Does Insurance Cover ABA Therapy in South Dakota?
Find out how ABA coverage works in South Dakota and the exact questions to ask your insurer.
How ABA Coverage Works in South Dakota
South Dakota has an autism insurance mandate. That means state-regulated health plans, the ones you buy on your own or get through a small employer, must cover medically necessary ABA therapy. But that mandate does not apply to every plan.
If your employer self-funds its health plan, it falls under a federal law called ERISA. That law exempts those plans from state mandates. So a self-funded plan can choose not to cover ABA, even though many do cover it anyway. This is why two families working for the same company can get completely different answers.
The quickest way to know your situation is to ask your HR department or benefits administrator one question: Is our plan fully insured or self-funded? That answer tells you which rules apply.
The Exact Question to Ask HR and Your Insurer
Once you know your plan type, call the number on your insurance card and ask these exact questions. Write down the answers, the date, and the name of the person you spoke with.
Ask: Does my plan cover applied behavior analysis for autism? If yes, what are the specific coverage limits, such as a maximum number of hours per week or a dollar cap per year? Do I need a prior authorization, and if so, what is the process? What are my out-of-pocket costs, like copays, coinsurance, and deductible?
If your plan is fully insured and the state mandate applies, the insurer must cover ABA, but limits can still vary. If your plan is self-funded, the answer depends entirely on what your employer chose to include.
What a Prior Authorization Needs
Most insurers require prior authorization before ABA therapy starts. That means the therapy provider sends in a treatment plan and the insurer approves it before you begin. The process usually takes a few weeks.
Your ABA provider will handle most of this, but you can help by gathering the right documents. You will likely need a formal autism diagnosis from a qualified professional, like a developmental pediatrician or a psychologist. You will also need a prescription or referral from your child's doctor, and sometimes a recent evaluation report.
Ask your insurer for the exact list of requirements. Some plans want specific forms, like a prior authorization request form, and they may have deadlines for submitting it. Missing a deadline can delay therapy, so start early.
What to Do If You Get a Denial
If your insurer denies coverage, do not give up. You have the right to appeal. The denial letter will explain why they said no and give you a deadline to appeal, usually 180 days from the date of the letter.
First, read the denial letter carefully. It will list the specific reason, like 'not medically necessary' or 'out of network.' Then, ask your ABA provider to write a letter of medical necessity. That letter should explain why ABA is needed and how it will help your child.
You can also ask your insurer for a copy of the medical policy they used to make the decision. That policy will tell you exactly what criteria they use, so you can address each point in your appeal. If the first appeal fails, you can request an external review by an independent third party.
South Dakota Medicaid as an Option
If your family qualifies for South Dakota Medicaid, that is a separate route to ABA coverage. Medicaid covers medically necessary ABA for children under 21 through a federal program called EPSDT, which stands for Early and Periodic Screening, Diagnostic and Treatment.
That means if your child is on Medicaid and a doctor says ABA is medically necessary, Medicaid must cover it. The exact process depends on your Medicaid plan, so call the number on your member card and ask how to get ABA services.
Your member card will have the name of your managed care plan, if you have one. That plan has its own rules for prior authorization and provider networks, so ask for the specific steps.
Finding ABA Providers in South Dakota
We list ABA agencies across the counties we cover. The largest concentration is in Minnehaha County. Pennington County and Codington County also have listings.
When you call an agency, ask if they accept your insurance and if they have experience with your specific plan. Also ask about their waitlist, because some agencies have a wait of several months.
If you have a self-funded plan that does not cover ABA, ask the agency about private pay options or sliding scale fees. Some agencies offer payment plans, but that varies.
South Dakota listings right now
29 ABA agencies across 8 South Dakota counties.