ABA for Treatment of Autism

MIT employees and their dependents who participate in an MIT medical plan are eligible for Coverage of Applied Behavioral Analysis (ABA) therapy for the treatment of autism in early childhood ─ from ages 3 through 6.

How to Obtain Coverage

The MIT health plans cover ABA services for covered dependents from age three through age six to diagnose and treat autism spectrum disorders (ASD) with a pre-authorization from Blue Cross Blue Shield.

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.

Since most ABA providers are out-of-network, they may not bill Blue Cross directly. Therefore, most providers will ask that you pay for ABA services out-of-pocket. You can then submit a Subscriber Claim Form directly to Blue Cross Blue Shield for reimbursement, less the $20 per visit copayment, which you will be responsible to pay.

FAQs

What is ABA and why is MIT covering it?

ABA is a behavioral reinforcement program that includes techniques for increasing useful behaviors and reducing those that may cause harm or interfere with learning. MIT added this benefit after more than a year of study by the Employee Benefits Oversight Committee (EBOC) in response to interest by members of the MIT community.

Who can provide ABA services and where can they be delivered?

The majority of ABA services are delivered by Board Certified Behavioral Analysts (BCBA) or Para-professional Technicians supervised by a BCBA. Independently licensed behavioral health professionals may also deliver ABA services. To be covered, services must be provided in the home, in a professional office setting or in an environment such as day-care or pre-school. Services provided in a school setting will not be covered.

Is pre-authorization for ABA services required?

Yes. In addition, you will be required to have a diagnosis of an Autism Spectrum disorder within the last 6 months by a physician or independently licensed behavioral health professional and a written recommendation for ABA services from a physician or independently licensed behavioral health professional. You can begin the authorization process by calling or having your ABA provider call the Behavioral Health number on the back of your MIT medical plan membership card.

Why is MIT only covering children from ages 3 through 6?

This benefit is intended to bridge the gap between publicly sponsored early intervention benefits available to children under age 3 and support available to school-age children through individual education plans. This approach focuses resources on pre-school children for whom ABA therapy appears to be most effective. Children are eligible for ABA coverage from their 3rd birthday until their 7th birthday.

How many hours of ABA services will be covered?

Your BCBA will perform an initial assessment of your child that typically takes between 8 and 10 hours. The BCBA will then develop and submit a behavioral plan to Blue Cross Blue Shield of Massachusetts (BCBSMA), MIT’s claims administrator, with a recommendation for the number of hours of ABA per week. Based on the requirements of the behavioral plan, BCBSMA will work with your ABA provider to determine the number of hours approved each week. Typical authorizations are between 10 and 20 hours per week, although more or fewer hours may be approved depending on the behavioral plan.

Will I have any out of pocket expense?

Beginning January 1, 2015, you will be required to pay a $10 copayment if you have an MIT Primary Care Provider (PCP), or $20 if you have a Blue Cross Blue Shield PCP or receive out-of-network services.

Does ABA require ongoing review?

Yes. BCBSMA will review the progress of the behavior plan with your provider every six months.

Does this benefit apply to students?

The possible extension of these benefits to children of students covered by an MIT medical plan is under consideration.