Are ABA services covered?
Tufts Health Plan covers medically necessary ABA services for autism spectrum disorder when the member meets the criteria outlined in the applicable Tufts Health Plan medical necessity guidelines. Those guidelines include the following:
- The member has a definitive diagnosis of an autism spectrum disorder.
- Services are provided by a board certified behavior analyst (BCBA) or by other qualified health care professionals under the supervision of a BCBA (i.e., by a board certified assistant behavior analyst, masters level clinician or other paraprofessional).
- Services are provided or supervised by a BCBA in the Tufts Health Direct network.
- A parent or guardian is involved in the training of behavioral techniques.
Please note: Services related to autism spectrum disorders that are provided by school personnel as part of an individualized education program (IEP) are not covered. Please click here for more information about IEPs.
Prior authorization is required for all ABA services
The BCBA providing the services must submit the initial Applied Behavioral Analysis Autism Service Request Form. You can fax the form to the Tufts Health Plan behavioral health department at 888-977-0776.
Once we receive the form, a Tufts Health Plan authorized reviewer will make a determination regarding authorization of services. Authorizations are provided in six month increments. Time authorized may be allocated at the discretion of the BCBA. The BCBA providing the services may request additional authorization for services at any time, as necessary. Plan eligibility requirements are based on member’s age and medical necessity guidelines. No benefit limitations apply to medically necessary ABA services.
Coverage for physical, occupational or speech therapy related to an autism spectrum disorder requires separate authorization.
Questions?
If you have questions about your benefits or coverage or need help finding a BCBA provider in the Tufts Health Direct network, please call member services at 888-257-1985 (TTY: 711). We are available Monday through Friday from 8 a.m. to 5 p.m.