Before your child's first ABA session, Hope Center checks your insurance benefits. This step is called a verification of benefits, or VOB. It is free, and it happens before you commit to anything. This page explains what we ask your plan, what the answers mean, what a benefits check cannot tell you, and how to get the most out of it.
What is a verification of benefits?
A verification of benefits is a check with your health plan to find out what it covers for ABA and what it expects from you and from us. We contact the plan using the information on your insurance card and ask a set of specific questions. Then we explain the answers to you in plain language, so you know what to expect before services begin.
It is step two of our intake. You return the initial documents and complete intake, we verify your benefits, and only then do we request the initial assessment, which is scheduled once your insurer approves that request. The full order is on our intake timeline.
What does the benefits check confirm?
Every plan is different, but these are the questions that matter most for ABA:
| Question | Why it matters |
|---|---|
| Is the plan fully insured or self-funded? | Florida's autism insurance law applies to fully insured large-group plans and group HMOs. Self-funded employer plans follow their own plan documents and federal law instead. |
| Does the plan cover ABA for your child's diagnosis? | Insurance-funded ABA usually requires a diagnosis of autism spectrum disorder or Down syndrome. Some plans cover more, some less. |
| Is prior authorization required? | Most plans must approve the treatment plan before sessions are paid. Some also have rules for the assessment itself. |
| Is Hope Center in network for your plan? | Network status changes what the plan pays and what you pay. |
| What are your deductible, copay or coinsurance and out-of-pocket maximum? | ABA often means many sessions a week, so cost-sharing adds up. These numbers shape your monthly cost. |
| Does the plan need a doctor's prescription or order? | Florida's mandate lets fully insured plans limit coverage to treatment prescribed by the child's treating physician under a treatment plan. |
| Are there visit, hour or setting limits? | Some plans exclude services they consider educational, such as ABA during class time. |
| Is there a second plan? | Plans coordinate benefits. A second plan can change who pays first. |
Why does it matter whether my plan is fully insured or self-funded?
This is the question most families have never heard of, and it often decides whether ABA is covered.
Florida's Steven A. Geller Autism Coverage Act (Fla. Stat. 627.6686, and 641.31098 for HMOs) requires coverage of ABA, speech, occupational and physical therapy for autism and Down syndrome in group plans offered by an insurer licensed in Florida, plus the state employee plan. It does not apply to individual-market plans, individually underwritten plans or plans sold to small employers. It also does not reach self-funded employer plans, which the Florida Department of Financial Services says it has no authority over under federal ERISA law.
The law covers an "eligible individual": a child under 18, or someone 18 or older who is still in high school, diagnosed with a developmental disability at age 8 or younger. Even when the mandate applies, the plan can still use network rules, coordination of benefits and medical-necessity review.
Self-funded plans are common. UMR, for example, describes itself as a third-party administrator for self-insured groups, so a UMR card means the employer's plan document controls. That plan may cover ABA generously, or not at all. The benefits check finds out which. For more on this, see fully insured vs self-funded plans.
Which plans does Hope Center work with?
We work with Blue Cross Blue Shield (Florida Blue), Aetna, Cigna (Evernorth), UMR, Personify Health and TRICARE East (Humana Military). Optum: in network for mental health therapy; for ABA, call us for the current status, and see what this means for Optum members. We do not accept Medicaid or Medicare.
Being on this list does not mean every plan from that company covers ABA. A Florida Blue small-group plan and a Florida Blue large-group plan can have very different benefits. That is exactly why we check.
What does a benefits check not tell you?
A benefits check describes what the plan says about your coverage on the day we ask. It is not an approval and not a promise of payment. Your plan still decides:
- Medical necessity. The plan reviews your child's treatment plan before it authorizes hours. It can approve fewer hours than requested or ask for more information.
- Documentation. Plans set their own rules. UMR's ABA documentation form, for example, says IEPs and school evaluations are not acceptable as the only proof of diagnosis, and asks for current documentation if the diagnostic report is more than four years old.
- Changes during the year. A new job, a new plan year or a change in coverage can change your benefits. Tell us right away, and we will check again.
Your costs depend on your plan, and we will not promise a number until the plan answers. We check your benefits for free and explain your costs before you start.
What do I need to give you for the benefits check?
- A photo or copy of the front and back of every insurance card, including any second plan.
- The policyholder's name and date of birth, and your child's name and date of birth.
- Your child's diagnosis, and the diagnostic report if you have it.
- Whether your plan comes through an employer, the Marketplace, TRICARE or another source. If it comes through work, ask HR whether it is fully insured or self-funded. The answer helps.
Our documents checklist lists everything for the whole intake, not just this step.
How will I hear the results?
Once the plan answers, our team explains what it said: whether ABA is covered, what authorization is needed, and what your deductible, copay or coinsurance and out-of-pocket maximum look like. You can ask questions before you decide anything. Before services start, you sign a benefits verification that shows your costs, so you have them in writing. If you would like the results in a particular format, such as an email you can keep, ask on your first call.
If the numbers worry you, we offer a sliding scale, based on household income and family size, for your share after insurance, and self-pay for all services. We do not routinely skip copays or deductibles: Florida treats a general business practice of not collecting them as insurance fraud (Fla. Stat. 817.234(7)(a)). See our sliding scale and self-pay options.
Should I also call my plan myself?
You can, and some parents like to. It is your plan, and you have the right to ask. Calling yourself helps if the answers we get are unclear, or if you want to ask about things only you can, such as your plan documents (the summary plan description or certificate of coverage). Our insurance call script gives you the exact questions to ask, word for word. Write down the date, the representative's name and a reference number for every call.
What if my plan does not cover ABA?
You still have options. Self-pay is available for all of our services, and it does not require a diagnosis. If you pay yourself, federal rules give you the right to a Good Faith Estimate of expected charges when you ask for one or schedule a service at least 3 business days ahead. At Hope Center, self-pay families get our fee schedule and the recommended hours in writing before starting. Military families may have ABA through the TRICARE Autism Care Demonstration. If your plan through work does not cover ABA, ask HR whether the plan can be reviewed at renewal. The insurance page explains coverage types in more detail.
Ready for your free benefits check?
Send us your insurance card and your child's details, and we will check your benefits before you commit to anything. Request a free consultation and benefits check, call 561-337-8865 or email office@hopecenteraba.com. New to ABA? Our new families page walks you through what comes next.