ABA therapy often means several sessions a week, so copays, coinsurance and deductibles add up fast. It is natural to ask a provider, "Can you just bill my insurance and skip my part?" Some offices even advertise that you will pay nothing. In Florida, a provider that does this as a routine practice is taking a legal risk, and families can be affected too. This article explains the rule, why it exists, and what real options exist when cost sharing is hard to manage.
What does Florida law say about waiving copays?
Florida's insurance fraud statute, section 817.234, includes this paragraph, (7)(a):
"It shall constitute a material omission and insurance fraud, punishable as provided in subsection (11), for any service provider, other than a hospital, to engage in a general business practice of billing amounts as its usual and customary charge, if such provider has agreed with the insured or intends to waive deductibles or copayments, or does not for any other reason intend to collect the total amount of such charge."
Three parts of that sentence matter:
- "General business practice." The statute targets a routine practice, not a single unusual situation.
- "Usual and customary charge." The problem is billing the insurer a full price while not actually charging the patient that price.
- "Agreed with the insured or intends to waive." An agreement with the family, or even an unspoken plan not to collect, is enough.
The statute also says that in deciding whether a provider has such a practice, "consideration shall be given to evidence of whether the physician or other provider made a good faith attempt to collect such deductible or copayment." It has a narrow exception for bills reduced "as part of a bodily injury settlement or verdict," which does not apply to ordinary ABA billing.
Penalties are serious. Under subsection (11), a violation is a felony, and the degree depends on the value of the property involved: third degree under $20,000, second degree from $20,000 to under $100,000, and first degree at $100,000 or more.
Why is skipping a copay treated as fraud?
It can feel like a kindness, so the reason is worth understanding. Your plan's cost sharing is part of the price your insurer agreed to pay. When a provider bills its full charge but routinely collects nothing from the patient, the real price of the service is lower than the bill says, and the insurer pays on a misleading claim. Cost sharing also affects how people use care, which is part of how plans set premiums for everyone.
Federal programs take the same view. TRICARE's rules (32 CFR 199.9(b)) list "A pattern of waiver of beneficiary (patient) cost-share or deductible" as a type of abuse. The same rule notes that for a legitimate bad-debt write-off, the provider's records should show what efforts were made to collect, when the debt was written off and why. Provider contracts with commercial insurers often address cost sharing as well, so a waiver can also break the provider's contract.
What are the red flags?
Be cautious if any provider tells you:
- "We'll just take whatever your insurance pays."
- "You will never owe anything out of pocket, whatever your plan."
- "We don't bill copays" or "we write off every deductible."
- "Don't mention this to your insurance company."
A practice that ignores billing rules may also have other compliance problems. And if a plan later finds a pattern of waived cost sharing, it can deny or take back payments, which can disrupt your child's services. For other warning signs, see red flags in an ABA provider.
What are the legitimate ways to lower what we pay?
| Option | How it works | What to ask |
|---|---|---|
| Sliding scale | A published or written policy that adjusts what a family pays based on its situation, applied consistently | "Do you have a written sliding-scale policy, and how do I apply?" |
| Payment arrangements | The amount you owe stays the same, but it is spread over time | "Can we set up a written payment arrangement for my deductible?" |
| Hardship review | A documented, case-by-case decision for a family in financial hardship, rather than a routine practice | "Do you have a financial hardship policy, and what documents do you need?" |
| HSA, FSA or HRA funds | Pre-tax money used for qualified medical expenses | Ask your plan administrator whether ABA qualifies and whether a letter of medical necessity is needed |
| Choosing a plan with ABA in mind | Comparing deductibles and out-of-pocket maximums at open enrollment | See the open enrollment checklist |
| Self-pay with a Good Faith Estimate | Paying the provider directly, with a written estimate of expected charges | "Can I have a Good Faith Estimate in writing?" |
A few notes on these options:
- Your out-of-pocket maximum is your ceiling. Once you reach it for the plan year, an in-network covered service generally costs you nothing more until the year resets. Knowing that number helps you plan.
- Hardship decisions should be in writing. The statute focuses on a "general business practice," and good-faith collection efforts count. A provider's documented, individual hardship decision is different from waiving everyone's cost sharing, but plan contracts and program rules vary, so ask the provider how its policy works.
- Tax-advantaged accounts. IRS Publication 502 does not name ABA, but it allows "amounts you pay for therapy received as medical treatment." Ask a tax professional or your plan administrator. See using an HSA or FSA for ABA.
- Self-pay rights. If you are not using insurance, federal rules give you the right to a Good Faith Estimate of expected charges. See your right to a Good Faith Estimate.
What should I ask a provider about cost?
- "After my benefits check, what will my likely cost be per session and per month?"
- "Will you collect my copay, coinsurance and deductible, and when?"
- "Do you have a written sliding-scale or hardship policy?"
- "Can we set up a written payment arrangement?"
- "If my insurer denies a claim, what happens to my bill?"
Clear, written answers are a good sign. For the overall cost picture, see how much ABA costs in Florida.
How Hope Center handles cost sharing
Hope Center does not routinely skip copays or deductibles, because Florida law and payer rules do not allow it. What we do instead is explain your likely costs before services begin, through a free benefits check, and offer a sliding scale to help families with deductibles and copays. Self-pay is available for all of our services and does not require a diagnosis. Costs depend on your plan, so we talk them through with you individually. Read about our sliding scale and self-pay options, see insurance at Hope Center, contact us, or call 561-337-8865.
This article explains the law in general terms and is not legal advice. Questions about a specific billing arrangement belong with the plan or a Florida attorney.