Insurance Coverage for ABA Services
A knowledgeable healthcare consumer equals an empowered consumer.
Carpe Diem Intellectus has years of experience dealing with commercial health insurance benefit plans and associated payers. Our experience, coupled with our centralized Client Access Center and billing function provides you an advantage when trying to understand your health plan ABA benefits. Choosing an ABA provider is key to your child’s future. Understanding your ABA insurance benefit is key to your financial health.
Carpe Diem Intellectus participates in many commercial health insurance plans and we believe our role is to assist you in fully understanding your plan specifics so that you may make the best-informed decision about the services you choose.
Our Client Access Center team will assist you through the process of initial verification of benefits, admission paperwork, assessment scheduling, payer authorization, and in fully understanding your financial liability. When your plan changes due to a new job or employer annual open enrollment, we are here to help you during the process to ensure continued services.
WE ACCEPT MOST MAJOR INSURANCE PROVIDERS
Common terms related to insurance coverage include the following. We will help you understand what they mean to you through the intake process.
Benefit: the amount payable by the insurance company to a provider for ABA therapy costs.
Benefit level: the maximum amount that the health insurance company has agreed to pay for a covered ABA benefit.
Claim: a request by the ABA provider for the insurance company to pay for services.
Coinsurance: the amount you pay to share the cost of covered services after your deductible has been paid. The coinsurance rate is usually a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%.
Copayment: one of the ways you share in your ABA service costs. You pay a flat fee for certain expenses (e.g., $10 for every day of service), while your insurance company pays the rest.
Deductible: the amount of money you must pay each year to cover eligible medical expenses before your insurance policy starts paying.
Explanation of benefits: the health insurance company’s written explanation of how a medical claim was paid. It contains detailed information about what the insurance paid and what portion of the costs is your responsibility.
In-network provider: an ABA provider that is part of a health plan’s network of preferred providers. Generally, you pay less for services received from in-network providers because of negotiated rates.
Network: the group of providers that insurance companies contract with to provide services at discounted rates.
Out-of-network provider: an ABA provider that is not part of a health plan’s network of preferred providers. Generally, you pay more for services received from out-of-network providers.
Out-of-pocket maximum: the most money you will pay during a year for coverage. It includes deductibles, copayments, and coinsurance, but is in addition to your regular premiums. Beyond this amount, the insurance company will pay all expenses for the remainder of the year.
Payer: the health insurance company whose plan pays to help cover the cost of your services.
Provider: any ABA clinician or paraprofessional that provides ABA services.
The total cost to a family is based upon services rendered, such as: the assessment and report writing, Behavior Technician or BCBA direct therapy, supervision, and semi-annual reassessments and report writing, as required by the insurance company.
Payment for services is expected following the receipt of the insurance company-issued Explanation of Benefits. Butterfly Effects provides for an electronic invoice based upon the insurance company payment. Families have seven days to ask for clarification of the invoice before charges are rendered. A web-based portal is accessible 24 hours/day to conveniently make a payment. Private pay rates are also available through the Client Access Center.
Costs for ABA services are eligible for Flexible Spending Account (FSA) and Health Savings
