Understanding Health Insurance and Accessing ABA Therapy for Your Child
Understanding insurance can be challenging, especially when trying to secure necessary services like Applied Behavior Analysis (ABA) therapy for your child. ABA therapy is a highly effective, evidence-based intervention for children with autism, and understanding how to access it through your health insurance is crucial. Here’s a comprehensive guide to help you through this process.
1. Understanding Your Health Insurance Policy
Review Your Policy: Start by thoroughly reviewing your health insurance policy. Look for sections related to behavioral health, mental health services, or autism-specific treatments. Key aspects to consider include:
- Coverage Limits: Understand the extent of coverage for ABA therapy, including the number of sessions covered and any monetary caps.
- In-Network Providers: Determine if your insurance requires you to use in-network providers for ABA therapy to be covered.
- Co-pays and Deductibles: Be aware of your financial responsibilities, such as co-pays, co-insurance, and deductibles.
Contact Your Insurance Company: If the policy document is unclear or you are still having trouble understanding insurance, call your insurance company’s customer service line. Ask specific questions about ABA therapy coverage, required documentation, and the process for obtaining approval.
2. Getting a Diagnosis and Prescription
Obtain a Diagnosis: Most insurance plans require a formal autism diagnosis from a qualified professional, such as a developmental pediatrician, neurologist, or psychologist. This diagnosis is essential for accessing ABA therapy.
Get a Prescription: Once you have a diagnosis, your child’s healthcare provider should write a prescription or referral for ABA therapy. This document is often required by insurance companies to approve coverage.
3. Finding an ABA Provider
In-Network Providers: Check if your insurance plan has a list of in-network ABA providers. Using in-network providers can significantly reduce out-of-pocket costs.
Out-of-Network Providers: If you prefer an out-of-network provider, inquire about the process for obtaining coverage. Some plans may offer partial reimbursement for out-of-network services, but this can vary widely. Bloomwell offers flexible payment plans for families that choose to work with us.
Provider Credentials: Ensure that the ABA provider you choose is certified by the Behavior Analyst Certification Board (BACB) and meets your insurance company’s qualifications.
4. Obtaining Authorization
Pre-Authorization Requirements: Many insurance plans require pre-authorization for ABA therapy. This means you child will need to get approval from your insurance company before starting therapy.
Submit Necessary Documentation: Gather and submit the required documents, which typically include:
- Autism diagnosis report
- Prescription or referral for ABA therapy
- Detailed treatment plan from the ABA provider, including goals, methods, and expected outcomes
Bloomwell’s team of experts will gather this documentation and submit it to you insurance company on your behalf and will keep you informed about any decisions or additional documentation that might be requested by your insurance company.
5. Understanding Your Financial Responsibilities
Co-pays and Co-insurance: Familiarize yourself with the co-pay or co-insurance amounts you will need to pay for each ABA therapy session.
Deductibles: Know your deductible amount and whether you have met it for the year. ABA therapy costs may apply to your deductible before the insurance starts covering the sessions.
Out-of-Pocket Maximum: Be aware of your plan’s out-of-pocket maximum, which is the most you will have to pay for covered services in a plan year. Once you reach this amount, your insurance should cover 100% of the costs.
6. Keeping Records
Document Everything: Keep detailed records of all interactions with your insurance company, including dates, names of representatives, and summaries of conversations.
Track Expenses: Maintain a log of all expenses related to ABA therapy, including co-pays, out-of-pocket payments, and any reimbursements received. This can be helpful for tax purposes and future insurance claims.
7. Addressing Denials and Appeals
If your claim is denied, Bloomwell’s insurance experts will request a detailed explanation from your insurance company. Common reasons include missing documentation or not meeting medical necessity criteria. We will then file an appeal on your behalf. The appeal process usually involves submitting additional documentation and a letter explaining why the therapy is necessary for your child. It also can often involve a phone conversation between one of our BCBAs and the insurance company’s provider. As always, we will keep you updated every step of the way.
If your appeal is denied, we will also help you navigate any potential next steps which could include:
- Escalating the matter to external review boards;
- Seeking assistance from an insurance advocate; or
- Engaging an attorney specializing in health insurance claims.
8. Exploring Additional Resources
State Mandates: Some states have mandates requiring insurance plans to cover autism treatment, including ABA therapy. Research your state’s specific laws and regulations.
Medicaid and CHIP: If you have Medicaid or the Children’s Health Insurance Program (CHIP), these programs often cover ABA therapy. Contact your state’s Medicaid office for more information.
Employer Assistance: Some employers offer additional support or resources for employees with children with special needs. Check with your HR department to see if any such programs are available.
Understanding insurance can be challenging and how to secure ABA therapy for your child through health insurance can be a complex process. We are here to help you understand your policy, obtain the necessary documentation, and advocate for you and your child. By taking these steps, you can ensure your child receives the beneficial therapy they need to thrive.
