Does Insurance Cover ABA Therapy in Maine?
Find out if your Maine plan covers ABA, what to ask HR, and what to do if you're denied.
How ABA Coverage Works in Maine
Maine has a state autism insurance mandate. That means most plans sold in the state must cover medically necessary ABA therapy for children with autism. But the mandate only applies to fully insured plans, which are regulated by the state.
If you get insurance through a large employer, your plan might be self-funded. Under federal law (ERISA), self-funded plans are exempt from state mandates. That's why two families at the same company can get different answers: one has a fully insured plan, the other has a self-funded one.
The good news: many self-funded plans cover ABA anyway. The only way to know for sure is to check your specific plan documents.
Ask These Questions First
Before you call an ABA agency, get the facts from your insurer. Call the number on your insurance card and ask:
Does my plan cover ABA therapy for autism? Is my plan fully insured or self-funded?
What are the specific coverage limits, like number of hours per week or total visits per year? Do I need a prior authorization? What paperwork does that require?
Write down the name of the representative and the date. Ask them to send you the relevant plan language in writing or by email.
- Ask for the plan's ABA coverage policy by name.
- Ask if there's a separate deductible for ABA.
- Ask if there's a maximum number of hours per week.
- Ask if you need a referral from a doctor.
What Prior Authorization Involves
Most plans require prior authorization before ABA starts. That means your provider sends clinical documentation to the insurer, and the insurer approves the treatment plan before services begin.
Typically, you'll need a formal autism diagnosis, a prescription or referral from a doctor, and a detailed treatment plan from the ABA provider. The plan should include goals, proposed hours per week, and the expected duration of services.
Ask your ABA agency to handle the prior authorization. They do this every day and know what your insurer expects. But you should still follow up with the insurer to confirm the authorization was approved and note the approval number.
If Your Claim Is Denied
If your claim is denied, you have the right to appeal. The denial letter will explain why and give you a deadline to appeal, usually 60 days. Don't miss it.
Start by asking your ABA provider for a peer-to-peer review. That's a call between your provider and the insurer's medical director. Often, a direct conversation can resolve the issue.
If that fails, file a formal appeal with your insurer. Include a letter from your doctor explaining why ABA is medically necessary. If the plan is fully insured, you can also contact the Maine Bureau of Insurance for help.
For self-funded plans, you can request an external review through the federal Department of Labor. The denial letter should tell you your rights.
MaineCare as a Coverage Route
If you qualify for MaineCare (Medicaid), ABA is covered for children under 21 when it's medically necessary. This is through the EPSDT benefit, which requires states to cover necessary services for kids.
You'll need to be enrolled in MaineCare first. Your child's doctor can help with the referral. Your managed care plan's member card will have the name and phone number for customer service.
MaineCare may have its own prior authorization process, so ask your ABA provider to check requirements before starting.
Finding ABA Providers in Maine
We list ABA agencies across the counties we cover. The largest concentrations are in Cumberland County, York County, and Androscoggin County.
When you call an agency, ask if they accept your insurance. Some agencies are in-network with certain plans, others are out-of-network. If they're out-of-network, ask about self-pay rates and whether they offer a sliding scale.
Also ask about waitlists. Some agencies have months-long waitlists, so it's smart to contact several and get on multiple lists.
Maine listings right now
31 ABA agencies across 8 Maine counties.