Navigating ABA Therapy Insurance in Georgia: A Parent's Guide

For parents in Georgia, securing an autism diagnosis for your child is the first step on a long journey. The next, and often most daunting, is figuring out how to pay for the intensive therapies that can make a world of difference. The good news is that Georgia has laws in place to help families access Applied Behavior Analysis (ABA) therapy. The bad news is that the system can be incredibly complex.

This guide is designed to help you understand your rights, navigate the insurance maze, and find the resources you need to get your child the care they deserve.

Understanding Georgia's Autism Insurance Law: Ava's Law

In 2015, Georgia passed a landmark piece of legislation known as Ava's Law. This law mandates that certain health insurance plans provide coverage for the diagnosis and treatment of Autism Spectrum Disorder (ASD). This was a huge victory for families across the state.

Here’s what Ava’s Law provides:

• Coverage for ABA Therapy: The law explicitly includes coverage for habilitative or rehabilitative services, which includes Applied Behavior Analysis.

• Age Limit: Coverage is mandated for children and young adults from birth through age 20.

• Annual Benefit Cap: Under the law, coverage for ABA therapy is subject to a maximum annual benefit of $35,000.

This $35,000 cap is a critical number to be aware of. While it provides significant support, high-intensity ABA programs can exceed this amount, so it's essential to plan accordingly.

Which Insurance Plans Are Covered?

This is where it gets tricky. Ava's Law applies to state-regulated insurance plans. This generally includes:

• Plans purchased on the individual marketplace (HealthCare.gov).

• Fully insured plans provided by employers (typically smaller to medium-sized businesses).

However, the law does not apply to all plans. The most common exception is self-funded (or self-insured) plans. These are plans where a large employer pays for employee healthcare costs directly, rather than paying premiums to an insurance company. These plans are regulated by federal law (ERISA), not state law, and are not required to comply with Ava's Law.

How do you know if your plan is self-funded? The best way is to ask your HR department directly. You can ask, "Is our health plan fully insured or self-funded?"

A Step-by-Step Guide to Getting ABA Therapy Covered

1. Confirm Your Diagnosis: You will need a formal ASD diagnosis from a qualified medical professional (like a developmental pediatrician or psychologist) to submit to your insurance company.

2. Call Your Insurance Company: This is a crucial step. Do not rely on a pamphlet or general information. Call the member services number on the back of your insurance card and ask the following questions:

   • "Is my plan fully insured or self-funded?"

   • "What are my benefits for Applied Behavior Analysis (ABA) therapy for a child with an autism diagnosis?"

   • "Is there an annual dollar cap on my ABA therapy benefits?"

   • "Do I need a pre-authorization for ABA therapy services?"

   • "Which ABA providers in the Atlanta area are in-network with my plan?"

3. Choose an In-Network Provider: Whenever possible, choosing a provider that is in-network with your insurance will save you a significant amount of money and paperwork. Our directory can help you find Atlanta ABA providers and you can then cross-reference that list with your insurance company's network.

4. The Pre-Authorization Process: Your chosen ABA provider will typically handle this for you. They will submit your child's diagnosis and their proposed treatment plan to the insurance company. The insurance company will review this information to determine that the services are "medically necessary" and approve a certain number of hours for a set period (usually 6 months).

What if My Insurance Denies Coverage or I Hit the Cap?

It can be devastating to receive a denial or realize you've exhausted your benefits. Do not give up. You have options.

The Katie Beckett Waiver (Deeming Waiver)

For families with private insurance who have high medical costs, the Katie Beckett Waiver is a lifeline. This Georgia Medicaid program allows children with significant medical needs to receive Medicaid benefits regardless of their parents' income.

If your child qualifies for the Katie Beckett waiver, Medicaid can act as a secondary insurance, picking up the costs that your primary insurance doesn't cover. This can be used to pay for copays, deductibles, or services after you've hit your primary insurance's $35,000 cap.

Other Financial Assistance

• Provider Payment Plans: Many ABA centers understand the financial strain on families and may offer payment plans or a sliding fee scale.

• Non-Profit Grants: Organizations like the United Healthcare Children's Foundation and C.A.R.E. for Children Foundation offer grants to help families pay for medical expenses.

Navigating the financial side of ABA therapy is a marathon, not a sprint. Be persistent, be organized, and don't be afraid to ask for help. By understanding the rules and leveraging the resources available, you can secure the services your child needs to thrive.

Have more questions? Connect with our community and find the resources you need in the Atlanta area.