Does Insurance Cover ABA Therapy in Maryland?
Find out if your Maryland plan covers ABA therapy and what to do if it doesn't.
How ABA Coverage Works in Maryland
Maryland has a state autism mandate that requires many health plans to cover ABA therapy. But that mandate only applies to fully insured plans, which are plans where the employer buys coverage from an insurance company. If your plan is self-funded, meaning your employer pays claims directly, the state mandate does not apply.
Self-funded plans are governed by federal law, ERISA, and they are not required to follow Maryland's mandate. Many self-funded plans still cover ABA, but it is not guaranteed. This is why two families at the same company can get different answers: one might have a fully insured plan, the other self-funded.
Ask Your Employer These Questions
Before you call an ABA agency, find out exactly what your plan covers. The fastest way is to ask HR two questions: Is our health plan fully insured or self-funded? And does the plan cover ABA therapy for autism?
If HR does not know, call the number on the back of your insurance card. Ask the same two questions. Also ask for a copy of the plan's medical policy on ABA or applied behavior analysis. That document lists any limits, like visit caps or age restrictions.
Prior Authorization and What It Needs
Most plans require prior authorization before ABA can start. That means your provider sends clinical documentation to the insurer, and the insurer approves a set number of hours. The approval is not forever; you will need to renew it, often every six months.
The paperwork usually includes a formal autism diagnosis, a treatment plan with goals, and a recommendation from a licensed professional. Ask your ABA agency to handle this. They do it every day and know what your specific insurer wants.
What to Do If Your Claim Is Denied
If your claim is denied, you have the right to appeal. Start by reading the denial letter. It will say why it was denied and give a deadline, often 180 days from the date of the denial. Do not miss that deadline.
Your appeal should include a letter from your ABA provider explaining why the therapy is medically necessary. If the first appeal fails, you can request an external review, which is an independent review by a third party. In Maryland, you can also contact the Maryland Insurance Administration for help with complaints about a fully insured plan.
Maryland Medical Assistance for ABA
If you qualify for Maryland Medical Assistance, also called Medicaid, ABA is covered for children under 21 when it is medically necessary. This is through the Early and Periodic Screening, Diagnostic and Treatment benefit, which requires states to cover medically necessary services.
Your child's doctor or a developmental pediatrician can help you get a referral. Your Medicaid plan's name is on your member card. Call the number on the card to ask about ABA coverage and how to find a provider.
What to Expect in Terms of Hours and Costs
ABA hours vary widely. Some children get 10 hours a week, others get 40. The number depends on your child's needs and what the plan approves. Your provider will recommend a range, and your insurer will decide what to cover.
Costs also vary. If you have a copay, it might be $30 per visit. If you have a deductible, you pay full price until you meet it. For example, if the rate is $100 per hour and your child gets 20 hours a week, that is $2,000 a week and about $8,600 a month. That is why knowing your plan's coverage limits matters before you start.
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