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Insurance Terminology

ABA and Insurance- What You Need To Know

For any parent, receiving an autism diagnosis for your child can be an overwhelming experience. Figuring out just what kind of help your child needs, along with who to trust and where to go … that’s all hard enough. Eventually, it hits you — how am I going to pay for the therapy my child needs? Can I get ABA therapy insurance coverage? This guide explains the options — whether you have insurance or not — for accessing Applied Behavior Analysis (ABA) treatment for your child.

Common Insurance Terms to Know :

Deciphering what your insurance covers means learning a whole new language. Here’s a list of commonly used insurance terms and definitions. Keep in mind, each insurance plan has its own rules, so confirm with your plan representatives what they cover and what they don’t.

Premium :  A monthly cost (sometimes split between pay periods) paid to the insurance company and often partially paid by the employer. Premiums are not applied to out-of-pocket costs.

Patient or Beneficiary Responsibility: The portion of costs of medical services that the beneficiary pays for before the insurance plan pays its portion.

Co-pay :  A set rate you pay for some prescriptions, doctor visits, and other types of services. Not all plans have co-pays, and co-pays do not apply to all services. Co-pays do not typically count toward your deductible.

Co-insurance :  A cost-sharing structure in which the insurance company pays a percentage of the care costs and the beneficiary is responsible for the remaining percentage of costs. These costs are usually applied after a deductible is met.

Deductible :  A deductible is the amount you pay each year before your health plan begins to share in the cost of covered services. Some medical fees may or may not be included in the deductible.

Out-of-Pocket (OOP) Maximum :  Out-of-pocket maximum is the most you could pay for covered medical expenses in a year. Most co-pays will count toward your out-of-pocket maximum.

In-Network Benefits :  Most insurance plans have a network of providers that meet the plan’s credential requirements and accept the plan’s reimbursement rates for services. Services from in-network providers are covered at a higher rate for the beneficiary than out-of-network providers.

Out-of-Network (OON) Providers :  If a provider does not have a contract with your insurance plan, they’re considered out-of-network. Some plans have some out-of-network benefits, but the amount paid by the beneficiary is usually much higher. If there are no out-of-network benefits, the beneficiary may be responsible for the full price of the service. Providers may also charge additional out-of-network fees.

Preferred Provider Organization (PPO) Plans :  On a PPO plan, you generally pay less for in-network services, but you usually pay more for premiums. Many PPOs have some out-of-network benefits and a larger network of providers in a larger area. A referral is usually not necessary to see a specialist.

Health Maintenance Organization (HMO) Plans :  HMOs only cover providers that are in your plan’s network. If a beneficiary uses an out-of-network provider, the beneficiary will have to pay full price for the services, except in emergency situations. HMOs usually have localized networks (only in a certain area), and have lower cost premiums, but higher service costs for beneficiaries. HMOs also generally require a referral by a primary care doctor for any specialist visits.

Quote of Benefits :  A quote of benefits may be available from your medical provider with information from your insurance plan about the rates at which they will pay for covered services and what the beneficiary is responsible for paying. It is always a good idea to double-check these rates directly with your insurance plan.

Pre-Authorization :  Some plans require pre-authorization before agreeing to cover certain services. Most insurance plans require pre-authorization for ABA therapy services. Insurance companies also often require reauthorization after a certain time period in order to continue covering ABA therapy.

Tips for Finding Out if You have ABA Therapy Insurance

You may feel compelled to call your insurance company immediately after getting a diagnosis. If you follow these tips first, you’ll save yourself time and frustration:

  • Know the terminology :  Most insurance plan representatives will explain your ABA therapy insurance coverage using terms like co-pay, co-insurance, etc.
  • Always Double-Check :  It’s not uncommon to get different information regarding your benefits from different insurance representatives. Representatives may also give conflicting information to the provider and the beneficiary. Always confirm any estimate of costs before treatment.
  • Get Names & Reference Numbers :   When speaking to representatives from your insurance company, make sure you always get the person’s name and a reference number. That way, you can refer back to it if you ever get conflicting information.
  • Keep Everyone in the Loop :  If you change plans, make sure you research how those changes can affect your coverage. Also, let your medical providers know as soon as possible if you are changing plans to avoid unforeseen charges.
  • Ask about Single Case Agreements (SCAs) :  Some insurance companies will allow single case agreements with a provider outside of its network. Each plan has its own criteria for allowing these agreements. Our team at Thrive Behavior Centers can assist you in finding out if your insurance plan will allow a single case agreement.