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While autism treatments continue to evolve, applied behavior analysis (ABA) remains one of the most commonly used options in the United States. ABA is a critical tool for helping children and adults with autism improve important life skills, such as communicating, learning, and interacting socially.
However, while this therapy is essential for people with autism, accessing it isn’t always easy due to insurance, financial considerations, and legislation.
But with new healthcare regulations, employers now have a unique opportunity to play a more active role in supporting employees and their families who rely on ABA therapy.
What Is ABA Therapy?
ABA therapy focuses on encouraging positive behaviors rather than punishing undesired behaviors. By rewarding desirable behaviors, board-certified behavior analysts (BCBAs) reinforce actions that help those with autism thrive and develop social, learning, and communication skills that can improve their quality of life.
For example, if a therapist is teaching a child to independently put away an item, they may give the child a small reward when they do so. Similarly, to develop communication skills, a person may be directed to shake hands when meeting someone new or to say thank you when being given an item.
Challenges Affecting ABA Therapy
Although ABA therapy is widely recognized as a necessary and helpful treatment, several challenges can prevent people from receiving this care.
Rising Costs
Costs can deter families from seeking ABA therapy, even if they have insurance. Coverage varies, with some plans offering comprehensive coverage of ABA therapy and other plans having limited support for this therapy. A lack of support in navigating difficult appeals processes can lead to increased stress for families.
Out-of-pocket costs for ABA therapy are daunting, ranging from $60–$200 per hour, leaving many families to research available financial aid options, such as assistance programs, resources through nonprofit organizations, and additional insurance coverage.
At the same time, healthcare costs in general have exponentially increased, leaving families to juggle basic healthcare expenses, including prescriptions, doctor visits, and specialist appointments. In the U.S., average out-of-pocket costs in 2022 rose to $1,425 per person — not even including insurance premiums.
All of this combined can make it nearly impossible for patients to get the ABA therapy they need, simply due to financial restrictions.
Lack of Autism-Specific Providers
In addition to costs being a barrier to seeking care, many people with autism don’t have ready access to the care required for their individual health needs.
Physician knowledge of autism is critical to delivering quality care. However, many physicians lack the autism-specific knowledge that’s essential to screen, diagnose, and refer those with autism to a specialist.
The demand for BCBAs increased by 58% between 2023 and 2024, underscoring the recognition of ABA therapy as an effective treatment and the lack of providers currently available to handle this demand. In addition, research reveals that 51% of families don’t know where to receive treatment and have limited access to information.
Families who don’t have access to ABA therapy within their community often avoid seeking care due to long-distance travel, additional costs, time commitments, and disruption to work schedules.
Shift Toward Value-Based Care
The shift toward value-based care in ABA therapy means that reimbursement is now tied to measurable patient outcomes, emphasizing quality over quantity. While this approach encourages better, more effective care, it can also create challenges for families seeking timely treatment, which is already challenging due to a lack of providers with autism-specific knowledge.
With a value-based approach, providers are required to meet specific performance metrics, which can lead to even longer wait times as they work to demonstrate the efficacy of their services. Families may experience delays in accessing necessary treatments, and securing immediate coverage may become more complex.
Healthcare Mandates Impacting ABA Therapy
Healthcare mandates play a critical role in shaping access to ABA therapy. Federal- and state-level regulations have expanded coverage requirements, helping more families obtain the support they need, but they’ve also introduced new complexities for employers and health plans to navigate.
Insurance Mandates
Many states have enacted laws requiring health insurance plans to cover autism-related treatments, including ABA therapy. These laws mandate that private insurers cover ABA therapy for children with autism, but the specifics vary by state. In some cases, the laws set limits on the amount of coverage provided and the age of the child eligible for coverage, while others provide more extensive benefits.
The introduction of such mandates has made ABA therapy more accessible, reducing the financial burden on families. However, employees may still face gaps in coverage if they live in states with more limited mandates or if their employer's insurance plan doesn’t fully comply with state regulations.
Medicaid and Medicaid Waivers
Medicaid programs, which vary by state, are another essential source of coverage for children with autism. Some states have expanded Medicaid benefits to cover ABA therapy, while Medicaid waivers are used in others to provide services. These waivers often have strict eligibility criteria, such as income limits and specific documentation requirements, which can impact access to treatment.
Additionally, individual states determine the maximum number of people who can receive a waiver. Because of this, there are limited spots available, and people often linger for years on a waiting list before they can receive the care they need.
Mental Health Parity and Addiction Equity Act
Initially passed in 2008 and updated in 2024, the Mental Health Parity and Addiction Equity Act (MHPAEA) ensures that insurance coverage for mental health and behavioral health services, including ABA therapy, is no less favorable than coverage for medical and surgical services. The law requires insurers to offer equal coverage for autism treatments, such as ABA therapy, preventing plans from limiting access to necessary services based on the type of care.
The MHPAEA helps families access the same level of benefits for ABA therapy as they would for other medical treatments, making it easier for employees to seek treatment without facing discrimination in their health plans. However, enforcement can sometimes be inconsistent, and employees may still face challenges in securing coverage due to variations in insurer interpretation of the law.
Impact on Employee Access to ABA Therapy
While these regulatory changes have increased access to ABA therapy, there are still significant challenges and barriers to receiving care. Employees may experience disparities in coverage based on where they live, what’s included in their employer’s health plan, or whether their state has adopted comprehensive autism coverage mandates.
In addition, while legislation mandates coverage, there can still be variations in the number of therapy hours allowed, the types of qualified providers covered, and the age limits for therapy.
As a result, employees seeking ABA therapy for their children may need to navigate complex insurance policies and regulations, potentially facing obstacles such as denials, age restrictions, or insufficient therapy hours covered. Additionally, with changes in how insurers process and approve claims for ABA therapy, employees might encounter delays or require additional documentation to secure the appropriate care for their children.
How Employers Can Support Employees
Understanding these challenges and potential solutions puts employers in a prime position to support employees through the changing healthcare landscape.
Employers can help connect employees with the autism treatment and care they need in a few different ways.
Prepare for Increased Demand for ABA Therapy Services
As ABA therapy becomes more recognized and accessible, employers should anticipate a greater demand for this service. A growing number of employees may seek coverage for their child’s needs or their own. Understanding the nuances of their health benefits can make a huge difference in their ability to do so.
As an employer, you can help by adjusting health benefits to ensure ABA therapy services are easily accessible. By offering comprehensive coverage that includes therapy, testing, and necessary follow-up treatments, you can make it easier for employees to get the help they need.
Providing employees with tools to help navigate the process, such as care navigation solutions, can also help alleviate some of the stress of locating the right provider for their needs.
For example, NaVcare from Vālenz Health® can help employees find high-quality, affordable care with professional guidance. Care navigators work one-on-one with members to guide them toward in-network facilities and providers, answer questions about benefits and out-of-pocket expenses, and assist members with claims.
Understand Legal and Compliance Considerations for Employers
Employers need to understand the legal obligations for providing autism treatment coverage. Complying with state and federal mandates related to ABA therapy benefits is crucial for avoiding legal issues and ensuring employees’ access to necessary care.
Employers should also make sure their benefits portal is clear and easy to understand. Employees must be able to quickly find all relevant coverage information and communications about benefits in easily accessible customer accounts.
Beyond portal communications, employers should also regularly schedule meetings, send emails, and offer direct access to HR and benefits coordinators.
Stay Ahead of Changing Regulations
With regulations around healthcare and ABA therapy continually evolving, it’s important for employers to regularly review and update employee benefits.
Staying ahead of changes in federal and state laws will ensure your workforce remains supported regardless of any regulatory shifts.
How to Navigate Changing Regulations While Supporting Employees
Evolving healthcare regulations present employers with challenges and opportunities. By staying informed, adjusting benefits plans, and offering additional support tools, such as NaVcare care navigation, you can make a meaningful impact on your employees’ well-being and help them live strong, vigorous, and healthy lives.
Connect with Valenz to learn more about how we can help you support your employees in the face of changing regulations and increasing demand for ABA therapy.