Does insurance cover adult autism testing?

The short version

There is no single national rule that every plan must pay for an adult autism assessment in a particular way. In practice, many plans cover diagnostic psychological evaluation as part of mental and behavioral health benefits, but the details differ: which clinicians are in network, how many testing hours are approved, and what you owe out of pocket. The only reliable answer comes from your own plan.

If your insurance comes through a large employer, a federal parity law also generally applies to mental health benefits. That does not guarantee any specific test is covered, but it limits how differently plans can treat mental health compared with physical health.

Questions to ask your insurer

Call the member services number on your card. Write down the date, the representative's name and a reference number. Ask:

1. Is a psychological or neuropsychological evaluation for possible autism covered for adults on my plan?
2. Do I need a referral from my primary care provider?
3. Is prior authorization required, and who submits it?
4. How many testing hours are usually approved?
5. Which in-network psychologists or neuropsychologists assess adults for autism?
6. What is my deductible, and how much of it have I met?
7. What copay or coinsurance applies to diagnostic evaluations?
8. Do I have out-of-network benefits, and what percentage do they reimburse?

Ask the clinician's office which procedure codes they bill for the evaluation. Giving those codes to your insurer gets you a more precise answer about coverage than a general question.

Know which kind of plan you have

The type of plan shapes which rules apply. Marketplace plans bought through HealthCare.gov or a state exchange must cover mental and behavioral health as an essential benefit. Many employer plans are self-funded, meaning the employer pays claims directly and federal rather than state insurance rules mostly apply, so state autism coverage laws may not reach them. Your benefits booklet or HR department can tell you which type you have. Short-term plans and health care sharing ministries often cover far less and may exclude mental health evaluation entirely.

Prior authorization

For psychological testing, the clinician's office often submits the request with a short explanation of why the evaluation is needed. Clear documentation of the difficulties you face at work, in relationships or with daily tasks can help. If a request is approved for fewer hours than requested, ask the clinician whether a focused assessment is still possible within that limit.

In network versus out of network

In-network clinicians have agreed rates with your plan, so your costs are usually lower and more predictable. Adult autism specialists are scarce in some networks, though, and waits can be long. Out-of-network clinicians may be available sooner, but you usually pay upfront and seek partial reimbursement with a superbill. If no in-network clinician can assess adults for autism within a reasonable time or distance, ask your insurer whether they will make a network exception.

If your claim is denied

A denial is not always final. Read the explanation of benefits to see the reason. Common reasons include missing prior authorization, a coding issue, or a judgment that the evaluation was not medically necessary. Your clinician can often help with a letter explaining why the assessment was needed.

Keep copies of everything you send and receive during an appeal, and note deadlines carefully. Appeals have time limits, and missing one can close the door even when the case is strong.

Common coverage pitfalls

• Assuming a covered therapy benefit automatically covers testing. They are often handled differently.
• Booking before prior authorization is approved.
• Not checking whether the clinician is in network for your specific plan, not only your insurer.
• Forgetting the deductible resets each plan year.
• Assuming coverage for a child's autism evaluation means the same rules apply to adults.

If you have no insurance

You still have options. Self-pay clinicians must usually provide a good faith estimate. University training clinics and some community mental health centers offer lower fees. You may also qualify for Medicaid, or for a Marketplace plan during open enrollment or after a qualifying life event. Our guides to Medicaid and low cost assessments cover these routes.

• Adult autism testing with Medicaid or MedicareHow adults can seek an autism evaluation with Medicaid, Medi-Cal or Medicare: what to ask your plan, finding a provider, and what to do if you are refused.
• Free and low cost adult autism assessmentsRealistic routes to a free or low cost adult autism assessment: Medicaid, community health centers, university clinics, sliding scales and research.
• How much an adult autism assessment costs in the USWhy adult autism assessment costs vary so much in the US, what a fee should include, how to get a good faith estimate, and ways to lower the bill.