Access to ABA Therapy

Publications
Apr 1, 2021
#7167.01

Access to ABA Therapy

Applied Behavioral Analysis is an evidence-based therapy. ABA therapy prevents or lessens the bad effects of behaviors that interfere with learning and social interaction.

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What is ABA Therapy?

Applied Behavioral Analysis is an evidence-based therapy. ABA therapy prevents or lessens the bad effects of behaviors that interfere with learning and social interaction.

The goals of ABA therapy can include:

  • Developing new behaviors,
  • Increasing or decreasing existing behaviors,
  • Bringing out behaviors resulting from specific settings,
  • Improving fine motor skill, hygiene, grooming, skills at home, punctuality, and job competence,
  • Increasing language and communication skills, and
  • Improving attention, focus, social skills, memory, and academics.

ABA therapy is adaptable to meet different needs. A qualified autism service provider can design, implement, and evaluate modifications for each person. ABA therapy involves an evaluation, treatment, and monitoring. To change behavior in a positive and meaningful way, trained providers use positive reinforcement strategies and Antecedent-Behavior-Consequences.

A qualified autism service provider supervises or directly provides ABA therapy. This person is usually a Board-Certified Behavior Analyst (BCBA). A program can also involve therapists or registered behavior technicians (RBTs). These therapists are trained and supervised by the BCBA or Behavior Management Consultant. Sometimes, a different licensed person will provide ABA therapy services as a qualified autism service provider.  These include:

  • physician
  • surgeon
  • physical therapist
  • occupational therapist
  • psychologist
  • marriage and family therapist
  • educational psychologist
  • clinical social worker
  • professional clinical counselor
  • speech-language pathologist
  • audiologist

However, the services provided must be within the experience and competence of the licensee.1

ABA therapy can occur in different locations. Therapy can take place at home, at school, and in the community. The number of weekly hours and time of treatment sessions vary. People typically coordinate and receive ABA therapy services through a school district, health insurance, or regional center.

There are different ways to get and fund ABA therapy services. Receiving ABA services and funding can be challenging. Generally, insurance, the school district, or regional centers will provide funding to eligible children. To get ABA therapy through a health insurance plan, school district, or regional center, you must know what type of health insurance you have.

Receiving ABA Therapy Through a Health Insurance Plan

Many health insurance plans cover ABA therapy. This section covers how to get funding and services through insurance. Including, Medi-Cal plans, plans bought through Covered California, individual plans bought from a private health insurance company, and employer-based health plans.

Receiving ABA Therapy through Medi-Cal

Does Medi-Cal cover ABA therapy?

Yes, for members under age 21.2 Under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Medicaid benefit,3 Medi-Cal covers all medically necessary Behavioral Health Treatment (BHT) for eligible beneficiaries.4 Behavioral Health Treatment is a Medi-Cal category of services including ABA therapy.5 A physician or psychologist must recommend ABA therapy as medically necessary. Medical necessity is based on whether the services will correct or ameliorate any physical and/or behavioral conditions.6 Medi-Cal does not require an autism diagnosis for ABA therapy services.7 Medi-Cal covers ABA services for fee-for-service and Medi-Cal managed care.8

Children with fee-for-service Medi-Cal will receive ABA therapy services from their local regional center.9 If you have fee-for-service Medi-Cal and want to explore the possibility of ABA therapy, contact your regional center to discuss services and funding. If you have fee-for-service Medi-Cal and are not a regional center client, contact a regional center to determine eligibility. If you have a Managed Care Plan, contact your managed care plan and ask about ABA therapy services. You can also go directly to your primary care provider (i.e., your pediatrician) and ask about ABA therapy services.

What are the criteria for ABA therapy services under Medi-Cal?

  • Be under age 21.
  • Have a recommendation from a licensed physician, surgeon, or psychologist that evidence-based Behavioral Health Therapy services are medically necessary.
  • Be medically stable.
  • Be without a need for 24-hour medical/nursing monitoring or procedures provided in a hospital or intermediate care facility for persons with intellectual disabilities (ICF/ID).10

Who is responsible for ABA therapy services if the child has private insurance and Medi-Cal?

Sometimes a child will have dual coverage. When a child has dual coverage, they can have Medi-Cal and other health coverage. This additional health coverage can include individual private plans or private group plans. If a child has dual coverage, they will receive ABA therapy services and funding from their private insurance.11 Medi-Cal will wrap around those services not covered by private insurance.12 For example, you may use Medi-Cal as a companion service to your private insurance to offset the cost of co-payments and/or co-insurance payments associated with Evidence of Coverage. If you have private insurance and fee-for-service Medi-Cal then your ABA provider should be a fee-for-service Medi-Cal provider to receive assistance with the cost of co-payments. If your ABA provider is not a Medi-Cal fee-for-service provider, contact a regional center for co-pay assistance.

What are my rights if I do not agree with a denial or change of my services?

If you have fee-for-service Medi-Cal, you can request a state hearing.

If you have a Managed Care Plan, you can request a state hearing after:

  • You have completed your managed care plan’s internal appeal process and have received a letter telling you that your health plan will not provide the service, or
  • You do not receive a letter telling you of the decision and it has been over 30 days.13

You can find more information about your managed care plan’s internal appeal process by contacting member services. This link is a list of contact information for all Medi-Cal managed care plans.

Requesting a State Hearing

You must submit a request for a state hearing within 90 days of your denial letter’s date.14 To request a state hearing, you can fill out the “State Hearing Request” form at www.dhcs.ca.gov/services/medi-cal/Pages/Medi-CalFairHearing.aspx and send it to:

California Department of Social Services
State Hearings Division
P.O. Box 944243, MS 19-37
Sacramento, CA 94244-2430

You may also call to ask for a state hearing. The number can be busy. You may get a message to call back later.

Toll-free phone: 1-800-952-5253
TTY: 1-800-952-8349

You can also submit a state hearing request online: https://acms.dss.ca.gov/acms/page.request.do?page=public.intakeForm.

Can I still get treatment while my state hearing request is pending?

Yes, if the notice is stopping or reducing services. Eligibility for “Aid Paid Pending” requires you:

  • Ask for a state hearing within ten days from:
    • The date the notice is postmarked, or
    • The date the notice was given to you, or
    • Before the date the notice says your treatment will stop or change.
  • Say you want to keep getting treatment during the hearing process.

It can take up to 90 days for your case to be heard and a decision sent to you.

Receiving ABA Therapy Through Private Health Insurance

Can I receive ABA therapy through a plan bought through Covered California?

Yes. The Affordable Care Act (ACA) of 2010 requires health insurance plans sold through Covered California to include a set of essential health benefits.15 These essential benefits can include ABA therapy.16 Under the ACA, your plan’s mental health treatment services must be like what your plan offers for comparable medical services. All Covered California plans must cover ABA therapy for eligible persons.   

Can I receive ABA therapy through the individual plan I bought directly through a private health insurance company?

Yes, if your child has an autism or other pervasive developmental disorder diagnosis. State law regulates private plans. SB 946, effective July 1, 2012, generally requires health care service plan contracts and health insurance policies to provide coverage for medically necessary behavioral health treatment.  This includes ABA therapy for individuals with autism or other pervasive developmental disorders. SB 946 applies to all health plans that provide hospital, medical or surgical treatment under the jurisdiction of the Department of Managed Health Care Services (DMHC) or the Department of Insurance (DI).17 If your child does not have an autism or other pervasive developmental disorder diagnosis your insurance may cover ABA therapy. Contact your health plan’s member services department to see if you plan also covers ABA therapy for persons without an autism or other pervasive developmental disorder diagnosis.

Can I receive ABA therapy through my employment-based health insurance?

State law regulates employer-sponsored health plans that are fully insured/fully funded. The state law regulating fully insured/fully funded employer-sponsored plans is SB 946. SB 946 requires healthcare service plan contracts and health insurance policies to provide coverage as noted above. SB 946 applies to all health plans that provide hospital, medical or surgical treatment under the jurisdiction of the Department of Managed Health Care Services (DMHC) or the Department of Insurance (DI).

In contrast, when a plan is self-insured/self-funded, it is regulated by federal law. While all self-insured/self-funded plans must comply with federal laws, an employer creates the plan’s benefit design. Some plans will cover ABA therapy, and others will not. Contact your health plan’s member services department or your employer’s Human Resources department to see if your plan is self-insured/self-funded and if ABA therapy is a covered benefit. If your plan does not cover ABA therapy services, request a letter of coverage and contact a regional center.18 A regional center may fund ABA therapy if you have a self-insured/self-funded health insurance plan that does not cover these services. You can also ask your employer to consider covering these services in their plan.

Who can I contact if my private health insurance denies my claim or request?

Private health insurance must process your claim or respond to your written request within 30 days.19 After receiving a denial or discontinued services, you can submit an appeal directly through your insurance Member Services department. You can find this contact information on your insurance card or in the benefits handbook. When you call, ask to speak to someone about an autism-related or behavioral health services appeal. Your insurance plan might request you submit the appeal in writing. Other plans might have an online appeal process. Regardless, the insurance company must respond to your appeal within 30 days.20 

When the insurance company denies your request, they are supposed to state the reason for denial. They are also supposed to make all related documents available to you. Request these documents if you do not already have them. When you appeal, include prior assessments, treatment plans, goals, and letters from your child’s pediatrician, the school district, or the regional center. These documents should all support the medical necessity of ABA therapy. Keep additional copies of all these documents during the appeal process.21

These resources provide additional information on the private insurance appeals process and SB 946:

  • Click here for DRC’s publication on appealing denials by private health plans.
  • Click here for DRC’s publication on SB 946.
  • Click here for a list of all plans under the Department of Managed Health Care Services (DMHC).
  • Click here for a list of all plans under the Department of Insurance (DI).

ABA Therapy in Public Schools

Your child can get ABA services through your child’s health insurance plan. However, if your child needs ABA therapy to access special education, it is possible to get educationally-related ABA therapy through your child’s school district. There are limitations on receiving and funding ABA therapy through the school district. This section explains federal laws on special education programs, how to request an Individualized Education Program for your child, and in what situations the school district will fund ABA therapy. In California, the Individuals with Disabilities Act governs special education programs.

What are the Individuals with Disabilities Act and the FAPE Standard?

In California, federal and state law governs special education programs. These laws include the Individuals with Disabilities Act (IDEA) and the California Education Code. The IDEA sets guidelines for special education program standards.

Students eligible for special education have a right to a free appropriate public education (FAPE).22 “Free” means the public school pays for special education and related services—not the family. “Appropriate” means special education meets the unique needs of the student. And, special education provides the student educational benefit. So, if a student needs ABA therapy to benefit from school, then the school district should pay for ABA therapy as a related service.23 And, FAPE requires that services meet appropriate preschool through secondary education (age 3 to 21) standards and follow an Individualized Education Program (IEP).24

What is an Individualized Education Program (IEP) and how do I request one for my child?

An Individualized Education Program (IEP) is a written plan that you and your student’s IEP team develop once your child becomes eligible for special education. The IEP team revises the IEP on an annual basis, at minimum. The IEP describes your child’s present levels of performance, learning goals, services, accommodations, modifications, and school placement.25

The first step to get an IEP is to request the school district assess your child for special education. You or anyone on your student’s school team can refer your student for assessment at any time. If you would like to refer your student for special education, send a written and dated request to your student’s school principal.26 The school must send you an assessment plan within 15 days of their receipt of a written referral for special education. This timeline is paused during school breaks greater than five school days (i.e., winter break and summer break).

The school district cannot assess your student until it receives your written consent for assessment. Make sure the school plans to assess your student in all areas of suspected disability. You can write on the plan that you want to know if your student needs ABA therapy at school. Then, sign consent to the assessment plan, request additional assessments if needed, and promptly return the signed plan to the school.

Once the school district receives your written consent for assessment, it must hold an IEP meeting to discuss your student’s special education eligibility within 60 calendar days.27 And, if your student is found eligible for special education, the IEP team must also develop an IEP for your student within the same timeline. Again, this timeline pauses for school breaks longer than five school days. The school district should discuss your student’s needs, create specific goals to address those needs, and identify what related services and accommodations your student needs in order to make progress on their goals.

The IEP team can agree that your student needs ABA therapy services at school to benefit from special education. If so, your child’s IEP will include ABA therapy as a “related service.” A related service is any service necessary to help a student benefit from their special education program.28 To “benefit from special education” generally means making meaningful progress toward meeting IEP goals and objectives.29 At the IEP meeting, parents should prepare to convince the IEP team that their child requires ABA to benefit from special education. For more information on the assessment and IEP process, including who must attend an IEP meeting and what you can do if you disagree with the school district’s assessments or IEP team’s decisions, visit.

Can my child’s IEP be delayed?

No. After creating an IEP, special education and related services must be provided to the child per the IEP. The Local Education Agency must ensure no delay in implementing a student’s IEP, including any case with a question about paying for special education and related services.30

Does the school district or my insurance pay for ABA therapy?

ABA therapy provided in your child’s IEP does not mean an insurance plan or similar third party no longer has to provide or pay for services to a child with a disability.31 Medi-Cal and private insurance must provide ABA therapy services to eligible children. The child getting therapy in an educational setting or for educational purposes does not relieve the insurer from covering the services needed outside of the educational setting.32

Can the school district request I use Medi-Cal or other public insurance plans to pay for the services?

The school district can ask for your consent to use a Medi-Cal to pay for your student’s related services, but you are not required to provide that consent. A public school district may use a child’s Medi-Cal or another public insurance plan to provide or pay for services as allowed under the insurance program.

However, if the purpose of ABA therapy is to provide FAPE to an eligible child, the school district cannot require parents to sign up for or enroll in Medi-Cal to cover the service.33 The school district may not require parents to incur an out-of-pocket cost for services such as payments of deductible or co-pays. If a deductible payment or co-pay occurs because of filing a claim for services, then the school district may pay the cost that the parent otherwise would have to pay.34

And a school district may not use a child’s benefits under Medi-Cal if using it would:

  • Decrease available lifetime coverage or any other insured benefit;
  • Result in a family paying for services otherwise covered by the public benefits or insurance program and that the child needs outside the time the child is in school;
  • Increase premiums or lead to benefits or insurance stopping; or
  • Risk loss of eligibility for home and community-based waivers, based on total health-related costs.35

The school district must obtain written parental consent before accessing a child or parent’s public benefits or insurance.36 If a parent does not consent to the use of their public benefits or insurance because they would incur a cost for the services, to ensure FAPE, the school district may use special education funds to pay for the services.37

What if my public benefit or public health insurance refuses to pay for the ABA therapy?

If a public agency, other than the school district, fails to provide or pay for the special education and related service, then the Local Education Agency must provide or pay for the services in a timely manner.38 The Local Education Agency is usually the school district responsible for developing the student’s IEP. See above for additional information on insurance’s coverage of cost for ABA therapy.

Can the school district use my private insurance to cover ABA therapy?

Yes, if you provide consent and your private insurance covers the services. When the services provide FAPE to an eligible child, a public agency may only access a parent’s private insurance proceeds if the parent consents. A parent must provide consent each time the school district proposes to access the parents’ private insurance proceeds. A parent’s refusal to permit the school district to access their private insurance does not relieve the school district of its responsibility to provide all required services at no cost to the parents.39

Private insurance sometimes requires a deductible payment or co-payment for services. In these cases, the school district may pay the cost that the parent would be required to pay.40 This way, the school district can access private insurance, and the parent will not incur a fee. A parent must still provide consent to the school district for the use of private insurance or benefits. If a parent does not provide consent to use their private insurance because they would incur a cost for services, to ensure FAPE, the school district may use its special education funds to pay for the services.41

ABA Therapy Through a Regional Center

Usually, health insurance plans and school districts provide ABA therapy services and funding. Occasionally, regional centers also provide and fund ABA therapy services.  Regional centers can provide and fund ABA therapy services under two programs - the Early Start Program and the Lanterman Act. This section briefly introduces California regional centers, the Early Start Program, the Lanterman Act, and regional center funding for ABA therapy. Regional centers can also give more documentation of medical necessity to health insurance plans. Even if you do not plan on getting ABA services through the regional center, it's beneficial to discuss options with them.

What are California regional centers?

California regional centers coordinate services to children and adults with developmental disabilities. There are 21 private, non-profit regional centers in California. Regional centers are under the Department of Developmental Services (DDS) and have to follow Title 17 and the Lanterman Act. Title 17 governs California’s Early Start program for infants and toddlers age 0 to 36 months.42 The Lanterman Act governs regional center services for people age 3 and older. Regional centers assess people’s needs and determine eligibility for services, including ABA therapy.  

What is the Early Start Program (0 to 36 months)?

The regional centers’ Early Start Program provides services for children age 0 to 36 months. Developed in response to the Individuals with Disabilities Education Act (IDEA) Part C43, the Early Start Program ensures intervention services for eligible infants and toddlers. This system of services takes a coordinated and family-centered approach to early intervention.44 A Regional centers’ documented evaluation and assessment determines an infant or toddler’s eligibility for early intervention through Early Start

Infants and toddlers 0 to 36 months old may be eligible for Early Start if they meet one of these criteria:

  • Have a developmental delay of at least 33% in one or more areas of cognitive, communication, social or emotional, adaptive, or physical and motor development including vision and hearing; or
  • Have a known cause of condition with a high probability of resulting in delayed development; or
  • Be considered at high risk of having a substantial developmental disability due to a combination of biomedical risk factors diagnosed by qualified personnel.45

Early intervention services vary. Consideration includes a person’s assessed developmental needs and the family’s priorities and concerns shared with the Individualized Family Service Plan (IFSP) team. Early intervention services can include ABA therapy. A toddler’s IFSP can identify services, including ABA therapy, to meet their individual needs.  

If you think your toddler might benefit from ABA therapy, contact your local regional center or school district. The regional center or school district will assign a service coordinator. The service coordinator will help you through determining eligibility and coordinating ABA therapy services.46

My child is under the age of 3, has some Autism-like characteristics, but has not received a diagnosis. Can they receive ABA therapy from a regional center?

If your child does not have an Autism diagnosis, they can receive ABA services from a regional center if they meet the eligibility criteria through Early Start.47

What is the Lanterman Act (3 years and older)?

The Lanterman Act is a California law requiring regional centers to provide services to people age 3 and older. The Act ensures people with developmental disabilities have the services and supports they need to integrate into community life and experience everyday living like those who do not have disabilities.48

To be eligible for regional center services under the Lanterman Act, a person must have a disability that:

  • Originated before age 18;
  • Is expected to continue indefinitely; and
  • Presents a substantial disability.

Qualifying conditions include Cerebral Palsy, Epilepsy, Autism, Down Syndrome, Intellectual Disability, and other disabling conditions similar to Intellectual Disability or requiring similar treatment.49 The Lanterman Act says regional centers must provide evaluation, assessment, and service coordination. They must also develop an Individual Program Plan (IPP). An IPP can show a medical need for ABA therapy or other Behavioral Health Treatment. A child’s school district or the regional center assumes responsibility for coordinating needed services and education support once a child is 3 years old. If a child is 3 or older, contact the local school district and/or regional center to arrange an assessment. 

Does the regional center provide ABA therapy and how much does it cost?

Regional centers provide evaluation, assessment, and service coordination at no cost to eligible people. However, regional centers must identify and pursue all funding sources for consumers receiving regional center services.50 Public or private insurance should be used first for medically necessary services such as ABA therapy. In California, Medi-Cal, most private insurance plans, and school districts must fund ABA services to eligible children. If insurance does not cover the service, Local Education Agencies (school districts) or regional centers will purchase or provide it.51

If Medi-Cal or private insurance denies your request for ABA therapy, a regional center may cover the cost. A regional center will only cover the cost for people who are eligible for regional center services. A regional center cannot fund ABA for a consumer 3 years of age or older without first receiving a copy of the denial from private insurance and/or Medi-Cal. The regional center must also determine that an appeal of the denial will not be successful.52 If you receive a denial from private insurance and/or Medi-Cal, contact your local regional center to determine if an appeal might be successful. If you are not yet eligible for regional center, you will need to apply.

A regional center may fund ABA services if a person has a self-funded/self-insured private health insurance plan. A regional center may also fund ABA therapy for health insurance plans that originated outside California. Regional centers will not purchase a service that would otherwise be available from Medi-Cal, Medicare, or private insurance when a consumer or a family meets the criteria for coverage but chooses not to pursue it.  

Can the regional center pay for my co-pays, co-insurance, and/or deductibles?

Yes. Regional centers may cover co-pays and deductibles if family income is less than 400% of the Federal Poverty Guideline.53 Ask your regional center service coordinator for co-pay funding.

I do not have a denial from private insurance or Medi-Cal. Are there any exceptions?

Yes. Regional centers may pay for behavioral services during these periods:

  • While you are pursuing coverage, but before you get a denial.
  • Pending a final administrative decision on an appeal if you provide the regional center with proof you appealed.
  • Until Medi-Cal, private insurance, or a health care service plan starts ABA services.54

Contact information for California regional centers:

To look up and contact your local regional center, please follow this link maintained by the California Department of Developmental Services: https://www.dds.ca.gov/rc/listings/.

General Tips:

If you are denied ABA therapy through your health insurance plan, ask for the reason in writing.

Make copies of all assessments, treatment plans, goals, and letters from your child’s pediatrician, the school district, or regional center supporting the medical necessity of ABA therapy.

Take notes. Write down the date of your call, the name of the person you spoke with, and what the person said.

Keep all supporting documentation in a binder created for this topic.

Publication #7167.01 (pdf)