Does Insurance Cover ABA Therapy in Oregon?
Find out if your Oregon plan covers ABA therapy and what to do if it doesn't.
How ABA Coverage Works in Oregon
Oregon has a state autism insurance mandate. That mandate requires many health plans to cover medically necessary ABA therapy for children with autism. But it does not apply to every plan.
The mandate binds fully insured plans. Those are plans where the employer buys coverage from an insurance company. It does not bind self-funded plans. In a self-funded plan, the employer pays claims directly and the insurer just administers the plan. Self-funded plans follow federal ERISA rules instead, and they are exempt from state mandates.
That is why two families at the same employer can get different answers. One might have full ABA coverage, the other might not. The difference is how the employer set up the plan.
Ask These Questions First
Before you call an ABA agency, find out exactly what your plan covers. Start with the benefits line on the back of your insurance card. Ask these questions:
Is my plan fully insured or self-funded? If the rep does not know, ask HR.
Does my plan cover applied behavior analysis (ABA) therapy for autism?
Are there any limits on the number of visits, hours, or total cost per year?
Do I need a prior authorization before starting ABA?
What is the process for getting that authorization?
Write down the date, the rep's name, and their answers. You will need that if you get a denial later.
- Is my plan fully insured or self-funded?
- Does my plan cover ABA therapy?
- Are there visit, hour, or dollar limits?
- Do I need prior authorization?
- What is the authorization process?
What Prior Authorization Requires
Most plans that cover ABA will require prior authorization. That means the insurer reviews the treatment plan before they agree to pay.
The provider you choose will typically handle this. They submit a treatment plan that includes the diagnosis, the recommended hours per week, and the goals. The insurer then approves or denies it.
You will likely need a formal autism diagnosis from a qualified professional. That could be a developmental pediatrician, a child psychologist, or a psychiatrist. The diagnosis must be on file before the authorization request.
Ask your insurer what documentation they need. Some plans want the diagnosis report, the treatment plan, and a letter of medical necessity. Others have their own forms. Get the list in writing.
What to Do If You Get a Denial
A denial is not the end. You have the right to appeal. The denial letter will say why they denied and how to appeal.
Start by calling the insurer and asking for a review. Sometimes a simple mistake causes the denial. If that does not work, file a formal appeal with the insurer. You can also ask for an independent external review, which is a second opinion from a neutral third party.
Keep every document: the denial letter, your treatment plan, the diagnosis, and any notes from calls. Send everything by certified mail so you have proof of receipt.
If your plan is self-funded, the appeal process may be different. Ask HR for the plan's specific appeal steps. You have the same right to appeal under ERISA, but the deadlines and forms can differ.
Oregon Health Plan as a Backup
If your private plan does not cover ABA, or if you do not have private insurance, the Oregon Health Plan (OHP) may help. OHP is Oregon's Medicaid program.
Medicaid covers medically necessary ABA for children under 21 through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. That is a federal requirement, so it applies to all state Medicaid programs.
To qualify, you need to meet income and other eligibility rules. You also need to be enrolled in a coordinated care organization (CCO), which is OHP's managed care plan. The name of your CCO is on your OHP member card.
If your child is on OHP, ask your CCO how to get ABA coverage. They have their own authorization process. Start with your child's primary care provider, who can refer you to an ABA provider.
Finding an ABA Provider in Oregon
Once you know your coverage, you can start looking for a provider. In Oregon, the listings for this state include agencies across the counties we cover. The largest concentrations are in Multnomah County, Washington County, and Deschutes County.
When you call an agency, ask if they accept your insurance. Also ask if they have experience with your specific plan. Some agencies are in-network with certain insurers but not others.
Ask about waitlists. Some providers have months-long waits. Ask if they offer an initial assessment and how soon you can start.
If you have a choice between providers, compare their approach and their hours. Some offer in-home therapy, others work in a clinic. Pick one that fits your family's schedule and your child's needs.
Oregon listings right now
101 ABA agencies across 15 Oregon counties.