What You Need to Know About ABA Therapy Insurance
For many families, navigating insurance for ABA therapy can feel overwhelming, making it tempting to put it off. But here’s the good news—you are not alone. With the right information and support, securing coverage for ABA therapy can be manageable and, more importantly, life-changing for your child.
At Stride Autism Centers, we understand how daunting this can feel, and we’re here to walk this journey with you. Let’s break it down, step by step, so you feel empowered and informed every step of the way.
Why Is ABA Therapy Insurance Important?
ABA therapy is an evidence-based intervention that helps children develop communication, social, and daily living skills so they can thrive. Many young children require 25+ hours per week for therapy to be clinically meaningful, making insurance coverage essential for most families.
Applied Behavior Analysis (ABA) is the scientific approach to understanding how learning occurs. It helps children develop skills step by step, enabling steady progress and long-term success. ABA therapy can take place in a clinic or at home, depending on the child’s needs and what works best for the family.
Over the past few years, insurance coverage for ABA therapy has improved significantly. While some policies still have annual caps or exclusions, these plans are becoming fewer and far between.
ABA therapy is evidence-based, and insurance companies see the value of early intervention. Studies have shown that children who receive appropriate ABA therapy early may require fewer services as they get older, making it a cost-effective approach for insurance companies in the long run.
So, if you have heard stories from friends about coverage being challenging, take heart—things have improved a lot.
Key Benefits of ABA Therapy Insurance Coverage:
- Access to Care: Insurance helps make intensive ABA therapy more affordable by reducing out-of-pocket expenses.
- Legislation Support: Many states require insurance companies to cover ABA therapy for autism, expanding availability.
- Encouraging Changes: More policies are removing restrictive coverage caps to expand access to families.
One of the most important things you can do is to review your insurance policy carefully. While ABA providers, like Stride, can help clarify benefits, it’s essential for families to understand their insurance coverage, especially for ABA therapy.
Key Insurance Terms Every Parent Should Know
Insurance language can feel like a foreign language at times, but understanding a few key terms can make all the difference in feeling confident when discussing coverage.
- Deductible: The amount you must pay before insurance starts covering costs.
- Co-Pay/Co-Insurance: The portion of costs you are responsible for after meeting your deductible.
- Pre-Authorization: Approval required before therapy can begin.
- In-Network vs. Out-of-Network Providers: An In-Network Provider is a medical practice or clinician who has a contract with your insurance company. Using an in-network provider, your out-of-pocket costs (such as copays, deductibles, and coinsurance) are typically lower. On the other hand, an Out-of-Network Provider does not have a contract with your insurance company. As a result, services may be more expensive, and your insurance may cover a smaller portion of the cost—or none at all—depending on your plan.
- Out-of-Pocket Maximum: The maximum amount you must pay in a benefit year before your insurance covers up to 100% of eligible claim costs. Given the high cost of ABA therapy, many families reach this maximum quickly. Stride offers payment plans, which can make this more manageable.
- Explanation of Benefits (EOB): A statement sent by a health insurance company to the policyholder after a medical service is provided. It is not a bill but rather a summary of how a claim was processed.
Being familiar with these terms allows you to advocate for your child with confidence and reduces the risk of unexpected costs.
How to Understand Your ABA Therapy Benefits:
Review Your Plan Carefully
Look for coverage details under behavioral health services or autism treatment. Be sure to check for any limitations, such as the number of sessions allowed and/or dollar or age caps.
Ask Questions
While many ABA therapy clinics, like Stride, handle insurance coverage determination, it’s not a bad idea to contact your carrier and get smart about your benefits and how things work. Below are some questions you can ask:
- Is there a certain number of hours allowed per benefit year or is it based on medical necessity?
- Are there any age-related restrictions?
- Are there annual or lifetime dollar caps?
- Are there diagnostic requirements/referrals required to begin ABA therapy?
Stay Proactive
Insurance policies often change from year to year. At the start of your new plan year, review updates and call your insurer to confirm if there are any modifications to your ABA/Behavioral health benefits.
If insurance terminology feels overwhelming, don’t hesitate to ask for help. We love helping our families navigate this process and obtain clarification on their benefits.
How to Verify Your ABA Therapy Insurance Coverage
Contact Your Insurance Provider
Call the number on the back of your insurance card and inquire about ABA therapy coverage. If pre-authorization is required, don’t stress—just make sure ABA is a covered benefit and ask about any caps and/or restrictions.
Gather Necessary Documentation
A formal autism diagnosis from a licensed medical provider, for example, an M.D., D.O., or Psychologist. There is variation on what type of medical provider is acceptable to insurance carriers.
In some areas, Nurse Practitioners may issue a diagnosis whereas in other states they may require a Psychologist or another Licensed Physician. Many therapy clinics, like Stride, will contact your prescribing physician for this documentation. We want to make the process as easy as possible for you.
Check Provider Networks
Confirm if your ABA provider is in-network. Many clinics, like Stride, handle the verification process for families. Our goal is to make the experience easy and stress-free.
If you are out-of-network, ask about coverage options or request a list of in-network providers.
Keep your ABA Provider Up to Date on Any Insurance Changes
To ensure your child’s ABA therapy claims are processed accurately and without delays or lapses in service, it’s important to keep the provider informed of any insurance updates. Whether you have primary, secondary, or tertiary coverage, providing the most current insurance details helps prevent denied claims, unexpected bills, or gaps in coverage.
If insurance information is outdated or missing, claims may not be processed correctly, leading to balances that could become your responsibility. Paying attention to these seemingly small details will go a long way in ensuring a smooth and stress-free billing experience.
Common ABA Therapy Insurance Problems and Solutions
Denials for Pre-Authorization
Most clinics, like Stride, have an Authorization Team that works directly with insurers to secure approvals and manage appeals to help you know what to expect.
Limited Coverage
If your policy has restrictions, you may have options to appeal or request extended services based on medical necessity. Sometimes, a letter from your child’s physician can make a big difference in securing additional coverage.
High Out-of-Pocket Costs
Many families benefit from secondary insurance, such as Medicaid, which can help cover out-of-pocket costs.
3 Tips for Getting the Most Out of Your ABA Therapy Insurance
- Keep Detailed Records
Save all communication with your insurance provider, including emails, phone call notes, and paperwork. - Use an Advocate
While not always necessary, some families choose to work with a medical billing advocate for complex claims. Stride’s billing team is also available to help answer ABA therapy insurance questions. - Know Your Rights
State laws and federal mandates, such as the Affordable Care Act, may provide additional protections for ABA therapy coverage. Being informed ensures you can advocate effectively for your child.
How Stride Autism Centers Helps Families with ABA Therapy Insurance
Insurance Navigation Assistance
Stride personally calls families in advance of the start of therapy to review benefits, potential costs, and answer any questions. We also provide a hard copy of the verification of benefits (VOB) for easy reference.
Comprehensive Support
From pre-authorization to claims submission, our team ensures that families can focus on their child’s progress. We are here to support you.
Conclusion: Making ABA Therapy Insurance Work for Your Family
Navigating ABA therapy insurance doesn’t have to be overwhelming. With knowledge, preparation, and the right support, securing coverage can be a smooth process. Stride Autism Centers specializes in helping families navigate ABA therapy insurance so their children can get the care they need.
If you have questions or need guidance, don’t hesitate to reach out. We’re here to support your family every step of the way.
Author: Megan Kanan, Sr. Prior Authorization Specialist
Megan Kanan is the Senior Prior Authorization Specialist at Stride Autism Centers. With over a decade of experience in prior authorizations, she has spent nearly three years helping families navigate insurance and ABA coverage.
Her deep expertise and commitment to excellence ensure that clients receive the best possible guidance and advocacy throughout the process. Passionate about making a difference, Megan works diligently to streamline approvals and remove barriers to care, allowing children to access the services they need.
