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Navigating the world of insurance and Medicaid for your child’s Applied Behavior Analysis (ABA) therapy can be stressful, and one of the biggest concerns for parents is facing unexpected costs. While Medicaid in Colorado, known as Health First Colorado, covers ABA therapy for children with autism, understanding how to avoid unplanned expenses is crucial to making the most of your coverage.
In this guide, we’ll walk you through the steps to minimize unexpected costs and ensure that your child gets the care they need without breaking the bank.
What Does Medicaid Cover for ABA?
The first step in avoiding unexpected costs is understanding exactly what Medicaid covers for ABA therapy. In Colorado, Medicaid covers a wide range of ABA services, including behavioral assessments, direct therapy, and parent training. However, coverage can vary depending on your child’s specific needs, so it’s essential to review your Medicaid plan carefully.
Some tips to ensure full coverage include:
- Confirming eligibility: Ensure your child is eligible for Medicaid, as coverage is only available for those who qualify.
- Understanding service limits: Be aware of any limits on the number of therapy hours or types of services covered under your plan.
- Working with an approved provider: Make sure your ABA provider is Medicaid-approved, as services from non-approved providers may not be covered.
Medicaid typically requires prior authorization before covering ABA therapy. This means your child’s ABA provider must submit a treatment plan that outlines the medically necessary services your child will receive. Without this prior approval, you may end up paying out-of-pocket for services that Medicaid would have otherwise covered.
How Do I Avoid Unexpected Costs?
- Start the authorization process early: Work with your ABA provider to submit the necessary paperwork as soon as possible.
- Ensure all services are included: Make sure the treatment plan includes all services, such as assessments, therapy sessions, and parent training, to avoid gaps in coverage.
- Stay on top of reauthorizations: Medicaid often requires ongoing reauthorization for continued therapy. Keep track of when your child’s current authorization expires to avoid interruptions in coverage.
Can I use any provider I want?
One of the most common reasons families encounter unexpected costs is using providers who are not approved by Medicaid. If you use a provider that is out of network or not approved by Health First Colorado, you could be responsible for the full cost of ABA therapy.
To avoid this:
- Verify provider approval: Always confirm that your ABA provider is Medicaid-approved before starting therapy. Click here for a list of providers.
- Check for network changes: Occasionally, providers may stop accepting Medicaid, so it’s a good idea to verify coverage periodically.
How Do I Coordinate Benefits with Private Insurance?
If you have both private insurance and Medicaid, it’s essential to coordinate benefits properly. Medicaid is considered the payer of last resort, meaning your private insurance must pay its share before Medicaid covers any remaining costs. Failing to coordinate benefits can lead to confusion and unexpected out-of-pocket expenses.
To avoid this:
- Ensure your primary insurance is billed first: Make sure your ABA provider bills your private insurance before Medicaid. Only the remaining balance should be submitted to Medicaid for coverage.
- Obtain prior authorization from both insurers: If both your primary insurance and Medicaid require prior authorization, make sure to submit requests to both. Missing prior authorization from either insurer can result in denied claims and unexpected costs.
- Keep track of deductibles: If you have a high deductible plan, Medicaid may help cover the deductible once your private insurance processes the claim. However, make sure you understand what Medicaid will and won’t cover, so you aren’t left with surprise bills.
How Do I Avoid Gaps in Coverage?
A lapse in Medicaid coverage can result in unexpected out-of-pocket expenses if your child continues to receive services during that time. Whether due to eligibility changes or missing paperwork, gaps in Medicaid coverage can be costly.
Here’s how to avoid coverage gaps:
- Keep Medicaid eligibility up to date: Regularly renew your child’s Medicaid coverage before it expires to avoid lapses in coverage. Medicaid will notify you when it’s time to reapply, so be sure to submit any required documents on time.
- Update your information: If there are changes to your household income or other factors that affect Medicaid eligibility, update your information with Health First Colorado immediately to prevent interruptions in coverage.
How Do I Avoid Billing Errors?
Even with Medicaid, billing errors or miscommunications can lead to unexpected charges. For instance, claims might be denied due to incorrect billing codes or delays in processing, leaving you responsible for costs that should be covered.
To avoid these errors:
- Request itemized bills: Ask your ABA provider for itemized bills to see exactly what services were provided and billed.
- Check Explanation of Benefits (EOB): Review the EOB from Medicaid and your primary insurance to ensure that claims were processed correctly and you’re not being charged for services that should be covered.
- Follow up on denied claims: If Medicaid denies a claim, work with your provider to resolve the issue quickly. Sometimes, denials are due to missing documentation or coding errors, which can often be corrected.
Can I Appeal Denied Coverage?
If Medicaid denies coverage for certain ABA services, don’t assume that you’ll have to pay out-of-pocket. You have the right to appeal denied claims, and in many cases, providing additional documentation or correcting errors can result in the claim being approved.
To avoid paying for denied claims:
- Understand the appeals process: Familiarize yourself with Medicaid’s appeals process so you can act quickly if a claim is denied.
- Gather supporting documentation: Work with your ABA provider to gather medical documentation that supports the need for the denied services.
- Submit appeals promptly: Be sure to submit your appeal before the deadline to increase your chances of success. Click here to file an appeal.
While Medicaid in Colorado offers comprehensive coverage for ABA therapy, unexpected costs can still arise if you’re not careful. By understanding your coverage, obtaining prior authorizations, and coordinating benefits between Medicaid and private insurance, you can avoid many of the financial surprises that parents commonly face.
Bright Pathways ABA Is Here to Help
At Bright Pathways ABA, we’re here to help you navigate the complex world of insurance and Medicaid. Our team works closely with families to ensure ABA services are fully covered and that you’re never caught off guard by unexpected expenses. Contact us today to learn how we can support your family’s ABA journey.
Disclaimer
The information provided in this article is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Bright Pathways ABA does not assume any responsibility for any outcomes or consequences resulting from the use of this information. Always seek the advice of a qualified healthcare provider with any questions regarding a medical condition or behavioral intervention.
