Understanding Your ABA Insurance Benefits is Key to Your financial Health

An informed parent is an empowered parent. At Behavioral Innovations, we understand the journey is complex, we’re here to help.

Behavioral Innovations has over 15 years of experience dealing with commercial health insurance benefit plans and associated payers. Our experience, coupled with our admission specialist team and dedicated authorization team, provides each parent an advantage when trying to understand their health plan ABA benefits.

Choosing an ABA provider is key to your child’s future. Understanding your ABA insurance benefits is key to your financial health.

Behavioral Innovations participates in many commercial health insurance plans. We believe our role is to partner in understanding your unique plan. We’re here to help every parent make the best-informed decision about the services they choose.

Common terms related to insurance coverage include the terms below. We will help you understand what they mean in order to better guide you through the intake process.

  • Benefit: the amount payable by the insurance company to a provider for ABA therapy costs.
  • Benefit level: the maximum amount that the health insurance company has agreed to pay for a covered ABA benefit.
  • Claim: a request by the ABA provider for the insurance company to pay for services.
  • Coinsurance: the amount you pay to share the cost of covered services after your deductible has been paid. The coinsurance rate is usually a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%.
  • Copayment: one of the ways you share in your ABA service costs. You pay a flat fee for certain expenses (e.g., $10 for every day of service), while your insurance company pays the rest.
  • Deductible: the amount of money you must pay each year to cover eligible medical expenses before your insurance policy starts paying.
  • Explanation of benefits: the health insurance company’s written explanation of how a medical claim was paid. It contains detailed information about what the insurance paid and what portion of the costs is your responsibility.
  • In-network provider: an ABA provider that is part of a health plan’s network of preferred providers. Generally, you pay less for services received from in-network providers because of negotiated rates.
  • Network: the group of providers that insurance companies contract with to provide services at discounted rates.
  • Out-of-network provider: an ABA provider that is not part of a health plan’s network of preferred providers. Generally, you pay more for services received from out-of-network providers.
  • Out-of-pocket maximum: the most money you will pay during a year for coverage. It includes deductibles, copayments, and coinsurance, but is in addition to your regular premiums. Beyond this amount, the insurance company will pay all expenses for the remainder of the year.
  • Payer: the health insurance company whose plan pays to help cover the cost of your services.
  • Provider: any ABA clinician or paraprofessional that provides ABA services.

The total cost to a family is based upon services rendered, such as: the assessment and report writing, Behavior Technician or BCBA direct therapy, supervision, and semi-annual reassessments and report writing, as required by the insurance company.

Payment for services is expected following the receipt of the insurance company-issued Explanation of Benefits. Costs for ABA services are eligible for Flexible Spending Account (FSA) and Health Savings Account (HSA) reimbursement.

Many families who are struggling to get their insurance to cover ABA services, look into a child-only policy plan.

This may be a good option to look into:

  • If the child lives with grandparents who do not have private insurance because they are eligible for Medicare, and the child is not eligible for Medicaid or the Children’s Health Insurance Program.
  • If the parents are divorced or live in different states.
  • For families affected by autism whose job-based coverage does not include ABA.

Marketplace plans are available for purchase only during open enrollment periods unless you have encountered certain life changes listed on the marketplace website.https://www.healthcare.gov/

For more information and questions regarding our services, we’re always here to support!

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