How to Obtain Coverage
The MIT health plans cover medically necessary assessment services for autism spectrum disorders (ASD), with a pre-authorization from BCBSMA.
To obtain a pre-authorization, your provider must contact the Blue Cross Blue Shield Behavioral Healthcare Coordination line at 1-800-524-4010. The provider will then need to provide the member's name, date of birth, and Blue Cross ID#, as well as their own name, address, and NPI number.
Please reach out to BCBSMA for a list of in-network ABA providers. Since most ABA providers are out-of-network, they may not bill BCBSMA directly. Therefore, out-of-network providers will ask that you pay for ABA services out-of-pocket. You can then submit a Subscriber Claim Form directly to BCBSMA for reimbursement, less your cost share (copayment/coinsurance), which you will be responsible to pay. Please see the FAQs below for additional information regarding out-of-pocket expenses for in- and out-of-network providers.
FAQs
What services are covered under ABA through BCBSMA?
BCBSMA’s coverage and definition of ABA services are consistent with Chapter 207 of the Acts of 2010 – An Act Relative to Insurance Coverage for Autism in the state of Massachusetts and is in accordance with national standards of applied behavior analysis societies (Council of Autism Service Providers, Association of Professional Behavior Analysis and the Associate for Behavior Analysis International).
The health plans covers medically necessary services to diagnose and treat autism spectrum disorders when the covered services are furnished by a covered provider. This may include (but is not limited to): a physician; a psychologist; or a licensed applied behavioral analyst. This coverage includes:
- Assessments, evaluations (including neuropsychological evaluations), genetic testing, and/or other tests to determine if a member has an autism spectrum disorder.
- Habilitative and rehabilitative care. This is care to develop, maintain, and restore, to the maximum extent practicable, the functioning of the member. This care includes, but is not limited to, applied behavior analysis that is furnished by or supervised by: a psychologist; a licensed applied behavioral analyst; or an early intervention provider.
- Psychiatric and psychological care that is furnished by a covered provider such as: a physician who is a psychiatrist; or a psychologist.
- Therapeutic care that is furnished by a covered provider. This may include (but is not limited to): a speech, occupational, or physical therapist; or a licensed independent clinical social worker.
- These covered services also include covered drugs and supplies that are furnished by a covered pharmacy when your prescription drug coverage is administered by Blue Cross and Blue Shield.
Your coverage for these covered services is provided to the same extent as coverage is provided for similar covered services to diagnose and treat a physical condition.
When physical, speech/language, and/or occupational therapy is furnished as part of the treatment of an autism spectrum disorder, a benefit limit will not apply to these services.
This coverage for autism spectrum disorders does not affect an obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan. This means that, for services related to autism spectrum disorders, no benefits are provided for: services that are furnished by school personnel under an individualized education program; or services that are furnished, or that are required by law to be furnished, by a school or in a school-based setting.
Please contact BCBSMA for specific guidelines and requirements.
Who can provide ABA services and where can they be delivered?
BCBSMA covers medically necessary ABA services for support of autism spectrum disorders (ASD) when diagnosed by a psychiatrist, psychologist, neurologist, developmental pediatrician, or other licensed physician experienced in the diagnosis and support of autism and when furnished or supervised by an appropriately trained, licensed psychologist or a licensed applied behavior analyst (LABA). This coverage may include medically necessary ABA services provided by an appropriately trained, licensed psychologist or LABA who accompanies the child to receive support in certain community settings, such as the home, center (office), daycare, preschool, or camp. Please contact BCBSMA for specific details.
Is pre-certification/pre-authorization for ABA services required?
Yes. In addition, diagnosis of autism spectrum disorder by a psychiatrist, psychologist, neurologist, developmental pediatrician, or other licensed physician experienced in the diagnosis and support of autism and when furnished or supervised by an appropriately trained, licensed psychologist or a licensed applied behavior analyst (LABA) is required. You can begin the authorization process by calling or having your ABA provider call the Behavioral Health number on the back of your MIT health plan membership card. Pre-certification/pre-authorization is required for all inpatient and outpatient services.
How many hours of ABA services will be covered?
An ABA provider, as defined above, will perform an initial assessment of your child which is typically completed within 12 hours. They will then develop and submit a behavior plan to BCBSMA, with a recommendation for the number of hours of ABA services per week. Based on the requirements of the behavior plan, BCBSMA will work with your ABA provider to determine the number of hours approved each week.
Does ABA require ongoing review?
Yes. BCBSMA will review the progress of the behavior plan with your provider every six months.
Are there any non-covered services?
Yes. Please contact BCBSMA to obtain a list of non-covered services.
Will I have any out of pocket expenses?
Under the BCBS PPO+ Plan, there is no cost share for in-network ABA services. The out-of-network cost share is 25% coinsurance after the deductible and any amount above the allowed amount.
Under the BCBS High Deductible Health Plan (HDHP), the in-network cost share is 10% after the deductible. The out-of-network cost share is 25% coinsurance after the deductible and any amount above the allowed amount.
Need Help or Have Questions?
| Contact | Phone | More Information |
|---|---|---|
| Blue Cross Blue Shield of MA | 1-888-376-0218 | Blue Cross Blue Shield |
