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ABA Insurance Coverage

Published November 24th, 2022 by NYTPS Inc

Are Out-of-Pocket Expenses for ABA Not a Fiscal Reality?

Health insurance can be complicated, especially when ABA therapy is involved. As an accredited ABA therapy provider, we know what you face as a parent of a child with autism. When you are faced with a fury of questions and don't know what direction to take, here is a common-sense guide to finding the answers.

Research Your Current Health Plan

There are two versions of health plans offered by employers to employees who are on group insurance plans:

  • Fully funded/insured health plans are the traditional type of insurance offered by most employers, subject to state mandates requiring ABA therapy to be covered
  • Although not traditional, there are some self-funded health plans where your employer becomes your insurance provider instead of a third party. These self-funded healthcare plans are not subject to the same state mandates as fully funded commercial healthcare plans. However, a self-funded health plan company can choose to cover ABA therapy if it wants under its directives and protocols

Find Out Your Benefits Coverage with a Simple Phone Call

Let your fingers do the walking and call your employer benefits representative or the member services number on the back of your insurance card or documents to ensure that your healthcare plan covers ABA therapy.

What to Do When Your Child's ABA Coverage Is Non-existent or Minimal

Since it's prevalent for younger children with autism to require up to 40 hours of ABA therapy weekly, a child-only plan can be a wise financial decision. This plan lets your child receive the recommended therapy time to address their condition intensively. An insurance plan that is child-only coverage through the Healthcare Marketplace is a viable option when you are looking to maximize benefits for only one family member.

Healthcare Marketplace plans can only be purchased during Open Enrollment periods unless there is a qualifying life event. Open Enrollment for the year 2022 is November 1 - January 15. Selecting a plan during Open Enrollment ensures you have coverage for the following year.

Don't Subject Yourself to Surprises

When looking for the right health plan, consider the following:

  • The deductible you will have to pay this amount before insurance starts to contribute. Your deductible and your responsibility for paying it resets every year
  • You'll have either a copay or coinsurance amount of financial responsibility
    • Your copay is a flat rate you'll have to pay per visit, not by the hour, to a provider for any healthcare service, including ABA therapy
    • Your coinsurance is a percentage of the total charges you will be responsible for paying after you've paid the deductible
  • The out-of-pocket maximum is also essential to be aware of when it comes to choosing a plan. You'll have to pay this maximum for the entire year. Once you reach that amount, you won't have any other out-of-pocket expenses for ABA therapy for the rest of the year. Like your deductible, the out-of-pocket maximum also resets yearly, and you will be back to zero at the beginning of the following calendar year

At NYTPS, we know you have many decisions regarding your child's care and ABA therapy solutions. Should you need any direction, please call our office or submit an online enrollment form, and we will help you create a learning environment for your autistic child that will benefit them far into the future.


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