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Does Evernorth Cover ABA Therapy?

Does Evernorth Cover ABA Therapy?

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Does Evernorth Cover ABA Therapy?

Yes, Evernorth insurance may cover the cost of Applied Behavior Analysis therapy (ABA), depending on your specific plan. In addition, you may need to meet specific requirements to qualify for Evernorth ABA therapy coverage.1

To attract the attention of potential industry clients to its offerings, Cigna changed the name of its behavioral health services division to Evernorth. This open business model unites external partners in pharmacy, benefits administration, and care solutions with Cigna’s mental health services.2 As a result, Cigna clients don’t need to take any additional steps to receive Evernorth ABA therapy coverage and other Evernorth behavioral health benefits.3 Additionally, Evernorth offers behavioral health services to those whom Cigna does not insure.4

ABA therapy is founded on the science of learning and behavior. Typically, it is primarily used for autism therapy, teaching actions that will make patients’ lives safer and more satisfying.5 ABA therapy is an evidence based therapy that focuses on a behavioral approach.

Qualified clinicians help autistic individuals develop abilities such as:

  • Language and communication skills
  • Social skills
  • Hygiene and self-care practices
  • Leisure and play abilities
  • Motor skills

How to Verify Evernorth ABA Therapy Insurance Coverage

Athena Care is in-network with most major insurance plans, providing mental and behavioral health care throughout Tennessee. Filling out our free and confidential online insurance verification form is the best way to learn the details of your ABA therapy Evernorth coverage.

Let our highly qualified care coordinators handle the hassles of contacting your insurance provider for more information about your Evernorth ABA therapy benefits. A care coordinator will review your plan and thoroughly explain your options after you’ve submitted the form. Rest assured that all information shared and discussed remains confidential.

Requirements, Eligibility & Process for Evernorth ABA Coverage

When ALL of the following conditions are met, an ABA assessment is deemed medically necessary:6

  • The patient has been diagnosed with autism spectrum disorder (ASD) following the criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This diagnosis came from a healthcare provider licensed to practice independently and whose licensure board believes diagnostics are within their scope of practice. In addition, BOTH of the following requirements must be met:
    • The day that the diagnosis was finalized
    • Name, credentials, and type of license of the professional who made the diagnosis

An Evernorth ABA therapist who is a Board-Certified Behavior Analyst (BCBA), a Licensed Behavior Analyst (LBA), or mental health clinician with independent practice authorization and evidence of ABA training then conducts a thorough and comprehensive ABA assessment. This assessment requires additional criteria, including proper exam tools and obtaining a detailed developmental history.

As of December 1, 2020, if the provider is independently licensed or a BCBA and the client’s coverage covers ABA treatments, precertification is no longer necessary for specific assessment CPT codes with an autism diagnosis.

Following an assessment, an autism treatment plan is developed. The treatment plan will include a realistic transition strategy that is well-defined, quantifiable, and tailored to the patient. In addition, this treatment plan will consist of a process for ABA services fading across all contexts and settings where treatment will occur.

In all settings/environments where therapy will take place, the intended intensity of treatment takes into account the severity of the impairments, the goals of treatment, and the response to treatment. The programs are lengthy and demanding, averaging 15 to 40 hours each week over an individualized period.

For all non-ASD reasons, ABA is regarded as experimental, investigational, or untested. Medically necessary services are distinguished from those primarily educational, vocational, or related to work or academic achievement. While you can get ABA therapy without an autism diagnosis, most insurance companies won’t reimburse you for expenses.

How Much Does ABA Therapy Cost Without Insurance?

The average cost of ABA therapy is $120 per hour. Some children require up to 40 hours of ABA therapy each week to reach their full potential. This amounts to $4,800 per week or $249,600 per year without health insurance benefits.7

Forbes estimates the annual cost of ABA treatment without coverage is about $17,000. However, it might range from $45,000 to $100,000 annually for some children.8

Furthermore, the Centers for Disease Control and Prevention (CDC) projects that average annual medical costs for a child with one of the autism spectrum disorders are $4,110 to $6,200 higher than for children without the condition.9

Sources

  1. Evernorth Provider – Resources – Autism Information and Resources. static.evernorth.com/assets/evernorth/provider/resourceLibrary/behavioralResources/doingBusinessWithUs/cbhAutismInfoResources.html.
  2. Morse, Susan. “Cigna launches Evernorth, in a rebrand of its health services portfolio.” Healthcare Finance, 2020, https://www.healthcarefinancenews.com/news/cigna-launches-evernorth-rebrand-its-health-services-portfolio
  3. “Frequently Asked Questions.” Evernorth Health Inc., 2022, https://static.evernorth.com/assets/evernorth/provider/resourceLibrary/behavioralResources/faq.html
  4. “Evernorth Behavioral Administrative Guidelines.” Evernorth Health Inc., 2022, https://static.cigna.com/assets/chcp/pdf/resourceLibrary/behavioral/ebh-provider-admin-guide.pdf
  5. “Questions and Answers About ABA.” Autism Speaks, 11 Aug. 2021, www.autismspeaks.org/blog/questions-and-answers-about-aba.
  6. “Intensive Behavioral Interventions.” Evernorth, 15 Dec. 2021, static.evernorth.com/assets/evernorth/provider/pdf/resourceLibrary/behavioral/mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf.
  7. Tatom, Carol RBT. Autism Parenting Magazine, 2022, “How Much Does ABA Therapy for Autism Cost?” https://www.autismparentingmagazine.com/aba-therapy-autism-cost/
  8. Molko, Ronit. “What Is Covered? The Insurance Landscape for Autism Services.” Forbes, 18 Apr. 2019, www.forbes.com/sites/forbesbooksauthors/2019/04/18/what-is-covered-the-insurance-landscape-for-autism-services/?sh=133bbd3325c2.
  9. “Basics About Autism Spectrum Disorder (ASD) | NCBDDD | CDC.” Centers for Disease Control and Prevention, 31 Mar. 2022, www.cdc.gov/ncbddd/autism/facts.html.

If you suspect that you or someone you love suffers from mental health disorders, contact Athena Care today.

One of our friendly associates will help you get the help you need. Take this first step to feel better and take control. 

(615) 320-1155