puzzleNew York is one of 39 states in the country to enact an autism insurance mandate, which allows for coverage of a number of medical and behavioral treatments, including Applied Behavior Analysis (ABA). There are many questions families of children with autism might have, such as what services are covered and if children receiving an Individualized Education Program (IEP) are eligible for insurance funded services. Here are some basic facts you should know about the insurance mandate:

  • The insurance mandate covers diagnosis, and treatment of autism.
  • Treatment may include assistive communication devices, medical care, pharmacy care, therapeutic care (physical therapy, occupational therapy, speech therapy etc), and Applied Behavior Analysis (ABA).
  • Only plans regulated by NYS are subject to the mandate, including State Employee Plans, Individual Plans, Fully Insured Plans, Marketplace Plans
  • Many plans not regulated by NYS will cover ABA services!
  • To find out if your insurance covers ABA, have an ABA provider call for you
  • There are no age or lifetime dollar caps for ABA services. However, ABA is subject to a cap of 680 hours per insured individual per year
  • Children with an Individualized Education Program (IEP) are eligible for services under the insurance mandate, but the services must be supplemental in nature and provided outside of an educational setting.
  • Most insurance plans require authorization for ABA services. Your provider is responsible for finding out if authorization is required and for arranging prior authorizations when necessary.

If you have any questions regarding the insurance mandate, Eden II’s Diagnostic & Outreach Center will be hosting free monthly webinars providing more detailed information. To register, please visit www.eden2center.org or call 917-722-3986.