance began covering ABA therapy in 2011, under a Massachusetts act, ARICA. Following the passage of the Autism Omnibus Bill in 2014, MassHealth began covering ABA in 2015.
Who is eligible?
ABA is available to children diagnosed with autism under 21 enrolled in MassHealth Standard and CommonHealth, and to children under age 19 enrolled in MassHealth Family Assistance.
How does someone access coverage?
The child’s clinician (usually a developmental pediatrician, neurologist, psychologist), recommends ABA. The family then locates an ABA provider in one of the three MassHealth Managed Care Entities they are assigned to:
The provider requests authorization for ABA from MassHealth, performs an initial evaluation, and develops a treatment plan.
How long will this process take?
The length of time to access services is dependent on how long it takes to locate a provider with availability, how long it takes them to complete the initial evaluation and receive authorization for the treatment plan. Families should ask specific providers they are thinking of using for an estimate of how long it might take to start services.
Are there limitations on coverage?
Coverage is based on the plan’s medical necessity criteria. There are no annual or lifetime dollar or unit of service limitations on coverage.
Are social skills groups covered?
Yes, subject to medical necessity criteria.
What treatments are covered under the ARICA law and Omnibus Act?
The law covers the following care prescribed, provided, or ordered for an individual diagnosed with one of the Autism Spectrum Disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary.
Habilitative or Rehabilitative Care – this includes professional, counseling and guidance services and treatment programs, including but not limited to, applied behavior analysis supervised by a board certified behavior analyst, that are necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of an individual.
Pharmacy care – medications prescribed by a licensed physician and health-related services deemed medically necessary to determine the need or effectiveness of the medications, to the same extent that pharmacy care is provided by the insurance policy for other medical conditions.
Psychiatric care – direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
Psychological care – direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.
Therapeutic care – services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers.
How are education services affected?
Educational services are not affected and Insurers are not required to pay for in-school services. Conversely, schools may not require parents to access private insurance for services that are part of the IEP.