Most cost articles stop at "it depends on your plan." This one does the arithmetic. Below are four worked examples, a PPO with coinsurance, an HMO with a daily copay, a high-deductible plan and TRICARE, that show when a family reaches the out-of-pocket maximum and why the date your plan year resets matters so much for ABA.
Every dollar figure in the examples is made up for illustration. They are not Hope Center prices, not insurer rates and not a quote. Your own numbers come from your plan's Summary of Benefits and Coverage (SBC) and from a benefits check. For the bigger picture on cost, start with how much ABA costs in Florida.
Which numbers in my plan decide what ABA costs me?
Five numbers do almost all the work. Find each one in your SBC or plan booklet before you try any math.
- Allowed amount. The rate your plan has agreed to pay an in-network provider for each 15-minute unit of each ABA code. Your share is figured from this number, not from the provider's full charge. Your Explanation of Benefits (EOB) shows it for every claim; see reading ABA codes on your EOB.
- Deductible. What you pay before the plan starts sharing costs. Ask whether ABA falls under the deductible at all; some plans apply a copay to behavioral health visits without a deductible.
- Coinsurance or copay. Coinsurance is a percentage of the allowed amount (for example 20%). A copay is a flat amount per visit or per day. Ask how your plan counts a "visit" for ABA, because a child may have several codes billed on one date.
- Out-of-pocket maximum. The most you pay for covered, in-network care in a plan year. HealthCare.gov notes that premiums, out-of-network care and services your plan does not cover do not count toward it.
- Plan year start date. Deductibles and out-of-pocket totals reset when the plan year starts. Many plans reset on January 1, but some employer plans use another month. Your SBC shows the coverage period.
For Marketplace plans, HealthCare.gov sets the out-of-pocket limit for 2026 at "No more than $10,600 for an individual or $21,200 for a family," rising to $12,000 and $24,000 for 2027. Employer plans set their own limits, often lower.
Why does ABA reach the out-of-pocket maximum so often?
ABA is billed in 15-minute units, several days a week, often for months. A child with a weekly program produces many claims, so the allowed amounts add up quickly. That is why the out-of-pocket maximum, not the deductible, is usually the number that decides a family's yearly cost.
Florida law adds one protection. In plans covered by the state autism mandate (fully insured large-group plans, group HMOs and the state employee plan), coverage "may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable" than those for physical illnesses the plan generally covers (s. 627.6686(5)). So the plan cannot give ABA a harsher deductible than medical care. Self-funded employer plans follow their own documents and federal parity rules instead; see fully insured vs self-funded plans.
Example 1: a PPO with a deductible and 20% coinsurance
Illustrative numbers only. Say the plan has a $2,000 deductible, then 20% coinsurance, with a $6,000 in-network out-of-pocket maximum for your child. Say your child's approved ABA produces $3,000 in allowed amounts each month, and the plan year starts January 1. We also assume no other medical bills for your child that year, which in real life would count toward the same totals.
| Month | What you pay that month | Running total |
|---|---|---|
| January | $2,000 deductible plus 20% of the remaining $1,000 = $2,200 | $2,200 |
| February to July | 20% of $3,000 = $600 a month | $5,800 by end of July |
| August | $200, then the maximum is reached | $6,000 |
| September to December | $0 for covered in-network ABA | $6,000 |
The yearly cost in this example is $6,000 no matter how many approved hours your child gets after August. The pain is front-loaded: January is the most expensive month by far.
Example 2: an HMO with a copay per day
Illustrative numbers only. Say an HMO charges a $30 copay per day of ABA, with no deductible for these visits and a $4,000 out-of-pocket maximum. Your child has ABA 21 days a month.
- Each month: 21 days x $30 = $630.
- After six months (January to June): $3,780.
- July: $220 more, and the maximum is reached.
- August to December: $0 for covered in-network ABA.
The yearly cost here is $4,000, spread more evenly than in the PPO. One question changes this math a lot: does the plan charge one copay per day, or one per code or per visit? If a direct therapy session and a parent training session on the same date each draw a copay, the monthly figure goes up and the maximum arrives sooner. Ask the plan, and ask for the answer in writing.
Example 3: a high-deductible plan (HDHP) with an HSA
ABA is not preventive care, so in a high-deductible plan the deductible applies first. The State of Florida's 2025 HDHP booklet, for example, lists autism treatment at "80% of Allowed Amt after CYD" in network, meaning the plan pays 80% after the calendar-year deductible.
Illustrative numbers only. Say the deductible is $3,400, then 20% coinsurance, with a $7,000 out-of-pocket maximum. Allowed amounts are again $3,000 a month.
| Month | What you pay that month | Running total |
|---|---|---|
| January | The full $3,000 (all of it goes to the deductible) | $3,000 |
| February | $400 to finish the deductible, plus 20% of $2,600 = $920 | $3,920 |
| March to July | $600 a month | $6,920 by end of July |
| August | $80, then the maximum is reached | $7,000 |
An HDHP costs more early in the year but lets you pay with pre-tax HSA money. If you expect to reach the maximum every year, the HDHP's total yearly cost (premiums plus the maximum) may be close to, or higher than, a lower-deductible plan. Compare both totals at open enrollment; see using an HSA or FSA for ABA and the open enrollment checklist.
Example 4: TRICARE
TRICARE's Autism Care Demonstration says "All ABA services rendered on one day will be subject to one copayment," and those costs count toward the plan's catastrophic cap. The copay amount and the cap depend on your TRICARE plan and sponsor status, so we do not invent a figure here. The math works like Example 2: one copay times the number of ABA days, until the catastrophic cap is reached. See TRICARE Prime vs Select costs for ABA and the TRICARE ACD guide.
Why does the January reset matter so much?
Because ABA often reaches the maximum, starting late in a plan year can mean paying a big share twice. Illustrative: with the PPO in Example 1, a child who starts in October would cost $2,200 in October and $600 in each of November and December, for $3,400. On January 1 the deductible and maximum reset, and January costs $2,200 again. The family pays $5,600 in four months across two plan years.
You cannot schedule a child's needs around a plan year, and you should not delay care your child's doctor and BCBA recommend just to save money. But knowing the reset date helps you plan:
- Set aside money, or HSA or FSA funds, for the first months of a new plan year.
- If you change jobs or plans mid-year, your totals usually start over with the new plan.
- If two parents have coverage, the second plan may pick up part of what the first leaves; see coordination of benefits with two plans.
- Ask whether your plan has a family deductible and family maximum, and how a single child's spending counts toward them.
Which plan type costs less for ABA? A comparison
| Plan design | Early-year cost | Predictability | Watch for |
|---|---|---|---|
| PPO, deductible plus coinsurance | High until the deductible is met | Medium; monthly bills vary with units billed | Out-of-network care does not count toward the in-network maximum |
| HMO, copay per day or visit | Moderate | High, if one copay per day | Copay per code or per visit; referral and network rules |
| HDHP with HSA | Highest; full allowed amounts until the deductible | Low early, then like a PPO | Premium savings vs the larger deductible; HSA funding |
| TRICARE | One copay per ABA day | High | Plan type and sponsor status set the copay and catastrophic cap |
A checklist before you estimate your own costs
- Get your SBC and note the deductible, coinsurance or copay, out-of-pocket maximum and plan year dates.
- Ask the plan whether ABA is under the medical or behavioral health benefit, and whether the deductible applies.
- Ask how copays are counted for ABA: per day, per visit or per code.
- Confirm the provider is in network; out-of-network spending may not count toward your maximum. See in-network vs out-of-network ABA.
- Ask the provider for an estimate of monthly allowed amounts based on the recommended hours, once the plan is written.
- Add any other medical costs your child will have that year; they share the same deductible and maximum.
A note on copays: a provider cannot simply agree not to bill your share. In Florida, a provider that makes a general practice of not collecting deductibles or copayments can be committing insurance fraud under s. 817.234(7)(a). Hardship help and payment plans are different; see why providers can't routinely skip copays.
How Hope Center helps you work out your numbers
Hope Center for Behavior Change offers a free benefits check before services start. We confirm your plan's ABA benefit, deductible, cost-sharing and out-of-pocket maximum, and explain what your share is likely to be. Your actual costs depend on your plan. If the deductible or copays are a strain, we offer a sliding scale to help with deductibles and copays, and self-pay for all services. Start with insurance at Hope Center, request a free benefits check or call 561-337-8865.