Eligibility and Benefits: Understanding Eligibility for ABA Coverage through Insurance

Photo by Natalya Zaritskaya on Unsplash

Todd A. Ward, PhD, BCBA-D


Emily Roche

Director of Services, ABA Therapy Billing and Insurance Services, ABABilling.net

Dawn Mackey & Jamie Pagliaro

Rethink Behavioral Health

For the vast majority of agencies providing Applied Behavior Analysis (ABA) services, a thorough understanding of insurance laws at the state and federal level is critical in order to ensure the success of the company.  Fortunately, Emily Roche, Director of Services for ABA Therapy Billing and Insurance Services recently gave a webinar for Rethink on this very topic.  Below are two of the most important themes from her talk that are sure to help in your own business planning and in speaking with potential families interested in services.

Know the difference between “self funded” and “fully funded” insurance policies.

Though most states have laws mandating the coverage of ABA for autism services, these laws do not apply to self funded policies.  With a fully funded policy, the company pays a premium to an insurance company based on the number of employees enrolled in the plan.  The insurance company then pays any claims while the employees pay the deductible.

In a self-funded policy, however, the employers actually pay the claims themselves, while only utilizing the insurance company for administrative functions.  In these policies, the employer must cover federally mandated benefits and then pick and choose any other services to be covered.  Most importantly, they can choose to opt in or out of ABA coverage for autism.

If a potential family finds themselves needing ABA services but are under a self-funded policy that excludes services, Emily suggested to have the family contact their employer’s HR department.  In all likelihood, it is possible the company simply doesn’t know about ABA and the employees in their company that might need services.

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Communicating to potential families.

Emily stressed that it is important for your agency and potential families to be on the same page with insurance and to ensure you focus on the critical elements early in the process.  For example, in many cases, insurance policies fall under the laws of the state in which the company is based and not necessarily the state in which the family lives.  Many families can be under the mistaken assumption that since ABA is mandated in their state, that their fully funded plan will cover services according to their own state mandate.  This isn’t necessarily true.

Another commonly overlooked yet important piece of information concerns the back of the insurance card.  When families send copies of their insurance cards to your agency, the back of the card often contains critical information.  Emily noted “the back is your key to know where you are calling for benefits” and will likely have a specific number for behavioral health, an address to send your claims, and other crucial billing information.

Emily also stressed that families using insurance coverage should send you a copy of a previously completed diagnostic evaluation that says the child has an autism diagnosis.  Some families may have discussed the strong possibility of a diagnosis with their pediatrician or received an educational diagnosis, but only a report from an appropriately licensed provider will be accepted by insurance as proof of diagnosis.  Without the diagnostic evaluation, claims could be rejected, or worse, you could be subjected to an audit down the road and have the costs recouped by the insurance company.

Finally, take steps to ensure cost shares are clear.  Sometimes, families are unclear that they have a responsibility to the ABA provider to pay the deductible out of pocket.  If a family has  difficulty paying the deductible, your agency is free to offer a payment plan to extend the payment window but cannot waive any family cost shares.

For many more valuable tips and information on the insurance process, be sure to join Rethink and watch the full recorded webinar.  In the meantime, let us know your own pieces of advice for navigating the insurance world in the comments below, and subscribe to bSci21 via email to receive the latest articles directly to your inbox!

About ABA Billing

With over 25 years of progressive accounting management and software experience, coupled with over 7 years of ABA specific back office functions, ABA Billing offers top-notch, personal touch billing services to ABA providers as affordable rates.  We are a service organization built on the motto of having a “Helper’s Heart” – believing strongly in delivering exceptional customer results. For more information, visit ababilling.net

About Rethink Behavioral Health

Rethink Behavioral Health provides the tools every behavioral health provider needs to manage their practice and deliver quality ABA treatment effectively & efficiently. Rethink’s easy to use web-based software streamlines client care with sophisticated yet intuitive tools for both clinicians & administrators. For more information, visit http://www.rethinkbh.com.

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