Is ABA Therapy Covered By Insurance In New Mexico?

Introduction

Applied Behavior Analysis (ABA) therapy is a crucial intervention for individuals on the autism spectrum, aiding in the development of essential skills. For families navigating the complexities of autism treatment in New Mexico, understanding insurance coverage for ABA therapy becomes essential. This article examines the landscape of insurance coverage for ABA therapy within New Mexico, focusing on key legislative mandates, eligibility, and financial considerations.

Insurance Mandates for ABA Therapy in New Mexico

Existence of specific mandates for ABA therapy

New Mexico has established a clear mandate that requires health insurance policies to cover services related to autism spectrum disorder (ASD), specifically Applied Behavioral Analysis (ABA) therapy. Since the enactment of Senate Bill 39 in 2009, effective January 1, 2010, families with children diagnosed with autism have had access to essential services including screening, diagnosis, and treatment without facing lifetime dollar limits. This provision ensures that parents can secure necessary support without the burden of restrictive financial constraints.

The scope of mandated coverage goes beyond just ABA therapy; services such as diagnostic evaluations, speech therapy, occupational therapy, and physical therapy are also included. This comprehensive approach highlights New Mexico's commitment to proactive early detection and intervention strategies for children at risk of or confirmed to have autism.

Impact of SB 39 and HB 322 on coverage

SB 39 laid the foundation for autism coverage, which was later enhanced by House Bill 322 in 2019. This legislation removed previous age and dollar caps on coverage, thereby expanding access to ABA therapy not only for younger children but also for transition-age youth and adults. The removal of age restrictions means that individuals aged 19 to 22, who are still enrolled in high school, can receive crucial therapy sessions, further supporting their developmental needs as they approach adulthood.

In New Mexico, coverage for ABA therapy under private insurance providers varies; however, major insurers like Blue Cross Blue Shield of New Mexico and Molina Healthcare also adhere to the mandate, generally offering up to $36,000 per year for children under 19. Notably, this law ensures that even Medicaid-enrolled adults can access ABA therapy without age restrictions, allowing for continuous support to those in need.

Insurance policies in New Mexico are designed to support families effectively, ensuring they can access and afford necessary therapies for autism spectrum disorder.

The Role of Medicaid and Private Insurance

Eligibility for Medicaid and Private Insurance Coverage

In New Mexico, the Autism Insurance Act mandates that health insurance policies cover applied behavioral analysis (ABA) therapy for children diagnosed with autism spectrum disorder (ASD). For families whose child is eligible for Medicaid, ABA services are included as part of the Behavioral Health benefit package. This support applies to children up to 22 years old if they are enrolled in high school.

Private insurance providers such as Blue Cross Blue Shield, Presbyterian Health Plan, and Molina Healthcare also cover ABA therapy, though coverage specifics can differ considerably.

Differences in Coverage Based on Insurance Type

The cost of ABA therapy without insurance can be prohibitively high—ranging from $62,400 to $249,600 annually, with monthly expenses starting at roughly $4,800. In contrast, insurance coverage significantly mitigates these costs. Families using insurance are typically subject to a capped limit of $36,000 annually for children and young adults up to the age of 19, ensuring they have access to necessary treatments.

Medicaid expands beyond age limitations, allowing adults with autism to continue receiving ABA therapy without a strict cutoff. This distinction makes Medicaid a valuable resource for ongoing care, while private insurance can impose deductibles, further complicating access based on policy specifics. Overall, understanding these different coverages is essential for families navigating autism treatment in New Mexico.

Senate Bill 317 and Its Implications

Elimination of Out-of-Pocket Costs

Senate Bill 317, effective January 1, 2022, has transformed access to behavioral health services in New Mexico. This legislation mandates that all health plans regulated by the state, including private insurance and specific state plans, cover behavioral health services without imposing out-of-pocket costs for using in-network providers. This significant change aims to reduce the financial burden on families seeking essential therapies for conditions such as autism.

The bill ensures that individuals accessing services like therapy visits, mental health treatment, and behavioral health therapies—including Applied Behavior Analysis (ABA)—do not have to face cost-sharing. This means families can focus on their child's needs without the worry of high costs that often accompany such services.

Impact on Behavioral Health Services

By eliminating out-of-pocket costs, SB 317 encourages a more comprehensive engagement with behavioral health services, making them more accessible. This is particularly beneficial for families with children diagnosed with autism, as they often require ongoing and varied therapies. Without the financial barrier, the uptake of services is likely to increase, leading to improved outcomes for many individuals with Autism Spectrum Disorder (ASD).

What factors influence the out-of-pocket cost of ABA therapy?

The out-of-pocket cost for ABA therapy can vary significantly based on several factors:

• Session Frequency: More frequent sessions may lead to higher overall costs.
• Availability of Insurance Coverage: The extent of coverage provided in a family's insurance plan can greatly affect costs.
• Location: Pricing may differ based on the local cost of living and demand for services.
• Therapist Rates: Individual therapist rates can vary, impacting out-of-pocket expenses even with insurance coverage.

These aspects combined can lead to substantial variations in the financial responsibilities faced by families seeking ABA therapy.

Scope of Coverage for Autism Treatment

Types of therapies included in coverage

In New Mexico, the autism insurance mandate requires health insurance policies to cover a comprehensive range of services related to autism spectrum disorder (ASD), notably including:

• Applied Behavioral Analysis (ABA): A fundamental therapy aimed at improving specific behaviors.
• Speech Therapy: Assists in enhancing communication skills.
• Occupational Therapy: Helps individuals develop daily living skills.
• Physical Therapy: Supports physical health and mobility.

These services are essential in providing well-rounded support for children and adults diagnosed with autism, ensuring that they receive necessary treatments tailored to their needs.

Comprehensive support under New Mexico law

The New Mexico Autism Insurance Act, primarily brought into effect by Senate Bill 39 in 2009, mandates that both private and state-regulated insurance plans must cover services related to ASD without imposing any lifetime dollar limits. This legislative framework provides crucial financial support for families tasked with managing autism care, thereby enhancing access to necessary therapies.

Additionally, the state has taken proactive measures by integrating well-baby and well-child screenings into their coverage plans. This ensures early diagnosis and intervention, increasing the chances for better outcomes in managing autism. As of 2019, opportunities for transition-age youth and adults with autism were broadened when the state eliminated previous age limits on coverage, supporting individuals up to 22 if enrolled in high school.

How much does an ABA therapy session typically cost?

The cost of an ABA therapy session typically ranges from $120 to $150 per hour in the U.S., influenced by factors like location and insurance coverage. Sessions can last from two to five hours, with children needing between 20 to 40 hours of therapy per week. This leads to a potential annual cost of up to $249,600 at the higher end of these rates. However, numerous health insurance plans cover a significant portion of ABA therapy costs, greatly alleviating financial barriers for families. Medicaid, for instance, makes comprehensive coverage for autism-related services accessible across all 50 states, offering additional supports like the Katie Beckett waiver for eligible families.

Ensuring Coverage and Understanding Limitations

Checking compliance with SB 317

In New Mexico, individuals who are insured must confirm that their health insurance plans comply with the provisions of Senate Bill 317. This crucial legislation mandates that behavioral health services, including those for autism treatment, be provided without cost-sharing for in-network providers. To ensure adherence, families should reach out directly to their insurance companies or employers for information relevant to their specific plans.

It's especially important for families enrolled in self-insured plans, as federal regulations may allow these plans to impose cost-sharing that state laws do not. Checking coverage conditions can help families avoid unexpected expenses associated with necessary autism services.

Understanding insurance limitations

Even though New Mexico's autism mandate provides comprehensive coverage for Applied Behavioral Analysis (ABA) and other therapies for individuals with autism, it's essential for families to be aware of coverage limitations and exclusions.

Major private insurance providers, such as Blue Cross Blue Shield and Molina Healthcare, often outline specific coverage terms that may include deductibles or session limits. Families should carefully examine their policy documents to understand any potential restrictions that could impact access to vital services.

To navigate these complexities, consider consulting with a health insurance expert or advocate familiar with autism coverage rights in New Mexico. Understanding your benefits can empower families to make informed decisions related to autism treatment.

Conclusion

Navigating insurance coverage for ABA therapy in New Mexico involves understanding a landscape shaped by comprehensive legislative mandates, eligibility criteria, and recent reforms. With significant financial relief provided by both private insurance and Medicaid, families can better access the necessary therapies for autism spectrum disorder without prohibitive costs. By staying informed about the details of specific insurance plans and mandates like Senate Bill 317, families can ensure they maximize the benefits available to them for ABA therapy.

References

• New Mexico Insurance Requirements for Autism Spectrum Disorder
• New Mexico State-Regulated Insurance Coverage - Autism Speaks
• [PDF] New Mexico's law to eliminate out-of-pocket costs for behavioral ...
• Is ABA Therapy Covered By Insurance In New Mexico ...
• Autism - New Mexico Health Care Authority
• Is ABA Therapy Covered By Insurance In New Mexico?
• What Is The Age Limit For ABA Therapy In New Mexico?