What your family pays for applied behavior analysis (ABA) therapy depends on the care your child receives and how you pay for it. With insurance, your share comes from your plan's rules for deductibles, copays, or coinsurance. The practice's full charge and the amount your family owes can be different.
A written estimate for your child's assessment and ongoing sessions can help you plan for care. It can show the proposed services, the rates used, and the share your family is expected to pay. If you aren't using insurance, ask the practice for its self-pay rates and expected charges for those services.
Start with the amount your plan uses
For covered care, your health plan uses an allowed amount to calculate its payment and your share. This is the amount the plan recognizes for a service before dividing the cost between you and the plan. It can differ from the practice's full charge.
Network status matters, too. An in-network practice has a contract with your plan. Out-of-network care can have different payment rules and costs. Check the practice against your exact plan when checking ABA insurance coverage.
The services in the estimate also matter. An assessment and treatment sessions may have different charges or coverage rules. An estimate for the assessment alone covers just that part of care. Ongoing sessions need to be included for you to see their expected cost. For help understanding the clinician's proposed schedule, read about how ABA therapy hours are recommended.
How a deductible and coinsurance change the bill
A deductible is the amount you pay for covered care before your plan starts paying for services subject to it. Some services are covered before you meet the deductible. If your plan covers several family members, ask how its individual and family deductibles apply to your child's care and how much remains.
Coinsurance is a percentage of the allowed amount that you pay, usually after the deductible. If you haven't met the deductible, part of a bill may go toward that amount before coinsurance is calculated on the rest.
For example, suppose the allowed charges total $1,000 for covered, in-network services. You have $300 left on the deductible, then pay 20% coinsurance. There is no copay in this example, and your payments stay below the out-of-pocket maximum: the plan-year limit on qualifying costs you pay for covered, in-network care.
Part of the calculation — Amount
Remaining deductible — $300
Charges left after the deductible — $700
20% Coinsurance on that $700 — $140
Total you pay (deductible+coinsurance) — $440
The plan pays the other $560. If the next $1,000 in allowed charges falls in the same plan year, with the deductible now met and the same rules, your share would be $200.
The amounts in your family's estimate will depend on the services proposed for your child and your plan's coverage rules. HealthCare.gov also explains how coinsurance works.
Your plan might use a copay, which is a fixed amount for a covered service. Check whether it applies per visit, per day, or per service, and how it works with the deductible. That detail affects the total when an estimate includes several services.
Why an estimate and a later bill can differ
An estimate reflects the proposed services and the insurance information used to calculate it. The amount of care actually delivered, which services are covered, and the deductible remaining when claims are processed can change the result. A later service can bring additional charges if it was outside the estimate.
If care continues into a new plan year, an updated estimate can account for that year's deductible and other cost-sharing rules.
Once you reach the applicable out-of-pocket maximum, your plan pays 100% of the cost of covered, in-network benefits for the rest of that plan year. Premiums, noncovered care, out-of-network care, and charges above the allowed amount are outside that limit. For a family plan, ask how the individual and family limits apply to your child's care.
Some plans require prior authorization, or approval in advance for specific care. This is your plan's review of whether the proposed care is medically necessary. Authorization does not guarantee payment, so the estimate still needs to reflect your plan's payment rules.
Get an estimate you can use
A written estimate is easier to follow when it shows both the services and your expected share. The practice can explain what care it has included. Your health plan can explain how its rules apply.
Ask the practice what is included
Does this estimate cover the assessment, treatment sessions, or both?
What dates, services, and amount of care does it assume?
Which figures are the full charges, the allowed amounts, and my estimated share?
Is there any proposed service that is outside this estimate or expected to be paid for separately?
Keep the service details with the estimate. They give you and your plan the same starting point for checking the numbers.
Ask your health plan how it calculated your share
Is this practice in network for my exact plan, and are these services covered for my child?
How much of the individual or family deductible remains for this care?
Does a copay or coinsurance apply, and how is it counted across the services in the estimate?
How much remains before the relevant out-of-pocket maximum is reached?
Is prior authorization required for any of these services?
If a figure is unclear, ask the practice's billing team or your health plan to walk through it with you using the services and coverage rules in the estimate.
If you're paying without insurance
For uninsured or self-pay, non-emergency care, providers usually must give you a good faith estimate when you request one or schedule care at least three business days ahead. This estimate lays out expected charges before care. The Centers for Medicare & Medicaid Services (CMS) explains how to get a good faith estimate.
For your child's care, ask whether the estimate includes the assessment, ongoing treatment sessions, or both, and the expected charges for each. Reviewing those details with the practice can help you plan for care.
Getting help with the next step
Headstart's Family Experience team helps families with provider search, coverage checks, and intake. Care is provided by independent practices led by board-certified behavior analysts.
Get Started with ABA to connect with Headstart and work through those next steps.
