Illinois Insurance Requirements for Autism Spectrum Disorder

Illinois Law on Autism Spectrum Disorder Coverage

In 2011, Illinois passed a law requiring insurance companies to provide coverage for the diagnosis and treatment of ASD. The law applies to both individual and group health insurance plans, including self-insured plans. The law requires coverage for the following:

Applied Behavior Analysis (ABA): ABA is a therapy that uses positive reinforcement to teach new skills and improve behavior. ABA is considered the gold standard of behavioral therapy for ASD and is recommended by the American Academy of Pediatrics.
Occupational Therapy (OT): OT helps individuals with ASD improve their ability to perform everyday tasks, such as dressing, eating, and grooming. OT can also help with sensory integration issues, which are common in individuals with ASD.
Speech Therapy: Speech therapy can help individuals with ASD improve their communication skills, including speech, language, and social interaction.
Prescription Drugs: Insurance plans must cover all FDA-approved prescription drugs for the treatment of ASD, including medications for related conditions such as anxiety and depression.
Diagnostic Testing: Insurance plans must cover the cost of diagnostic testing for ASD, including psychological and neurological evaluations.

Coverage Limits and Requirements

Illinois law sets limits on coverage for autism treatment. Insurance plans must cover up to $36,000 per year for ABA therapy for children under the age of 12. There is no limit on coverage for OT or speech therapy. Insurance plans must also cover at least 20 visits per year for behavioral health services, including ABA, OT, and speech therapy.

To access coverage for autism treatment, individuals and families must meet certain requirements. Insurance plans may require a diagnosis of autism from a licensed physician or psychologist. They may also require a treatment plan from a licensed therapist, outlining the recommended treatment and the expected outcomes.

In addition, insurance plans may require pre-authorization for treatment. This means that individuals and families must obtain approval from the insurance company before beginning treatment. Pre-authorization may require submitting documentation, such as a treatment plan and progress reports.

Out-of-Pocket Costs

While insurance plans in Illinois are required to cover autism treatment, there may still be out-of-pocket costs. These costs can include deductibles, co-pays, and co-insurance. Individuals and families should review their insurance plan to understand their specific costs.

In addition, not all providers may accept insurance for ASD treatment. Some providers may require payment upfront and then submit a claim to the insurance company for reimbursement. It is important to check with providers about their insurance policies and to keep track of all medical expenses for tax purposes.

Examples of Insurance Plans Covering Autism Treatment in Illinois

Several insurance plans in Illinois provide coverage for the diagnosis and treatment of ASD. Blue Cross Blue Shield of Illinois, for example, covers ABA therapy, OT, speech therapy, and prescription drugs for the treatment of ASD. They also offer a care coordination program to help families navigate the healthcare system.

Aetna Better Health of Illinois is another insurance plan that covers autism treatment. They cover ABA therapy, as well as speech and occupational therapy. In addition, they offer case management services to help families access the care they need.

Other insurance plans that cover autism treatment in Illinois include United Healthcare Community Plan and Meridian Health Plan. It is important to note that coverage may vary depending on the specific plan and policy. Individuals and families should review their insurance plan documents or contact their insurance provider directly to understand their coverage for autism treatment.

Impact of the Law on ABA Therapy Coverage

The law requiring insurance companies to provide coverage for ASD treatment in Illinois has had a significant impact on individuals and families affected by autism. Prior to the law, many families struggled to access the care they needed due to high costs and limited coverage options.

Since the law's passage, more individuals with ASD have been able to access critical treatments like ABA therapy, OT, and speech therapy. The law has also helped reduce financial barriers for families seeking treatment.

However, some families still face challenges accessing care due to limited provider availability or insurance restrictions. In addition, the limits on coverage for ABA therapy may not be sufficient for some families who require more intensive treatment.

Despite these challenges, the law has undoubtedly improved access to care for many individuals with ASD in Illinois. It is important that individuals and families continue to advocate for expanded coverage options and increased funding for autism services to ensure that all those affected by ASD can access the care they need.

Is ABA Therapy Covered By Medicaid In Illinois?

Medicaid is a government-funded healthcare program for individuals with limited financial resources. In Illinois, Medicaid provides coverage for the diagnosis and treatment of Autism Spectrum Disorder (ASD), including ABA therapy.

However, individuals must meet certain eligibility requirements to qualify for Medicaid coverage. Eligibility is based on income and other factors, such as disability status and age.

People interested in accessing Medicaid coverage for autism treatment should contact their local Department of Human Services office or visit the Illinois Medicaid website for more information.

Does Blue Cross Blue Shield Cover ABA Therapy in Illinois?

Yes, Blue Cross Blue Shield of Illinois provides coverage for autism spectrum disorder (ASD) treatment. They cover Applied Behavior Analysis (ABA) therapy, occupational therapy (OT), speech therapy, and prescription drugs for the treatment of ASD. Additionally, they offer a care coordination program to help families navigate the healthcare system.

Coverage may vary depending on the specific plan and policy. Individuals and families should review their insurance plan documents or contact their insurance provider directly to understand their coverage for autism treatment.

Conclusion

Illinois law requires insurance companies to cover the diagnosis and treatment of autism, including ABA therapy, occupational therapy, speech therapy, prescription drugs, and diagnostic testing. While there are coverage limits and requirements, this law has made treatment more accessible for individuals and families affected by autism.

If individuals and families are having trouble accessing coverage for autism treatment, they can contact the Illinois Department of Insurance for assistance. With the right treatment and support, individuals with ASD can reach their full potential and lead fulfilling lives.