A 20-minute phone call can save weeks of confusion. Member services can tell you whether your child's plan covers applied behavior analysis (ABA), what the plan needs before therapy starts, and roughly what you will pay. The trick is asking the right questions in the right order, and writing down every answer. This page gives you a script to read aloud, a notes sheet to fill in, and what to do with the answers.
One rule before you start: what the representative says on the phone is helpful, but it is not a promise. Your plan documents decide coverage. Health plans say this themselves. The State of Florida's employee PPO booklet, for example, states that "oral and written statements cannot modify the coverage or benefits" it describes. That is why the script ends by asking for answers in writing.
What should I have ready before I call?
- The insurance card. Use the member services number on the back. Some cards list a separate behavioral health or mental health number; if yours does, start there.
- The subscriber's details. The plan will verify the policyholder's name, date of birth and member ID. If you are not the subscriber, the plan may need the subscriber on the line or their permission.
- Your child's details: full name, date of birth and diagnosis as written on the diagnostic report.
- The ABA billing codes. Commercial plans usually describe ABA with CPT codes 97151 to 97158. Having them in front of you helps the representative find the right benefit. Our guide to ABA billing codes explains each one.
- The provider's name and NPI, if you already have a provider in mind. The provider can give you its NPI number.
- A notes sheet (below) and about 30 minutes.
The script, part 1: what kind of plan is this?
Start here, because the answer changes which rules apply. Florida's autism mandate (s. 627.6686, Florida Statutes) reaches group plans from Florida-licensed insurers and HMOs, but not small-employer plans, individual plans or self-funded employer plans. The difference is explained in fully insured vs self-funded plans.
"Hi, I'm calling about behavioral health benefits for my child. Before we start, can you tell me: is this plan fully insured or self-funded? If it is insured, which company issued the policy, and in which state was it issued?"
"Is this plan subject to Florida's autism coverage law, section 627.6686?"
Representatives do not always know the answer to the second question. That is fine. Note what they say and check with HR, who can also tell you how many employees the company has. If the card says UMR, the plan is almost certainly self-funded: UMR's own ABA form calls it "a Third-Party Administrator (TPA) representing all self-insured groups."
The script, part 2: is ABA a covered benefit?
"Does my child's plan cover applied behavior analysis for a diagnosis of autism spectrum disorder? That's CPT codes 97151 through 97158."
"Are there any age limits, hour limits, visit limits or dollar limits on ABA?"
"Are there any exclusions I should know about, for example services that are considered educational?"
"Which settings are covered: home, clinic, school, daycare, the community? Is parent training covered, and can it be done by telehealth?"
Why the setting question matters: many plans limit ABA in a classroom. Aetna's autism policy, for example, notes that "many Aetna plans exclude coverage of educational services," such as ABA during class. Florida's mandate covers ABA for eligible children under 18, or 18 and older and still in high school if diagnosed at age 8 or younger, but plans may still apply network rules and medical necessity review. If your child has Down syndrome without an autism diagnosis, ask specifically about that, because some national insurer policies treat it differently from Florida's mandate. See does insurance cover ABA at school.
The script, part 3: what does the plan need before therapy starts?
"Is prior authorization required for the ABA assessment? Is it required for ongoing treatment?"
"Who handles the authorization: this company, or a separate behavioral health company? What is their phone or fax number?"
"What documents do you need? A diagnostic report, a doctor's prescription or referral, a treatment plan?"
"How long is an authorization usually approved for, and when does it need to be renewed?"
Rules differ by plan. Cigna's behavioral health arm (Evernorth) says on its ABA form that for standard requests the assessment codes 97151, 97152 and 0362T "no longer require prior authorization," while treatment still does. UMR says not all of its plans require prior authorization for ABA, but recommends a pre-determination review "even if Prior Authorization is not needed." UMR also says an IEP or school evaluation is not acceptable as the only proof of diagnosis. Across plans, reauthorization about every six months with progress data is common. The full process is in our prior authorization guide.
The script, part 4: is my provider in network?
"I'd like to check a provider. The name is [provider name] and the NPI is [number]. Are they in network for my specific plan, not just for your company in general?"
"Does my plan have out-of-network benefits for ABA? If so, what do I pay out of network, and can the provider bill me for the difference?"
"If there is no in-network ABA provider who can serve my child, what are my options?"
Networks are plan-specific. A provider can be in network for one employer's plan and not another, even with the same insurer's name on both cards. HMO and EPO plans often have no out-of-network benefits at all. See in-network vs out-of-network ABA and PPO, HMO and EPO network rules.
The script, part 5: what will we pay?
"What is my deductible for this benefit, and how much has been met so far this year? Is it a family deductible, an individual one, or both?"
"After the deductible, is ABA a copay or coinsurance? Is the copay charged per day, per visit or per code?"
"What is my out-of-pocket maximum, and how much has been met?"
"When does the plan year start over?"
ABA is billed in 15-minute units, often several hours a week, so a per-visit copay and a percentage coinsurance can lead to very different monthly costs. Our deductible math guide walks through examples. If your plan is a high-deductible health plan, ask whether you can use a health savings account; see using an HSA or FSA for ABA.
The script, part 6: closing the call
"Can you send me the ABA benefit details in writing, or tell me where they are in my plan documents?"
"Can I have the plan's medical policy or clinical criteria for ABA?"
"May I have your name and a reference number for this call?"
For an employer plan, also ask HR for the Summary Plan Description (SPD) or certificate of coverage. If the answer to any coverage question is "no," ask for the plan language it is based on.
Your notes sheet
| Item | Answer |
|---|---|
| Date and time of call; number dialed | |
| Representative's name; call reference number | |
| Fully insured or self-funded? State issued? | |
| ABA covered for this diagnosis? Codes 97151 to 97158? | |
| Age, hour, visit or dollar limits; exclusions | |
| Covered settings (home, clinic, school, daycare, community, telehealth) | |
| Prior authorization: assessment? treatment? who handles it? contact | |
| Documents required; authorization length | |
| Provider in network for my plan? Out-of-network benefits? | |
| Deductible and amount met; copay or coinsurance; out-of-pocket max and amount met | |
| Plan year start date | |
| Written confirmation requested? Where to find it |
Keep the sheets together with any letters from the plan. If a claim is denied later, notes with dates and reference numbers make an appeal much easier.
What should I do with the answers?
- Answers conflict with each other or with the documents? Call again, ask for a supervisor, and note both reference numbers. The written plan document controls.
- The plan is self-funded and excludes ABA? See how to ask your employer to add ABA.
- ABA is covered but a request is denied later? You have appeal rights. See how to appeal an ABA denial.
- You think a fully insured plan is not following Florida law? The Florida Department of Financial Services Insurance Consumer Helpline is 1-877-693-5236.
How Hope Center can help
You do not have to make this call alone. Hope Center for Behavior Change offers a free benefits check: we contact your plan, confirm whether ABA is covered and what authorization it needs, and explain your likely share in plain language. We are in network with Blue Cross Blue Shield (Florida Blue), Aetna, Cigna (Evernorth), UMR, Personify Health and TRICARE East (Humana Military). Costs depend on your plan, and self-pay with a sliding scale is available. Many parents still like to make their own call with this script so they hear the answers firsthand. Read how our verification of benefits works, visit insurance at Hope Center, request a free benefits check, or call 561-337-8865.