Great News for BlueCross BlueShield Health Members!

General Coverage:

BlueCross BlueShield provides coverage for ABA therapy as part of its behavioral health services for individuals diagnosed with Autism Spectrum Disorder (ASD). Coverage is typically available for children and adolescents, but the specific details depend on your plan.

State-Specific Mandates:

Coverage for ABA therapy can be influenced by state mandates. Many states require insurance plans, including those under BCBS, to provide comprehensive ABA therapy coverage without imposing annual or lifetime caps. However, the specifics can differ based on whether the plan is fully insured or self-funded.

Plan Variability:

Employer-Sponsored Plans:  The extent of ABA therapy coverage under employer-sponsored BCBS plans can vary greatly. Some plans may offer extensive benefits, while others might have limitations on the number of therapy hours or higher cost-sharing requirements. 

Medicaid and State Plans:  BCBS offers Medicaid and state-specific plans that usually provide substantial coverage for ABA therapy, in line with state Medicaid guidelines. However, it’s crucial to review your specific plan to understand the coverage details.

Medical Necessity & Pre-Authorization:

For ABA therapy to be covered, it must be considered medically necessary. This is typically determined through a formal evaluation and diagnosis by a licensed healthcare provider. BCBS often requires pre-authorization, meaning they must approve the therapy plan before treatment can begin.

Network Providers & Coverage Limitations:

Coverage might include limitations such as caps on therapy hours or restrictions on where therapy can be provided (e.g., home-based vs. clinic-based). To minimize out-of-pocket costs, it’s essential to confirm that your ABA provider is within BCBS’s network. 

Blue Jay ABA is an in-network provider with BlueCross BlueShield, ensuring that you have access to quality therapy services without unexpected costs.

To effectively manage your BlueCross BlueShield coverage for ABA therapy , follow these steps:

Review Your Policy: 

Start by carefully reviewing your BCBS policy to understand the specific details of your ABA therapy coverage, including any limits or exclusions.

Determine Plan Type: 

Identify if your plan is employer-sponsored, Medicaid-based, or part of a state-specific program, as coverage details and requirements can vary.

Obtain an ASD Diagnosis:

 Ensure that your child has been formally diagnosed with Autism Spectrum Disorder (ASD) by a licensed healthcare provider. This diagnosis is essential for accessing ABA therapy benefits.

Initiate Pre-Authorization: 

Contact BlueCross BlueShield to begin the pre-authorization process. You will likely need to submit a treatment plan and other necessary documentation for approval.

Verify Provider Network: 

Confirm that your ABA therapist is part of the BCBS network. Blue Jay ABA is an in-network provider with BlueCross BlueShield, ensuring you receive premium ABA services without additional costs.

Understand Coverage Limits: 

Be aware of any restrictions, such as annual caps on therapy sessions or limitations on the types of settings where therapy can be conducted.

Seek Assistance:

 If you have questions or encounter any issues, don’t hesitate to contact our team or BlueCross BlueShield’s customer service for guidance and support.