Frequently Asked Questions About Health Insurance and Funding for ABA Services
I don’t understand medical billing terms. How will I understand my benefits and coverage for ABA services?
We are here to help! Prior to billing or completing any services, Acuity Behavior Solutions’ staff will carefully review your coverage and responsibilities based on your health insurance plan with you.
How will I know about my deductible, out of pocket maximum, copayments or coinsurance?
We’ll let you know! Prior to completing or billing any services, Acuity Behavior Solutions’ staff will carefully review your coverage and responsibilities based on your health insurance plan. If you have any specific questions, we are happy to answer them and to direct you to the right people at your insurance company as needed.
Will Applied Behavior Analysis be a covered benefit under my plan?
We’ll check for you. California law (Senate Bill 946, frequently called SB946) now requires most health insurance plans to cover ABA treatment if they have a diagnosis of Autism Spectrum Disorder. Acuity Behavior Solutions’ staff will contact your insurance company for a complimentary benefits check. Most plans are legally required to cover ABA services for a child with a diagnosis of Autism Spectrum Disorder. Plans that may not be mandated to cover ABA are self-funded plans. These are different from “fully funded plans.” Fully funded plans are more traditional health plans where the employee pays the premiums and other payments to the insurance company directly. A self-funded insurance plan, also commonly called an Administrative Services Only (ASO) plan is where an employer provides its own benefits to employees and funds the plan. There are some ASO plans which do allow for or elect coverage for ABA services. Parents who work at companies with ASO plans which don’t cover the service can discuss the coverage with their human resources department.
What do I need to get started with ABA through my insurance plan?
We’re here to help! Acuity Behavior Solutions is able to get the process started for you after a quick phone call and after receiving the documents required – your insurance card, the diagnostic report for Autism Spectrum Disorder and a recommendation for ABA services. After receiving this information, Acuity Behavior Solutions obtains the needed authorization to get started!
What if my child doesn’t have a diagnosis of autism yet, but I have been told that my child might have autism?
Most insurance companies require the diagnosis of autism to authorize ABA services. Looking for a diagnostic assessment to determine if your child has autism? We can refer you to a caring and professional diagnosing clinician or medical doctor in your area.
What if I have a diagnosis of Autism from the school district?
Most insurance companies require the diagnosis to come from a psychologist or medical doctor. A medical doctor (MD) who can diagnose autism may include a psychiatrist, a neurologist, and in some cases a pediatrician. Looking for a diagnostic assessment to determine if your child has autism? We can refer you to a caring and professional diagnosing clinician or medical doctor in your area.
What if I want ABA but my child is diagnosed with something besides Autism Spectrum Disorder?
We provide ABA for many children, regardless of their diagnosis. Most private insurance companies, as well as Medi-Cal programs, require a diagnosis of Autism, Asperger’s Syndrome, or other disorders that fall on the autism spectrum to authorize ABA. While you can certainly petition to your insurance company to cover ABA for another disorder, the process may be quite long. We recommend private pay for those who want the proven benefits of Applied Behavior Analysis therapy but don’t have a diagnosis of autism.
Will I be required to get pre-authorization before ABA services starts?
We will handle the pre-authorization request for you. Acuity Behavior Solutions’ staff will use the information and documents provided to request pre-authorization for you. This is sometimes also called pre-certification or authorization. Once authorized by the insurance company, we are able to start services. Often, an assessment must be completed prior to the start of ABA therapy.
How long will ABA be authorized for? Does the insurance company just allow it to go on until it’s not needed anymore?
Most insurance companies authorize ABA for 6 months at a time. Applied Behavior Analysis requires a re-authorization every 6 months. This is done when the supervisor on your case writes a 6-month progress report, explaining the progress that has been made. Supervisors create this report and request the necessary authorization for your family member prior to the end of the 6-month authorization to avoid any interruptions in services. You will be provided a copy of the report, as well.
How many years will the insurance company authorize ABA?
Most insurance companies authorize ABA for 6 months at a time. Some children require several years of ABA in the home and other children require a shorter period of time. Health insurance plans typically approve ABA when it meets the requirements for medical necessity. This can occur for several 6 month authorizations.
I’m having a hard time contacting my insurance company about ABA services. What should I ask when I contact them?
Often, ABA falls under the mental health or behavioral health department. Make sure you are transferred to one of those lines, if there is an option to do so. Always have your insurance information (e.g., member ID, member’s birthdate) ready when calling your insurance plan.
What is a deductible?
A deductible is the amount you pay for health care services before your health insurance begins to pay. Please check with your health insurance plan provider for specifics and details on your plan.
What is a copay?
A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. You may also have a copay in addition to coinsurance. Most plans have a copay or coinsurance. Please check with your health insurance plan provider for specifics and details on your plan.
What is coinsurance?
Coinsurance is your share of the costs of a health care service. It's usually figured as a percentage of the amount we allow to be charged for services. You start paying coinsurance after you've paid your plan's deductible. Most plans have copay or coinsurance. Please check with your health insurance plan provider for specifics and details on your plan.
What is an out of pocket maximum?
Typically, the out-of-pocket limit is the maximum amount you will pay out of your own pocket for covered medical expenses in a given year. After you meet your out of pocket maximum, the insurance company will pay most covered expenses in full, according to your plan for the rest of the year, usually until December 31st. Please check with your health insurance plan provider for specifics and details on your plan.
When can I get my child started with ABA?
Contact us at 714-696-2862 to get the process started!