How Much Is ABA Therapy? The Real Cost, With and Without Insurance

 ABA therapy has a sticker price and a real price, and for most families they are nothing alike. Here is what ABA costs per hour and per year, and what you are likely to actually pay once insurance is involved. 

ABA therapy typically costs $60 to $150 per hour without insurance, which works out to roughly $60,000 to $150,000 per year at 20 hours per week. Those are the numbers that stop most parents in their tracks.

They are also numbers almost nobody pays. Every state requires insurers to cover ABA, and for an insured family the meaningful figure is not the sticker price. For many families, that amounts to between a few hundred and a few thousand dollars per year, regardless of how many hours their child receives.

This guide breaks down both numbers: what ABA costs, and what you are likely to actually pay.

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How much does ABA therapy cost?

Self-pay rates vary by region, by setting, and by who delivers the session. As a working range:

Why is ABA billed in 15-minute units?

Almost every explanation of ABA cost is given in hourly terms. Almost no insurance claim is. ABA is billed against a set of CPT codes in 15-minute units, at different rates depending on who delivered the service.

These are the codes you will see:

 97153 is the code you will see most, since it is the direct therapy your child receives, delivered by a Registered Behavior Technician. 97155 and 97156 are billed at a higher rate because they are delivered by a Board Certified Behavior Analyst, but they account for far fewer units. If you want a clearer picture of who is in the room and what each person does, what an ABA therapist does covers it. 

Does insurance cover ABA therapy?

Yes, in almost every case. The useful question is not whether your plan covers ABA, but which set of rules it falls under, because that determines what you can insist on. 

State-regulated plans

All 50 states and the District of Columbia have enacted autism insurance mandates requiring coverage of ABA. What they require varies enormously:

• New Jersey: No dollar cap and no age cap on ABA under state-regulated plans. The original 2009 law allowed a $36,000 annual limit to age 21, but the Department of Banking and Insurance determined that federal mental health parity rules removed monetary and age limits.
• Georgia: Coverage to age 21, capped at $35,000 a year.
• Most states: Coverage is available between ages 18 and 21, with dollar caps historically ranging from $25,000 to $72,000 per year, and a requirement that services be delivered by or under the supervision of a BCBA.

Circle Care provides ABA in New Jersey, Georgia, North Carolina, Maryland, and Utah, and the plans we are in-network with are listed by state.

Self-Funded Employer Plans 

If your employer self-funds its health plan, the plan is governed by federal ERISA law and is exempt from state insurance mandates entirely. Your card may say Aetna or Cigna, the network may be identical, and none of your state's autism law applies.

How to tell which you have:

• Ask HR directly: "Is our health plan fully insured or self-funded?" It is a routine question, and they will know
• Look at your Summary Plan Description for the phrase "self-funded" or "self-insured", or for a reference to ERISA
• A plan administered by a third-party administrator rather than an insurer is usually self-funded

Self-funded does not mean uncovered. Most large employers voluntarily cover ABA, and federal mental health parity rules still apply.

 Medicaid and EPSDT 

If your child is on Medicaid, the operative rule is EPSDT (Early and Periodic Screening, Diagnostic and Treatment), which requires states to cover medically necessary services for eligible children from birth to age 21.

Medicaid coverage also does not depend on family income in every case. Several states run waiver programs that let a child with a qualifying disability access Medicaid based on the child's own income rather than the household's. Georgia's, for example, is the Katie Beckett waiver, and it is worth investigating even if you have been told you earn too much.

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 What ABA actually costs a family with insurance 

 A worked example, using round numbers. Say your plan has a $3,000 family deductible, 20% coinsurance, and a $9,000 out-of-pocket maximum, and your child is authorized for 20 hours a week. 

Many families with good employer coverage land nearer the low end than the high, with a deductible met in the first two months and little after that. Others on high-deductible plans do pay several thousand. The only way to know is to have a provider verify the benefits before you commit to anything. 

 What to do if insurance doesn't cover ABA treatment 

If you have been denied, or you have no coverage, there are more routes than most families realize:

• Appeal the denial: A large share of ABA denials are overturned on appeal, and many are due to procedural issues. Ask for the denial reason in writing and the specific plan language it relies on.
• Medicaid and waiver programs: Worth checking even at higher incomes, because several states assess the child's income rather than the household's.
• Single-case agreements: If no in-network ABA provider is available within a reasonable distance, plans may be required to cover an out-of-network provider at in-network rates.
• Grants and assistance funds: National and state-level organizations fund therapy for families in need. Amounts are modest, but they are real.
• Your school district: From age three, services written into an IEP are provided at no cost. This is not a substitute for clinical ABA, but it changes what you need to purchase privately.

How Circle Care handles the insurance side 

Circle Care verifies your benefits before you commit to anything. That means calling your plan, confirming what is covered, obtaining prior authorization, and telling you your expected out-of-pocket cost in advance rather than after the first bill. You can see the plans we are in the network with by state.

If you are still comparing providers, how to choose an ABA agency for your toddler covers what to compare besides price, and what the ABA intake process involves walks through the first few weeks.

You do not need to have your insurance figured out before you call. We can help with that.

If You Need Help with Autism Services

If you live in the New Jersey area, and you are trying to figure out a way to establish services for your child who has been diagnosed with autism- we are here to help.

Circle Care Services can help you to figure out how much your insurance will cover for services. If your insurance doesn’t cover treatment, we can help you find the resources that will help to cover the costs of ABA therapy. Circle Care is here to help families. Give us a call and let us help you to find the perfect treatment options for your child with autism.