If you are paying for your child's ABA yourself, you have a federal right that insured families do not: a written Good Faith Estimate of what the care is expected to cost. It is one of the most useful tools a self-pay family has, and one of the least known. This guide explains what the estimate must include, how it works for a service like ABA that repeats every week, how it compares with the paperwork insured families get, and what you can do if the bill comes in much higher than the estimate.
The rules below come from the No Surprises Act regulations (45 CFR 149.610 and 149.620) and the CMS consumer pages. They are federal rules, so they apply in Florida the same way they apply everywhere else.
Who has the right to a Good Faith Estimate?
You have the right if you are uninsured, or if you have insurance but choose not to use it for this care. The regulation counts a person who has coverage but "does not seek to have a claim for such item or service submitted to such plan or coverage" as a self-pay individual. That matters for ABA, because families self-pay for many reasons:
- your child does not have a diagnosis yet, and insurance-funded ABA usually requires one;
- your plan excludes ABA, which is common in some self-funded and small-employer plans;
- your plan covers ABA but the provider you chose is not in its network, and you decide to pay directly;
- you prefer not to involve your insurer for privacy or other reasons.
If you use your insurance, the Good Faith Estimate rules for self-pay patients do not apply to that care. Insured families rely instead on a benefits check, the plan's prior authorization and the Explanation of Benefits (more on that below).
When should I get the estimate?
CMS sets the timing by how far ahead you schedule:
- Scheduled 3 to 9 business days ahead: you get the estimate within 1 business day.
- Scheduled 10 or more business days ahead: you get it within 3 business days.
- Scheduled 0 to 2 business days ahead: you are not entitled to one for that visit.
- Just asking, not scheduling yet: if you ask before you schedule, the provider must give it to you within 3 business days.
You can ask for the estimate on paper or by email, whichever you prefer. The practical tip: ask early, before the first assessment, so you can compare it with other options and plan your budget.
What must a Good Faith Estimate include?
Under 45 CFR 149.610, the estimate is a formal document, not a quick quote over the phone. It must include:
- your child's name and date of birth;
- a plain-language description of the main service (for example, ABA assessment and treatment) and the scheduled date, if there is one;
- an itemized list of the expected items and services, with diagnosis codes, expected service codes and expected charges for each;
- the name, National Provider Identifier and Tax Identification Number of the provider, and where the services are expected to happen;
- a list of related services that would need to be scheduled separately, with a disclaimer about them;
- a disclaimer that the estimate is only an estimate and actual charges may differ;
- a disclaimer about your right to dispute the bill if charges are substantially higher, and where to find information on that process; and
- a disclaimer that the estimate "is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services."
For ABA, the service codes are usually the adaptive behavior CPT codes, such as 97151 for the assessment and 97153 for direct treatment. If the codes on your estimate are unfamiliar, see ABA billing codes explained.
How does the estimate work for ongoing ABA?
ABA is a recurring service, often several sessions a week for many months. The regulation allows one estimate to cover recurring services, but "the scope of a good faith estimate for recurring primary items or services must not exceed 12 months." After that, you should receive a new estimate.
A good ABA estimate should make the assumptions clear, because the total depends on them. Look for:
- the assessment and how many units it is expected to take;
- direct therapy hours per week and the number of weeks covered;
- BCBA supervision and treatment plan updates (often a different code from direct therapy);
- parent training sessions;
- reassessments during the period.
Plans change. After the assessment, the BCBA may recommend more or fewer hours than first expected. If the provider "anticipates or is notified of any changes to the scope" of the estimate, it must give you a new one no later than 1 business day before the changed services are scheduled. Ask for the updated estimate whenever the recommended hours change.
One more detail: an estimate lists charges for a single provider or facility. If your child also sees a separate evaluator, speech therapist or another provider, each one gives its own estimate.
How does a Good Faith Estimate compare with what insured families get?
Parents who switch between self-pay and insurance often mix these documents up. Here is how they differ.
| Document | Who gets it | When | What it tells you | What you can do with it |
|---|---|---|---|---|
| Good Faith Estimate | Uninsured or self-pay patients | Before care, on request or when scheduling 3+ business days ahead | Expected charges, itemized, with codes, for up to 12 months of recurring care | Budget, compare providers, and dispute a bill $400 or more above it |
| Benefits check (verification of benefits) | Insured families | Before care | Whether ABA is covered, prior authorization rules, deductible, copay or coinsurance | Estimate your share; it is not a guarantee of payment |
| Prior authorization approval | Insured families | Before treatment starts, then at each reauthorization | The services and hours the plan approved, for what period | Appeal if hours are cut or denied |
| Explanation of Benefits (EOB) | Insured families | After each claim is processed | What was billed, what the plan allowed and paid, and what you owe | Check for errors and appeal a denied claim |
The key difference: an insured family's protection runs through the plan's contract and appeal rights. A self-pay family's protection runs through the estimate and the federal dispute process. See what a benefits check covers and how to appeal an ABA denial for the insured side.
What if the bill is much higher than the estimate?
You can use the federal patient-provider dispute resolution process if:
- the provider charged you $400 or more above its Good Faith Estimate; and
- you file within 120 calendar days (about 4 months) of receiving the first bill with those charges. CMS describes this as a bill dated within the last 120 days.
Filing costs a $25 non-refundable administrative fee. You can start online, or by mail or fax using the CMS form. An independent third party then reviews the bill and decides an appropriate payment. While the dispute is pending, the provider cannot move the disputed bill into collections or threaten to do so, and under 45 CFR 149.620 it must suspend late fees on it until the process ends. You must have the estimate to file, which is why you should keep every version. If you lose one, ask the provider for a new copy; providers must give you copies of estimates issued within the last 6 years.
An example, for illustration only: suppose an estimate lists a total of amount X for six months of therapy, and the final bills from that provider for the same period add up to X plus 500 dollars. The difference is more than 400 dollars, so you could file a dispute within 120 days of receiving the bill. If the difference were 300 dollars, the federal dispute process would not apply, though you could still ask the provider to explain the charges.
Questions about estimates or disputes go to the CMS No Surprises Help Desk at 1-800-985-3059.
Checklist: what to ask before you sign up for self-pay ABA
- Can I have a written Good Faith Estimate, by email or on paper, before the assessment?
- Which services, codes and units does it assume, and how many hours per week of direct therapy?
- Does it include supervision, parent training and reassessments?
- What period does it cover (up to 12 months)?
- Will you send a new estimate if the recommended hours change after the assessment?
- Is there a sliding scale or payment arrangement, and is it reflected in the estimate?
- Are there other providers involved who will send their own estimates?
Two related points. First, an estimate does not lock you into treatment; it is "not a contract." Second, a provider cannot simply agree to bill your insurer and skip your share; Florida law treats a general practice of waiving copays and deductibles as insurance fraud (see why providers can't waive copays). Self-pay with an honest estimate, or insurance with your usual cost share, are the two clean paths.
Can I use the estimate for an HSA or FSA?
The estimate itself does not decide whether ABA is a qualified medical expense. IRS Publication 502 says you can include "amounts you pay for therapy received as medical treatment," and therapy prescribed to treat a diagnosed condition generally fits. Your HSA or FSA administrator may want receipts and a letter of medical necessity. Ask the administrator or a tax professional before you rely on it. More in using an HSA or FSA for ABA.
Self-pay at Hope Center
Hope Center offers self-pay for all of its services, and a diagnosis is not required to self-pay. A sliding scale can help with costs. We do not publish a fixed price list, because the amount depends on the service, the hours and your situation. If you are considering self-pay, ask us for a written Good Faith Estimate and we will walk you through it. Read how our sliding scale and self-pay work and what ABA costs without insurance, see insurance at Hope Center, or contact us or call 561-337-8865.