If your insurance card says UMR, you are not in a typical insurance plan. That one fact explains most of the confusion families run into when they ask whether autism testing is covered. This guide explains what UMR is, why Florida's autism law usually does not apply, where to find your plan's real answer, and what UMR asks for in a diagnosis if you later request ABA therapy.
What is UMR, and why does it matter for autism testing?
UMR describes itself on its ABA documentation form as "a Third-Party Administrator (TPA) representing all self-insured groups." In a self-insured (self-funded) plan, your employer pays the claims with its own money and hires UMR to run the plan: process claims, manage networks and handle reviews. Your employer, not UMR, decides what the plan covers. Those choices are written in the plan document and summarized in the Summary Plan Description (SPD).
This matters because Florida's autism insurance law, the Steven A. Geller Autism Coverage Act (s. 627.6686), applies to insurers licensed and regulated in Florida. Self-funded employer plans fall under the federal law ERISA instead. The Florida Department of Financial Services says it "does not have authority over self-insured plans under the Employee Retirement Income Security Act of 1974." So the state law that requires autism screening and treatment coverage in fully insured large-group plans does not, by itself, decide what a UMR plan covers.
That does not mean UMR plans avoid autism care. Many employers choose to cover it, and federal rules still apply, including preventive care requirements for most plans and mental health parity rules. It means you have to read your own plan.
Is autism screening covered under a UMR plan?
Usually. HealthCare.gov lists autism screening at 18 and 24 months among the children's preventive services that most health plans must cover, generally with no copay or coinsurance in network. That requirement reaches many employer plans, including most self-funded ones, though some older grandfathered plans are exempt and the page notes coverage can vary. Screening is usually done by your pediatrician at a well-child visit with a tool like the M-CHAT.
Is a diagnostic autism evaluation covered?
In most employer plans, a diagnostic evaluation is covered as a medical or behavioral health service, with your normal deductible, copay or coinsurance. But because each employer writes its own plan, the details differ. The questions that change your cost are:
- Does the plan cover psychological or neuropsychological testing for autism, and under which benefit?
- Does testing need prior authorization or a pre-determination?
- Is the evaluator in the plan's network?
- Does the plan exclude any autism-related services? Some plans list exclusions in the SPD.
Here is an example, for illustration only. Two parents in the same Florida city both carry a UMR card, but they work for different employers. One employer's plan covers psychological testing and ABA for autism with the usual deductible. The other employer's plan requires prior authorization for testing, uses a different network and has a higher deductible. Both cards look alike; the plans are not. That is why a friend's experience with UMR, or a coverage page about another UMR plan, cannot tell you what yours covers.
Where do I find the real answer?
| Question | Where to find it | Tip |
|---|---|---|
| Is my plan self-funded? | Your HR or benefits office; the SPD | A UMR card almost always means yes. The SPD may say "self-funded," "self-insured" or "administered by UMR." |
| Is autism evaluation covered, and what will I pay? | UMR member services (number on your card); your benefit summary | Ask for the service by name and by CPT code (96130 to 96133 for psychological or neuropsychological testing) |
| Is prior authorization needed? | UMR member services; the clinic's billing office | Ask who submits it and how long a decision takes |
| Are autism services excluded? | The full plan document or SPD (ask HR for a copy) | You have a right to request plan documents from the plan administrator |
| Is ABA covered after a diagnosis? | UMR member services; the plan's behavioral health benefits | Ask whether ABA needs prior authorization or a pre-determination review |
When you call, have your child's member ID and the evaluator's name and NPI ready. Write down the date, the representative's name and the reference number, and ask for important answers in writing.
What does UMR require as proof of an autism diagnosis for ABA?
If you think ABA therapy may be recommended, it helps to know UMR's documentation rules before the evaluation. UMR's form "ABA Therapy Documentation Requirements" (UMF0035) says:
- For an initial ABA evaluation, or a new UMR member already in services, the provider must submit "proof of an autism diagnosis via the diagnostic evaluation (or if not available a written referral from diagnosing Physician with diagnosis on it)."
- "IEPs and school evaluations are NOT acceptable as the sole proof of diagnosis."
- If the diagnostic report is more than 4 years old, current documentation is also needed, for example an IEP, a physician's progress or well-visit note, or a mental health therapy note reflecting current behaviors.
- Not all UMR plans require prior authorization for ABA, but UMR recommends a pre-determination medical necessity review even when prior authorization is not needed.
- ABA prior authorization reviews have up to 15 days for a decision, and UMR states that ABA cases are not considered urgent or expedited.
The practical takeaway: a school eligibility decision alone will not open ABA coverage under a UMR plan. A diagnostic evaluation from a qualified clinician, with a report you keep a copy of, is the document to plan around. See does UMR cover ABA therapy for the treatment side.
What if the plan denies the evaluation or excludes autism services?
- Get it in writing. Ask for the denial letter, the reason and the plan provision used.
- Appeal. Self-funded plans must offer an internal appeal under federal claims rules, and for most plans you have 180 days from the denial notice. Follow the steps in the denial letter.
- Ask about parity. Federal mental health parity law limits how plans can restrict mental health benefits compared with medical benefits. If the plan treats autism services more strictly, ask the plan to explain in writing.
- Get help. For self-funded employer plans, the U.S. Department of Labor's Employee Benefits Security Administration takes questions at 1-866-444-3272.
- Talk to HR. Employers set the plan design and sometimes change it at renewal when employees ask.
Our guide on fully insured vs self-funded plans explains the legal background.
Free routes while you sort out coverage
- Under 3: Early Steps evaluates at no out-of-pocket cost and does not need a doctor's referral. Call 1-800-218-0001.
- 3 and older: your school district must evaluate at no cost to you when a disability is suspected. A school evaluation supports an IEP, but remember UMR will not accept it as the only proof of diagnosis for ABA.
A side-by-side cost comparison is in how much an autism evaluation costs in Florida.
How Hope Center can help
Hope Center works with UMR plans and offers diagnostic evaluations through our clinical director with a supervising licensed psychologist, plus ABA therapy. We can run a free benefits check on your UMR plan and explain what your employer's plan covers. Only part of an evaluation is billed to insurance, so ask us what your share would be. Your costs depend on your plan; self-pay with a sliding scale is also available. Visit insurance at Hope Center, request a benefits check or call 561-337-8865.