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Coverage for ABA through the Health Insurance Marketplace

What is the Health Insurance Marketplace?

The Health Insurance Marketplace is an online portal accesible at www.healthcare.gov that helps people find and enroll in a health insurance plan.  All plans sold on the Marketplace must comply with certain federal guidelines, including provision of the Essential Health Benefits for that State.

You can purchase a Health Insurance Marketplace plan only from the State in which you permanently reside.  Some states have established their own state-based Marketplace while others utilize either a State-partnership or Federally-facilitated Marketplace.  Regardless of which type of Marketplace is in effect in your State, it can be accessed from the healthcare.gov website.

Is coverage for Applied Behavior Analysis available in health plans purchased through the Health Insurance Marketplace?

Applied Behavior Analysis (ABA) is an Essential Health Benefit and required to be covered in Marketplace plans in the following 29 States plus the District of Columbia:  Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oregon, Texas, Vermont, Washington, West Virginia and Wisconsin. 

In these states, ABA also must be covered in non-grandfathered small group and individual plans sold outside the Marketplace.  (A “non-grandfathered plan” is a plan that was purchased after March 23, 2010.  As of January 1, 2016 a “small group plan” is defined as a plan sold to an employer with less than 100 employees.                 

Are there efforts underway to require coverage for ABA in Marketplace plans in all states?

Autism Speaks remains dedicated to advocating for meaningful health insurance coverage for all individuals with autism regardless of where they live.  For the most recent update on current efforts in your State, please email advocacy@autismspeaks.org.

I am otherwise happy with my employer-sponsored health insurance plan except that it does not provide coverage for ABA.  If coverage for ABA is available in my State’s Marketplace plans, can I keep my family’s existing health insurance and purchase a Marketplace plan only for my child with autism?

 Yes.  The Affordable Care Act requires health insurers who offer coverage on the Health Insurance Marketplace to also offer the same coverage as a plan in which the only enrollees are under the age of 21 i.e., “child-only plans.

Although you will not be eligible for a discounted Marketplace plan if your child has access to an employer-sponsored plan you can still purchase a non-discounted child only Marketplace plan.  Some plans allow you to carry more than one policy while others do not.  Please check with your plan administrator if you are considering dual coverage for your child.

Can I purchase a child-only plan through the Health Insurance Marketplace at any time?

Marketplace plans are available for purchase only during open enrollment periods.  The 2016 Health Insurance Marketplace open enrollment period begins November 1, 2015 and ends January 31, 2016.  You may be able to purchase a Marketplace plan outside the open enrollment period if you qualify for a special enrollment period (e.g., change in marital status, move to a different State).