Does Ambetter Insurance Cover Autism Testing & Therapy Treatment?

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Does Ambetter Cover Autism Testing & Treatment?

Yes, Ambetter insurance may be able to cover autism testing and treatments in Tennessee, depending on the specifics of your insurance plan. The Tennessee Department of Commerce and Insurance published a bulletin in 2019 requiring insurance providers to cover medically necessary care for Autism Spectrum Disorder (ASD).¹

Ambetter autism testing and treatment are listed under children’s preventive services in their Preventive Services Guide.²

How to Verify Ambetter Autism Coverage

Our highly qualified, knowledgeable care coordinators can help you navigate information about Ambetter coverage for autism treatment therapy in Tennessee. All information you provide or discuss is confidential.

What is Autism?

Autism Spectrum Disorder (ASD) is a developmental disorder that can cause serious social, communication, and behavioral challenges. People with autism may have a broad range of cognitive, reasoning, and problem-solving abilities and disabilities, ranging from gifted to severely impaired.³

Types of Autism

There are five types of autism:⁴

• Asperger’s Syndrome
• Rett Syndrome
• Childhood Disintegrative Disorder (CDD)
• Kanner’s Syndrome
• Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS)

Signs & Symptoms of Autism

Although people with autism often don’t stand out from others in terms of appearance, they may communicate, interact, behave, and learn differently. Autism symptoms can include, but are not restricted to, the following:⁵

• Difficulty developing social communication and interpersonal skills
  • Example – Does not respond to name by nine months of age
• Restricted or repetitive interests or behaviors
  • Example – Becomes upset by minor changes in routine
• Delayed cognitive, learning, language, and movement skills
• Hyperactive, impulsive, and/or inattentive
• Epilepsy or seizures
• Unusual sleeping and eating patterns
• Gastrointestinal issues (i.e., constipation)
• Mood swings or emotional reactions that are out of the ordinary
• Anxiety, tension, or excessive worry
• Fearlessness or greater than expected fear

Is Autism Testing Covered by Ambetter?

Ambetter autism testing and diagnosis are covered according to their Preventive Services Guide. However, coverage details will vary depending on your specific plan. You might have to pay co-pays and deductibles out of pocket.

Since there is no blood test or other medical test for autism spectrum disorder, a diagnosis can be difficult. So instead, clinicians look at the child’s behavior and developmental history to make a diagnosis.

Developmental monitoring examines your child’s growth and development to see if they meet milestones in play, learning, speaking, acting, and movement. Parents, grandparents, early childhood specialists, and other caregivers can perform developmental monitoring.

Developmental screening pays attention to your child’s growth. You’ll either respond to some questions about your child, or your child will take a brief test. Developmental screening can be done by doctors, nurses, and other health care, community, or educational workers.

About 13% of children in the United States between the ages of 3 and 17 have a developmental or behavioral disorder. Many kids also have language difficulties or other issues that hinder their preparation for school. However, many kids with developmental disabilities are not identified before age ten. By this point, there may have already been substantial delays and missed opportunities for treatment.⁶

Autism can be found in children as early as 18 months. Therefore, a diagnosis made by a trained autism specialist by the age of two is reliable.

Are Autism Treatments & Medications Covered by Ambetter?

Yes, the Tennessee Department of Commerce and Insurance bulletin of 2019 mandated insurance companies to cover medically necessary care for autism, including evidence based therapies like Applied Behavior Analysis (ABA).⁷

Ambetter coverage for autism treatment doesn’t usually include prescription drugs. However, as mandated by the Affordable Care Act (ACA), some outpatient prescription drugs and/or over-the-counter medicines may be covered under the preventive benefit.

Certain medications can manage symptoms, but they cannot change the fundamental symptoms of Autism Spectrum Disorder.⁸ For instance, antipsychotic meds, like risperidone, can treat serious behavioral issues,⁹ and antidepressants can treat anxiety. It’s essential to keep all medical professionals informed about any prescription drugs or dietary supplements your child is taking. Some drug-supplement interactions can result in side effects.

According to research, medication is most effective when combined with evidence-based psychotherapy such as Applied Behavioral Analysis (ABA). ABA therapy can help improve language and communication skills, attention, focus, social skills, memory, and academics.¹⁰ In addition, Ambetter insurance autism coverage does not require a formal diagnosis to receive treatment for certain symptoms, like speech therapy for language deficits.

Your plan’s benefits will determine your eligibility and the details of your Ambetter insurance autism coverage for treatments and medications.

How To Find Ambetter Autism Testing & Treatment Clinics Near Me?

Athena Care’s multiple locations throughout Tennessee make gaining access to autism testing and treatment simple. A care coordinator can assist you with questions or concerns about Ambetter autism coverage Monday through Friday, 7:00 a.m. to 6:00 p.m.

Here, you’ll find a list of practitioners organized by city and information about their backgrounds and specialties.

Before meeting with a specialist, make a list of these items before your child’s appointment:¹¹

• Your child’s current medications, including vitamins, herbal remedies, and over-the-counter drugs, as well as their dosages
• Any worries you may have regarding the growth and behavior of your child
• When your kid started talking and when they hit certain developmental milestones.
  • If your child has siblings, list their developmental milestones, as well
• A description of how your child engages in play and communication with their siblings, parents, and other children
• Don’t be afraid to ask questions regarding the following:
• Education, training, license, and years of experience
• Specialties and services offered
• Treatment methods and philosophies
• Insurance companies they work with
• Office hours
• Pricing
• Session length
• The specialist’s education/expertise

How Much Does Autism Testing & Treatment Cost Without Insurance?

The following costs are only estimates; actual costs will depend on your location and other factors. Therefore, the below might not accurately reflect what you’ll pay in Tennessee for autism testing or treatment without Ambetter autism coverage.

Doctor’s visits alone can range from a few hundred dollars to more than $2,700. In the United States, the typical cost of psychotherapy ranges from $100 to $200¹² a session, dependent upon the state and the length of the session. For example, the average price of Applied Behavior Analysis (ABA) is $120 an hour. In addition, some children require up to 40 hours of ABA therapy every week to reach their full potential, which comes to $4,800 per week or $249,600 per year.¹³ Finally, the cost of a supply of 30 risperidone 1 mg oral tablets is about $18.¹⁴

Can Autism Affect My Insurance Coverage?

No. Under Tenn. Code Ann. 56-7-2367 (2006), contracts and insurance policies that offer benefits for neurological illnesses must also provide benefits and coverage for the treatment of autistic children under age 12.¹⁵ According to the law, neurological disorders include Autism Spectrum Disorder.

Additionally, the Affordable Care Act stipulates that most health insurance policies may no longer deny coverage to anyone due to a pre-existing illness, such as autism, or limit or raise the cost of it.¹⁶

Sources

1. “Tennessee State-Regulated Insurance Coverage.” Autism Speaks, Autism Speaks, www.autismspeaks.org/tennessee-state-regulated-insurance-coverage. Accessed 8 July 2022.
2. “Preventive Services Guide.” Ambetter of Tennessee, Celtic Insurance Company, 1 Jan. 2020, www.ambetteroftennessee.com/content/dam/centene/ambettertn/pdfs/TN%20Amb_PreventiveGuide.pdf.
3. “What is Autism Spectrum Disorder?” U.S. Department of Health & Human Services, 2020, https://www.cdc.gov/ncbddd/autism/facts.html
4. “What Are the 5 Types of Autism?” Integrity, Inc., 2021, https://www.integrityinc.org/what-are-the-5-types-of-autism/
5. “Signs and Symptoms of Autism Spectrum Disorders.” U.S. Department of Health & Human Services, 2021, https://www.cdc.gov/ncbddd/autism/signs.html
6. “Your Better Health Center – Developmental Monitoring and Screening.” Ambetter of Tennessee, Celtic Insurance Company, www.ambetteroftennessee.com/resources/better-health-center/disease-prevention/developmental-monitoring-screening.html. Accessed 28 July 2022.
7. “Tennessee State-Regulated Insurance Coverage.” Autism Speaks, Dec. 2019, www.autismspeaks.org/tennessee-state-regulated-insurance-coverage.
8. Mayo Clinic Staff. “Autism Spectrum Disorder – Diagnosis and Treatment – Mayo Clinic.” Mayo Clinic, Mayo Foundation for Medical Education and Research (MFMER), 6 Jan. 2018, www.mayoclinic.org/diseases-conditions/autism-spectrum-disorder/diagnosis-treatment/drc-20352934.
9. “Medication Treatment for Autism.” NIH, 2021, https://www.nichd.nih.gov/health/topics/autism/conditioninfo/treatments/medication-treatment
10. “Applied Behavior Analysis.” Autism Speaks Inc., 2022, https://www.autismspeaks.org/applied-behavior-analysis
11. “Autism Spectrum Disorder – Diagnosis and Treatment – Mayo Clinic.” Mayo Clinic, Mayo Foundation for Medical Education and Research (MFMER), www.mayoclinic.org/diseases-conditions/autism-spectrum-disorder/diagnosis-treatment/drc-20352934. Accessed 28 July 2022.
12. Tatom, Carol RBT. Autism Parenting Magazine, 2022, “How Much Does ABA Therapy for Autism Cost?” https://www.autismparentingmagazine.com/aba-therapy-autism-cost/
13. “Risperidone Prices, Coupons and Patient Assistance Programs.” IBM Watson Micromedex, Cerner Multum™, ASHP, 2022, https://www.drugs.com/price-guide/risperidone
14. “Autism and Insurance Coverage State Laws.” National Conference of State Legislatures, NCSL, 24 Aug. 2021, www.ncsl.org/research/health/autism-and-insurance-coverage-state-laws.aspx.
15. Digital Communications Division (DCD). “The Affordable Care Act and Autism and Related Conditions.” HHS.Gov, U.S. Department of Health and Human Services, 1 Feb. 2021, www.hhs.gov/programs/topic-sites/autism/aca-and-autism/index.html.