Giving Insurers the Full Treatment Picture When insurers limit autism treatment to a single approach, SLPs can use a number of health and education documents to appeal those decisions. Bottom Line
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Bottom Line  |   April 01, 2017
Giving Insurers the Full Treatment Picture
Author Notes
  • Laurie Alban Havens, MA, CCC-SLP, is director of ASHA private health plans and Medicaid advocacy. lalbanhavens@asha.org
    Laurie Alban Havens, MA, CCC-SLP, is director of ASHA private health plans and Medicaid advocacy. lalbanhavens@asha.org×
Article Information
Special Populations / Autism Spectrum / Bottom Line
Bottom Line   |   April 01, 2017
Giving Insurers the Full Treatment Picture
The ASHA Leader, April 2017, Vol. 22, 34-35. doi:10.1044/leader.BML.22042017.34
The ASHA Leader, April 2017, Vol. 22, 34-35. doi:10.1044/leader.BML.22042017.34
Treatment for autism spectrum disorder (ASD) and other conditions that involve communication difficulties can—and often should be—collaborative. But despite assurances from private insurers, Medicaid and state mandates, some speech-language pathologists may encounter situations that clearly favor applied behavior analysis (ABA) or other treatments over speech-language services for people with ASD.
Some private insurers may include only ABA as a treatment for ASD, to the exclusion or limitation of other treatments, specifically speech-language pathology. But federal guidance and other insurers indicate that the client’s needs are the most important factor in determining treatment, and that no one treatment fits all. SLPs can help get this message across by educating health and education administrators, appealing denials, and advocating with health plans.
Different approaches
Because ASD affects social skills, communication and behavior, and because symptoms may range from mild to severe, people with ASD experience a wide range of difficulties.
An SLP’s evaluation of a client with ASD determines social skill, communication, language and behavior needs and an appropriate treatment plan to meet those needs. Treatment may include any combination of traditional speech-language approaches, augmentative and alternative communication, and behavioral intervention. SLPs use a range of approaches as part of an effective treatment program.
By contrast, behavior analysis focuses on the principles that explain how learning takes place. ABA homes in on techniques related to these principles to bring about meaningful and positive change in behavior.

The Centers for Medicare and Medicaid Services issued two policy statements addressing treatment for ASD, reinforcing in both that ABA is one—but not the only—treatment modality, and that CMS does not endorse or require any particular ASD treatment.

Payer policies and state mandates
Directives from commercial and third-party payers support determining the best treatment program for each client, including speech-language pathology and other approaches such as ABA. However, many insurance companies limit coverage for ASD treatment to a certain number of sessions or dollar amount; if beneficiaries choose to pursue ABA treatment first, there may be no benefit left for speech-language services.
In addition, 47 states have mandates that require certain commercial insurers to provide coverage for ASD. However, some insurers choose to carry out those mandates by covering only ABA treatment for ASD. Some states specify ABA coverage in their mandates, but many others address speech-language pathology and other treatments as well.
Medicaid, the joint federal-state government health care program for low-income people and families, covers qualified services for people with ASD. In 2014, the Centers for Medicare and Medicaid Services (CMS) issued two policy statements addressing treatment for ASD, reinforcing in both that ABA is one—but not the only—treatment modality, and that CMS does not endorse or require any particular ASD treatment. State Medicaid agencies, which determine what services are medically necessary for eligible beneficiaries, adhere to long-standing obligations under the Early and Periodic Screening, Diagnostic and Treatment benefit that provide medically necessary ASD treatment services to those ages birth–21.
Although the Federal Employee Health Benefits Program (FEHBP) specifically expanded ABA coverage for federal employees in 2017, the expansion does not exclude other medically necessary treatments. In its call letter for FEHBP benefit and rate proposals, the Office of Personnel Management—which administers the federal program—stated, “We expect all carriers to offer clinically appropriate and medically necessary treatment for children diagnosed with ASD.”
Schools also must provide the most appropriate treatment for students with ASD, according to a 2015 Department of Education directive. The guidance, released in response to ASHA advocacy, indicates that ABA may not be considered the only treatment for ASD, and that SLPs and other professionals should be included in all decisions regarding ASD evaluation, eligibility determinations and treatment programs.
Resources
SLPs who are told that insurance covers only ABA—and not speech-language treatment—can turn to a number of policy documents indicating that coverage should not be limited. These documents call for people with ASD to receive the most appropriate treatment for their specific needs.
SLPs can also address specific questions to reimbursement@asha.org.
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April 2017
Volume 22, Issue 4