Empowering You with Insurance Information

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Receiving an autism diagnosis for your child can be overwhelming, and understanding your insurance coverage is essential. Applied Behavior Analysis (ABA) Therapy is a recognized and effective treatment for addressing many symptoms associated with autism. This guide will help explain insurance coverage and common terminology.

Empowered Pathways is in-network with the following insurance providers:

• Advanced Health Services (AHS - MS State and School Plans)
• Blue Cross Blue Shield
• Blue Cross Blue Shield Federal Plans
• Select Administrative Services
• UnitedHealthcare
• Additional In-Network Insurance Providers Coming Soon!

Using an in-network provider can help minimize your out-of-pocket costs.

All states now have mandates requiring some level of ABA Therapy coverage for autism, including both commercial and state insurance plans. These mandates vary by state, so it’s important to familiarize yourself with the specific benefits available in Mississippi.

Generally, commercial insurance policies must provide ABA therapy coverage when an autism diagnosis is present. However, specifics like the amount of coverage, age limitations, and other nuances can differ based on the state and individual plans.

Understanding your plan, its limitations, and your out-of-pocket costs is crucial. Here are some common insurance terms and their definitions. For any uncertainties, contact your provider’s Member Services.

• Insurance Premium: The monthly cost of your insurance plan, often shared between you and your employer.
• Patient or Member Responsibility: Your share of the costs for medical services received under the plan, which can vary based on whether the provider is in-network or out-of-network.
• Deductible: The amount you pay each year before your health plan starts sharing the cost of covered services.
• Co-pay: A flat rate you pay per visit, common for in-network services. Your insurance plan covers the remaining cost of the claim.
• Co-insurance: A cost-sharing structure, often for out-of-network services, where you pay a percentage of the medical claim and your insurance covers the rest.
• Out-of-Pocket Maximum: The maximum amount you could owe for covered medical expenses each year. After reaching this amount, insurance covers everything at 100%.
• In-Network Benefits: Lower out-of-pocket costs for services from providers within your insurance network.
• Out-of-Network Benefits: Higher out-of-pocket costs for services from providers outside your insurance network, if allowed by your plan.

Empowered Pathways specializes in supporting children diagnosed with Autism. ABA Therapy coverage requires a medical diagnosis, which must be conducted using a standardized evaluation tool by a qualified M.D. or Ph.D. A copy of the diagnostic evaluation record is needed for a pre-authorization of services.

Empowered Pathways does not offer diagnostic evaluations at this time.

Understanding the differences between an educational diagnosis and a medical diagnosis of Autism is crucial for parents, educators, and healthcare providers. These distinctions influence the services and supports a child can access both in school and through medical insurance.

• Purpose: An educational diagnosis is conducted to determine if a student qualifies for special education services under the Individuals with Disabilities Education Act (IDEA).
• Process: This diagnosis is typically performed by a multidisciplinary team within the school system, which may include psychologists, special education teachers, speech therapists, and other specialists.
• Criteria: The focus is on how the autism spectrum disorder (ASD) affects the child’s educational performance. The assessment examines areas such as communication, social interaction, and behavior within the school environment.
• Outcome: If the team determines that the child's ASD adversely affects their educational performance, the child is eligible for an Individualized Education Program (IEP), which outlines specific educational goals and services.
• Regulations in Mississippi: Mississippi follows federal IDEA guidelines. The Mississippi Department of Education provides specific criteria and procedures for the evaluation and identification of students with autism for special education services.

• Purpose: A medical diagnosis is made to identify and treat ASD as a health condition. This diagnosis can help families access medical treatments, therapies, and services.
• Process: This diagnosis is usually made by a healthcare professional such as a developmental pediatrician, neurologist, psychiatrist, or licensed clinical psychologist.
• Criteria: The diagnosis is based on criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which includes persistent deficits in social communication and interaction, along with restricted, repetitive patterns of behavior, interests, or activities.
• Outcome: A medical diagnosis can lead to recommendations for various treatments and therapies, such as Applied Behavior Analysis (ABA), speech therapy, occupational therapy, and medication management.
• Insurance Regulations: In Mississippi, most insurance companies require a medical diagnosis of ASD to approve coverage for therapies and treatments. This includes both private insurance and Medicaid.

• Focus: An educational diagnosis is focused on the impact of ASD on learning and school performance, while a medical diagnosis addresses the overall health and developmental needs of the individual.
• Conducted By: Educational diagnoses are performed by school-based teams, whereas medical diagnoses are made by healthcare professionals.
• Eligibility for Services: An educational diagnosis qualifies a child for special education services and supports within the school system. A medical diagnosis is necessary for accessing medical treatments and therapies covered by insurance.

Both types of diagnoses play critical roles in supporting children with autism. An educational diagnosis ensures that a child receives the necessary educational accommodations, while a medical diagnosis opens the door to medical and therapeutic interventions. Understanding these differences helps parents and caregivers navigate the system more effectively to provide comprehensive support for their children.

Given the intensive nature and cost of ABA therapy, most insurance plans require pre-authorization for the initial ABA assessment and ongoing therapy. This includes your child’s Comprehensive Diagnostic Evaluation and a treatment plan created by a Board Certified Behavior Analyst (BCBA). Empowered Pathways assists with the pre-authorization process, verifies benefits, submits necessary documentation, and monitors authorization requests to minimize stress for families.

When contacting your insurance provider’s member services, it’s helpful to know the terminology and what to ask. Always confirm any cost estimates before treatment and document every conversation, including the names and reference numbers of representatives you speak with.

State mandates have improved access to care, but there are exceptions that allow certain employer-sponsored and marketplace plans to reduce coverage or opt out altogether. It's crucial to understand the specifics of your plan to ensure coverage benefits for ABA Therapy.

Mississippi law (Miss. Code Ann. §83-9-26) requires health insurance policies to cover the screening, diagnosis, and treatment of autism spectrum disorder. Effective January 1, 2016, this coverage must be included in health insurance policies issued, amended, or renewed in Mississippi. Key points include:

• ABA Coverage: Must be provided, limited to 25 hours per week up to the age of eight. Extensions are possible based on medical necessity. *Some insurances do not have this age restriction.
• No Discrimination: Insurers cannot terminate or refuse coverage solely because of an autism diagnosis.
• Benefit Parity: Coverage for autism-related services must have the same dollar limits, deductibles, or coinsurance as other medical services.
• Review of Treatment Plans: Insurers can review treatment plans every six months, with the cost of review covered by the insurer.
• Broad Coverage: Includes behavioral health treatment, pharmacy care, psychiatric care, psychological care, and therapeutic care.
• Exclusions: Certain types of insurance, like Medicare supplements, accident-only, and disability income policies, are not included in this mandate. While self-funded policies are not included in the mandate, some policies do offer coverage for ABA therapy. It is important to request information regarding your specific policy.

Empowered Pathways is here to help. We verify coverage, create a Notification of Benefits (NOB), and ensure your out-of-pocket costs are predictable and understandable. Our goal is to make your experience as stress-free as possible.

Empowered Pathways is dedicated to supporting children with autism and their families. Understanding your insurance coverage is a critical step in accessing the services your child needs. For further assistance, please contact us at 228.800.1810 or hello@empoweredpathways.com.