Vermont Act 158 requires private insurance and Medicaid to cover medically necessary treatments for the condition of autism and early childhood developmental disorders. One of the key therapies that is now covered is Applied Behavioral Analysis (ABA): a therapy that is highly recognized as an effective treatment for autism.
ABA Treatment at Home vs. School
Some school age children are able to access “ABA” at school. A behavioral interventionist may be hired by the school to help the child access his or her education, rather than to treat the child for the underlying challenges of autism. Most often, a behavioral interventionist is hired by a school to help a child with problem behaviors that may be considered dangerous or disruptive and then only after all in-house interventions have been exhausted. The decision to have behavioral intervention is a decision made by the IEP team, however the actual agency or individuals who carry out the service is a hiring decision made by the school and not the parent. There is no minimum training requirement for the person working with a child on problem behaviors and the skill can vary from an untrained 1:1 para to an outside agency with a program designed and supervised by a BCBA (Board Certified Behavior Analyst).
ABA delivered at home or in the community is determined not by the IEP team, but by medical necessity: a diagnosis and a prescription for treatment. The purpose of the therapy is to treat the underlying challenges of autism, which could include anything from problem behaviors, such as aggression, issues with transitions, or toileting challenges to developing positive behaviors and skills such as communication, social skills and independence. The treatment must be provided by a licensed professional or a BCBA and can be provided at home, in the community or in a clinical setting.
A home program runs the whole year, including summer and during school breaks. This can be very important for individuals with autism who need consistency.
A Prescription from the Doctor
Autism is a medical condition. Medical conditions are diagnosed by doctors. Treatments are prescribed by doctors. Therefore, your first step for a parent seeking is to talk to your child’s doctor about prescribing the necessary treatment for your child to treat the underlying condition of autism. You may find it helpful to bring information to the doctor about ABA (if this is the therapy you are seeking) as many will be prescribing this therapy for the first time. The doctor’s prescription should specify that the treatment is for “home and community for the treatment of autism”. The prescription could be for a set amount of therapy, such as “20 hours per week of ABA”. The doctor may also order an evaluation done by a professional (BCBA, speech therapist, etc.) to get more information. Vermont law also allows for a prescription for treatment to come from a licensed psychologist in addition to a licensed physician.
Your child does not have to be on an IEP (or even in school) to get a prescription for treatment for therapy at home. This means that individuals with higher functioning forms of autism, who may not otherwise get access to therapies at school, may be eligible to receive much needed therapies at home, including help with improving social skills. The law covers to age 21 for both Medicaid and private insurance. However, due to the Affordable Care Act, an individual may be able to get treatment until age 26.
A Choice of Providers
Once you have a prescription for treatment, you can contact your insurance company or Medicaid (if primary) and ask for a list of providers (speech therapists, BCBAs, occupational therapists, etc.). By law, both Medicaid and private insurance companies need to offer a choice of providers.
Getting Your Child What He or She Needs
In practice, accessing ABA treatment for a child in need of such therapy can be a challenge. One of the barriers is lack of information about the law, understanding the significance of what is available and knowing where to start. Be sure to document your efforts and document information that was provided to you by private insurers and Medicaid.
* There have been successful cases of individual with Down syndrome getting access to ABA services.