So you have been recommended ABA by your doctor, but you’re not sure how your insurance will cover it. Fortunately, New Hampshire requires meaningful coverage for autism, which includes therapies such as ABA, under state regulated plans. New Hampshire’s autism insurance bill, HB 569, was enacted in 2010 and became effective on January 1, 2011.
How do I know if I have a state regulated plan?
There are different kinds of insurance plans that determine what laws govern your plan. To find out what type of insurance plan you have, refer to your detailed plan policy, also known as a Summary Plan Description. You may have to reach out to your employer or insurance company in order to receive this detailed and lengthy document. It has all the nitty gritty information about your plan, such as annual and lifetime limits and restrictions, as well as information about the type of plan you have.
To which plan types does the STATE autism insurance law apply?
- Individual Plans – NO
- Fully Insured Large Group Plans -YES
- Fully Insured Small Group Plans – YES
What services are covered by law?
- Applied Behavior Analysis
- Direct or consultative services provided by a licensed professional including a licensed psychiatrist, licensed advanced practice registered nurse, licensed psychologist or licensed clinical social worker
- Speech, occupational, and physical therapy
Does New Hampshire have caps on ABA coverage?
Yes. Coverage for ABA is limited to individuals ages 0 to 21 years and is subject to annual dollar caps. For individuals 0 to 12 years of age, coverage is capped at $36,000 per year. For individuals 12 to 21 years of age, coverage is capped at $27,000 per year.
What if NH law does not apply to my plan?
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits. This includes quantitative treatment limits like age and dollar caps. What this means is that if your plan covers something for physical health, they have to cover the same for mental health.
For example, if they cover 50 hours of speech therapy a year for someone with a mouth injury, they have to cover 50 hours of speech therapy for someone with a mental health disorder. In other words, they cannot discriminate between a physical disability and a mental disability.
Do I need to submit a treatment plan to my insurance company?
Before you can send in a treatment plan, you must have a formal diagnosis of autism from a qualified doctor and letter of medical necessity. Qualified doctors include: neuropsychologist, developmental pediatrician, or neurologist.
Then your insurance company will require a treatment plan signed by credentialed BCBA based off their assessment that includes:
- Frequency and duration of the treatment
- An indication that the treatment is medically necessary
- A signature from the primary care provider and a licensed/credentialed specialist
Make sure you check with your insurance company to find out what is required. You’ll find their phone number on the back of your insurance card or you can visit their website.
The good news is that many ABA providers, Ready Set Connect included, will help you through this process. The ABA centers will submit the information to your insurance company for approval on services. Your referring physician will typically provide said document to you and/or directly to us. We will take that information and conduct an insurance check for you.
If any additional information is required on your part, we will reach out to let you know. Once approved, we’ll discuss your options and set up an evaluation to get you started.
Still have questions?
We’re happy to help! Reach out to us here.