ABA Therapy Glossaryfor Parents

All terms

In-network vs out-of-network

An in-network provider has a contract with your health plan, while an out-of-network provider doesn't, which usually means you pay more.

What it means

Your plan's network is the group of providers, facilities and suppliers it has a contract with. An in-network provider has agreed to a discount with your plan. So you pay your deductible, copay or coinsurance on the plan's allowed amount. For covered services, an in-network provider can't bill you for the gap between their charge and that amount.

An out-of-network provider has no contract with your plan, and you'll pay more to see one. That provider may bill you for the gap, which is called balance billing. What you spend out of network also doesn't count toward your out-of-pocket limit. Some plans generally won't pay for out-of-network care except in an emergency, while others will but charge you more.

What it looks like for your child

Seeing an in-network provider doesn't mean applied behavior analysis (ABA) is approved. ABA usually also needs prior authorization (your plan's sign-off before care starts). If no in-network ABA provider can see your child, you can ask your plan about a single case agreement. If you see an out-of-network provider, you may be able to file your own claim with a superbill.

A federal law called the No Surprises Act guards against some surprise out-of-network bills, such as from the emergency room. Its list doesn't include therapy at home or in an office.

What to ask your BCBA

  • Ask your plan about the network: Ask your plan whether a provider is in-network for your exact plan.
  • Ask about out-of-network benefits: Ask your plan whether it covers out-of-network care and how that spending counts.
  • Ask about a network gap: If no in-network ABA provider can see your child, ask your plan how to request a single case agreement.

Looking for in-network ABA therapy for your child?

In-network care usually costs you less, though ABA often still needs your plan's approval before it starts.

Get matched with a BCBA
A parent watching their young child play on the floor at home

Sources

Reviewed by
Samantha Ridout, M.Phil., BCBA

Related terms

How costs are shared over a plan year. Labels: one plan year, deductible:, you pay, copay or / coinsurance:, you and the plan / share, out-of-pocket / maximum reached:, plan pays 100% of / covered in-network / benefits, monthly premiums: not counted

Deductible, copay and out-of-pocket maximum

You pay the deductible before your plan starts paying, then usually a copay or coinsurance, up to a yearly out-of-pocket maximum for covered in-network care.

Definition →
How a single case agreement comes about. Labels: family, health plan, out-of-network / provider, request, agreement for one / patient, negotiate terms, in-network cost sharing / for this provider

Single case agreement

A single case agreement (SCA) is a one-time contract between your health plan and an out-of-network provider to cover one patient's care.

Definition →
What a superbill lists and where it goes. Labels: patient, provider tax ID, diagnosis code, CPT code and units, billed amount, place of service, health plan, family, file a claim, explanation of benefits

Superbill

A superbill is an itemized receipt from an out-of-network provider that you can send to your health plan to ask for reimbursement.

Definition →
The parts of an explanation of benefits. Labels: not a bill, service / and date, provider / charges, allowed / charges, paid by / insurer, patient / balance

Explanation of benefits (EOB)

An explanation of benefits (EOB) is a statement your health plan sends after a claim, showing what it paid and what you may owe.

Definition →

Medical necessity and prior authorization

Medical necessity means care is needed to diagnose or treat a condition, and prior authorization is your plan's approval of a service before it begins.

Definition →