5 Common Challenges in Getting Insurance Coverage for ABA Services and How to Overcome Them

Applied Behavior Analysis (ABA) therapy is well known for helping individuals with autism develop important skills and improve their overall quality of life. But getting insurance coverage for ABA therapy can be tricky.

How to Make Sense of Your ABA Therapy Insurance Coverage

Insurance policies can vary greatly when it comes to ABA therapy coverage. Some plans may limit the number of sessions, have exclusions or requirements that make it hard to get services. To understand your coverage you need to read your policy, especially the behavioral health, therapy and autism sections. If anything is unclear contact your insurance company and ask for written documentation of what is covered, including types of therapy, session limits and pre-authorization requirements.

It’s also helpful to have an insurance advocate or a professional who is experienced in ABA therapy coverage to help you understand your policy and benefits.

Know the Laws in Your State for ABA Coverage

Several states have laws that require insurance companies to cover ABA therapy, but these laws vary greatly. For example:

• Arizona (AZ): In Arizona most insurance plans must cover medically necessary ABA therapy for individuals under 21.
• Florida (FL): Florida mandates ABA coverage for children up to 21 years old, services are typically reimbursed at a set rate for medically necessary therapy.
• New York (NY): New York requires coverage for ABA therapy and insurers cannot deny coverage based on age, severity of condition or other factors.

If you live in a state with a mandate your insurer may be required to cover ABA therapy. But each state has different laws and rules so be sure to check your state’s mandate and your insurance company to confirm your coverage.

Does Scottsdale Pediatric Behavioral Services (SPBS) Take Your Insurance?

At Scottsdale Pediatric Behavioral Services (SPBS), we currently accept Blue Cross Blue Shield, Cigna and Aetna insurance.

We are constantly working and negotiating with major insurance companies to establish an acceptable rate for all parties, enabling us to offer affordable services to all families.

If you have any questions about insurance coverage, please contact us and we’ll help you understand your policy and guide you through the process of getting ABA coverage.

Pre-Authorization Requests

Many insurance plans require pre-authorization before they will cover ABA therapy. This process can be time consuming and requires a lot of documentation which often leads to delays and complications. To make the pre-authorization process smoother, it’s important to understand your insurer’s requirements and gather the necessary documents such as treatment plans, progress reports and medical necessity statements. Stay organized and communicate clearly with your ABA provider and insurance company to speed up the process.

Don’t give up if your pre-authorization is denied.Take time to review the denial notice and examine the reasons for the denial. If it’s due to missing information or coding errors make the necessary corrections and resubmit. If it’s based on medical necessity you can work with your ABA provider to submit additional documentation to support the need for therapy. Most insurance companies have a formal appeal process so be sure to follow those steps and include any additional information that can strengthen your case.

What to Do When Your ABA Claim is Denied

ABA claims can be denied for errors such as incorrect coding, incomplete information or disagreement on medical necessity. These denials can delay access to services and create financial burden.

If your claim is denied you can start by reviewing the denial notice to understand why the claim was denied. Common reasons are incorrect coding or missing documents. Make sure all claims are coded correctly and have all necessary information before submitting. If the denial is for medical necessity you can work with your ABA provider to provide further evidence that supports the need for therapy. In many cases insurance companies will allow you to appeal the decision. Be sure to submit a formal appeal with any additional documentation and keep detailed records of all communications.

Out-of-Pocket Expenses

Even with insurance coverage many families still face out-of-pocket expenses such as co-pays, deductibles and co-insurance. These expenses can add up quickly especially when therapy is ongoing.To manage these out-of-pocket expenses start by understanding your policy’s cost-sharing requirements including deductibles and co-pays. With this knowledge you can plan and budget for these costs. You may also be eligible for financial assistance programs or sliding scale fees with some ABA providers. If your plan has a Health Savings Account (HSA) or Flexible Spending Account (FSA) consider using pre-tax dollars from these accounts to pay for qualified medical expenses which can help reduce the financial burden.

Finding ABA Providers for Your Insurance

Insurance plans have a network of preferred providers and it’s not always easy to find an in-network ABA therapist especially in areas with limited options. Start by checking your insurance provider’s directory to see if they have in-network ABA therapists. If the directory doesn’t list any options you can contact your insurer to see if they offer out-of-network benefits and what the process is for getting coverage for out-of-network services.

In some cases your insurer may cover out-of-network therapy if you can demonstrate the medical necessity of the service. Your ABA provider may also be able to help you navigate insurance networks and find potential options for coverage.

Insurance Terms to Know

Dealing with insurance policies can be confusing with all the unfamiliar terms. Knowing some of the insurance terms can help you better navigate the process of getting ABA therapy coverage:

• Medical Necessity: Services that are necessary to diagnose or treat a medical condition. For ABA therapy to be covered it must be medically necessary which means it must be required to treat your child’s condition.
• COB (Coordination of Benefits): If your child is covered by more than one insurance plan, Coordination of Benefits ensures that both plans work together to avoid overlap. This determines which plan will be the primary payer and which will be secondary.
• Out-of-Network Exception: Many plans prefer in-network providers but some plans have provisions for out-of-network care. If there are no in-network providers available insurers may allow coverage for out-of-network services if you can prove the need.

Reach Out to Scottsdale PBS Today

While getting insurance for ABA therapy can be tough, understanding the process and knowing how to handle common obstacles can make a big difference. By reading your policy carefully, managing pre-authorizations and appeals, handling out-of-pocket expenses and finding the right providers you can increase your chances of getting the coverage your child needs.

If you need more help or guidance contact us at Scottsdale Pediatric Behavioral Services. Our team can help you navigate the insurance maze and get your child the therapy they deserve.

FAQs

What is ABA therapy and why is it important?

ABA therapy is a behavioral treatment approach that teaches and reinforces desired behaviors. It’s especially helpful for individuals with autism to develop skills such as communication, social interactions and daily living tasks. Research has shown ABA therapy can improve quality of life and promote long-term skill development.

What challenges might I face when trying to get insurance for ABA therapy?

Some common hurdles are:

• Differences in what each plan covers
• Needing pre-approval before services start
• Getting denied and having to appeal
• High out-of-pocket costs
• Trouble finding in-network providers

Dealing with insurance can be frustrating but there are ways to make it more manageable. Start by learning what your plan covers and doesn’t cover and make sure you have the right paperwork ready if pre-approval is needed. If your claim is denied, don’t be afraid to appeal. Sometimes adding more details or documentation can turn things around. For non-covered costs ask your provider about payment plans or look into using a Health Savings Account (HSA). If there are no in-network options nearby you can talk to your insurer about exceptions or ask your ABA provider for help finding alternatives.

How do I understand what my insurance policy covers for ABA therapy?

Read your policy carefully focusing on behavioral health and autism services. If needed contact your insurer and ask for detailed information on covered therapies, session limits and pre-authorization requirements.

What is the role of an insurance advocate in getting ABA therapy coverage?

An insurance advocate can help interpret policy details, navigate pre-authorizations and appeals and provide guidance on maximizing coverage and minimizing out-of-pocket costs. They can help resolve disputes and make sure you understand your benefits.