Understanding ABA Therapy Insurance Coverage

Common Insurance Terms to Know

Premium

A monthly cost paid to the insurance company, often partially paid by the employer. Premiums are not applied to out-of-pocket costs.

Patient or Beneficiary Responsibility

The portion of costs 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 services. Co-pays don't typically count toward your deductible.

Co-insurance

A cost-sharing structure: the insurance company pays a percentage of the cost, and the beneficiary pays the rest. Usually applied after the deductible is met.

Deductible

The amount you pay each year before your health plan begins to share in covered costs. Some medical fees may or may not count toward it.

Out-of-Pocket (OOP) Maximum

The most you could pay for covered medical expenses in a year. Most co-pays count toward your out-of-pocket maximum.

In-Network Benefits

Most plans have a network of providers who accept the plan's reimbursement rates. Services from in-network providers are covered at a higher rate.

Out-of-Network (OON) Providers

Providers without a contract with your insurance plan. Some plans have OON benefits, but the amount paid by the beneficiary is usually much higher.

PPO Plans

You generally pay less for in-network services but more for premiums. PPOs usually offer some out-of-network benefits and don't require a referral.

HMO Plans

HMOs only cover providers in your plan's network (except in emergencies). Lower premiums, higher service costs, and a referral required for specialist visits.

Quote of Benefits

Information from your insurance about the rates they will pay for covered services and what you're responsible for. Always double-check directly with your insurance.

Pre-Authorization

Some plans require pre-authorization before covering certain services. Most plans require it for ABA therapy and reauthorization after a set period to continue coverage.