Getting Started with
Applied Behavior Analysis
If the potential client has one of the following insurances that we are in-network with, then you will need to have a diagnosis of Autism from an MD or psychologist. It needs to be a full diagnosis report signed by the provider indicating a diagnosis of Autism (Dx codes 84.0 or 299.0). You can talk to the member services department of your insurance about finding a provider that does Autism testing and diagnosing. You can also contact our office and our intake person can provide you a list of diagnosing providers that we recommend and work with for the type of insurance that you have.
- Anthem BCBS
- Blue Shield of CA / Magellan
- MHN / Health Net
- United / Optum
If the potential client has IEHP insurance through Medi-Cal then you do not need a diagnosis of Autism. They cover ABA for a multitude of development disabilities including ADD/ADHD, Cerebral Palsy, Down’s Syndrome, and many other disabilities. You don’t even need a signed diagnosis report – just a recommendation from an existing doctor (usually the pediatrician or primary doctor). They can enter their recommendation through the IEHP provider portal or they can provide a letter using the wording that they “recommend ABA services”. It should be on the doctor’s office’s letterhead and signed by the doctor. You can have an electronic recommendation routed directly to our agency if they include our NPI number which is 1194107771.
Medi-CalIf the child does not have commercial insurance or insurance through Medi-Cal, then we recommend that you apply for Medi-Cal. Medi-Cal is California’s version of Medicaid. Even if your combined household income is above the threshold for normally qualifying for Medi-Cal, there is a good chance that you can get an exemption for a child with developmental disabilities. Medi-Cal is a great option for a family with a disabled child because there are no deductibles and no co-pays for visits or pharmacy. A $20 to $40 dollar copay with a commercial insurer will be applied for every ABA claim for a service provided if that is the part of the plan coverage. That can really add up! Here are some resources for getting more information about Medi-Cal and exemptions:
- CA Dept of Healthcare website: https://www.dhcs.ca.gov/services/Pages/Medi-CalWaivers.aspx
- Medi-Cal Eligibility (916) 552-9200
- Covered California Exemption information and application: https://www.coveredca.com/learning-center/tax-penalty-details-and-exemptions/exemptions/
- Inland Regional Center – Riverside Office – (951) 826-2600
- The Inland Regional Center (IRC) is an excellent resource for parents and guardians of children with developmental disabilities and we recommend every client’s family to reach out to them and get the child established with them and be assigned a case worker. Their mission is to help families find resources for the child’s needs, including Medi-Cal, exemptions, and ABA services, PT, OT, and Speech Therapy.
- Once Medi-Cal is approved, you will receive a letter in the mail asking if you want to choose IEHP or Molina as the child’s primary insurance provider. You should select IEHP if the child does not a diagnosis of Autism for reasons explained above. If you have an official diagnosis report then Molina is a fine option as well.
Once you provide us the information and documentation we need for your insurance – then we can submit an authorization request from them. A new case starts with an ABA Assessment performed by a Board Certified Behavior Analyst (BCBA). That will entail a testing, observation, and Q&A session with the child and parents/guardians. That will either be in-person at your home or neutral site OR it can be done online through telehealth if it is feasible.
The BCBA may need a 2nd follow-up appointment if further testing/observation is needed. They then take that information, build an ABA program for the child, and write an extensive report outlining the program, measurable goals, and recommended number of hours for each type of therapy (one-on-one, supervision, program development, parent/guardian training, and social skills development).
We have 90 to 120 days authorized to complete that process but we try and get it finished ASAP so we get the program going. If that assessment report is accepted, then we are given a 6-month authorization to perform ABA services. Every 6-months thereafter, we have to submit an updated progress report and new authorization request. The goal eventually is to graduate the child from the program and form an Exit Plan, but it totally depends on progress and the severity of the Autism or other disability.
Don’t hesitate to reach out with any questions!
Call/Text 951-381-0750 and ask for Scott or email me at firstname.lastname@example.org. I will help you with any inquires to the best of my ability, regardless of whether we can provide ABA services to your child/ward or not. The most rewarding part of my job is to assist people with getting services for children when they are unsure of how to go about it or are frustrated with the systems.
Getting qualified for ABA can be a confusing and laborious process!!! Let me guide you or answer your questions.