Insurance Coverage

Deciphering what your insurance covers sometimes means learning a whole new language! We can help! Keep in mind, each insurance plan has its own rules, so confirm with your plan representatives what they cover and what they don’t, or contact us and we'll do the work! Consider the example in the associated visual as you review the below list of commonly used insurance terms and definitions: 

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

• Out-of-pocket 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 meaning you pay less for services. 
• Out-of-network 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. 
• 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. 
• Peer Review: A review with your insurance company and provider discussing your child's progress and future goals for learning. Peer reviews are important in order to obtain initial treatment or continue treatment
• File An Appeal: Sometimes, after a peer review, ABA treatment, or other services, may be denied by your insurance provider. If this happens, you can request that the decision in your case be looked at again.
• Authorized Hours: The number of hours your insurance provider will authorize for certain services, like ABA therapy. If you disagree with the amount of hours authorized, you are able to file an appeal.

• 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.

Before submitting any requests for ABA therapy insurance, your child will need a medical autism diagnosis. All insurance plans require a medical diagnosis of autism spectrum disorder before authorizing ABA services. The medical diagnosis should also include diagnostic testing for autism and cognitive testing. Plans will require the diagnosis to be conducted by either a medical doctor (M.D.) or a Ph.D.

Professionals who can evaluate for and diagnose autism include the following:

• Developmental pediatricians
• Licensed psychologists
• Some neurologists
• Some pediatricians

A medical diagnosis of autism is different from educational eligibility. If your child receives specialized supports through an Individualized Education Plan (IEP) at school, however, does not have a medical diagnosis of autism, most likely, this educational eligibility will not be accepted by your ABA therapy insurance plan. Think of the public education school systems and medical fields as two different entities. An educational eligibility of autism does not cross over to the world of private therapeutic treatment, since it’s based on educational need. In the same way, education professionals may take a medical diagnosis into account, but it does not guarantee special education services in public school districts.

If your child has an educational eligibility, but not a medical diagnosis of autism, or you suspect your child needs an evaluation, we may be able to provide a list of referrals to providers in your area who evaluate individuals for autism. Call or email us for more information.