Two health plans can have similar monthly premiums but offer very different access to ABA therapy. Your child’s current provider may be in network for one plan but not another, and authorization requirements, behavioral-health networks, deductibles, coinsurance, and out-of-pocket limits can also vary.
That is why the monthly premium should not be the only factor you compare. The better approach is to look at provider access, ABA coverage requirements, and total expected family costs together.
Open Enrollment Quick Start
Before choosing a plan:
- Confirm your enrollment deadline and available plan options
- Check whether your child’s ABA provider is in network for the exact plan, not just the insurer
- Review how ABA benefits and prior authorization work
- Compare the deductible, copay or coinsurance, and out-of-pocket maximum
- Consider all of these factors together before making a selection
Identify Your Enrollment Window and Available Plans
Start by confirming which enrollment period applies to your family. Employer-sponsored plans set their own open enrollment dates, while Marketplace coverage follows a separate schedule.
Confirm your own deadline before comparing plans so you know how much time you have and when the new coverage would begin.
Gather the Exact Plan Details
For each plan you are considering, collect:
- Exact plan or product name
- Plan ID, if available
- Summary of Benefits and Coverage (SBC)
- Provider directory or network information
- Behavioral-health or ABA benefit information, if provided separately
Do not rely only on the insurer name or broad labels such as Gold, Silver, HMO, or PPO. Network participation and ABA benefits can vary by specific plan, so use the exact plan name and ID when checking coverage.
Check the Exact Provider Network
Network verification is one of the most important steps when comparing plans for a child who receives ABA therapy. A provider may participate with one plan from an insurer but not another, even when both plans carry the same company name.
What to Confirm
- Use the exact plan name or plan ID: Do not rely only on the insurer name when checking network status.
- Verify with both the insurer and provider: Check the insurer’s directory, then confirm directly with the ABA provider.
- Ask about behavioral-health networks: Some plans use a separate behavioral-health organization with its own provider network.
- Check out-of-network benefits: If your preferred provider is not in network, ask whether out-of-network ABA services are covered and what cost sharing applies.
- Keep a record: Note the date, phone number, representative’s name, and reference number when confirming network status by phone.
BridgeCare can help verify whether it participates with a specific plan. When contacting the team, provide the exact plan name and plan ID whenever possible.
Compare ABA Benefits and Authorization Requirements
A plan may list ABA as a covered benefit, but the authorization rules and service limits can still vary significantly. After confirming network participation, review how the plan actually handles ABA services.
Questions to Ask
- Is prior authorization required for the initial ABA assessment and for ongoing treatment?
- What diagnostic or clinical documentation is required?
- Is a referral or prescription needed?
- How often is reauthorization required?
- Are there limits on visits, units, or hours?
- If fewer hours are approved than recommended, is an appeal or peer-to-peer review available?
- Are all service settings covered, such as clinic, home, school, or telehealth?
Do not rely only on a simple statement that “ABA is covered.” Confirm the details in the plan’s SBC and full benefit documents whenever possible.
Plans can handle authorization differently even when they are offered by the same insurer.
For a fuller explanation of how authorization and reauthorization typically work, see BridgeCare's guide to ABA insurance coverage and prior authorization.
Look Beyond the Monthly Premium
A lower monthly premium does not always mean a lower total cost, especially when a child receives ABA regularly. Compare the full cost-sharing structure, not just the premium.
What to Compare
- Deductible: What you pay before the plan begins sharing most covered costs. Check whether ABA is subject to the deductible.
- Copay or coinsurance: Your share of the cost for covered services. Depending on the plan, a copay or coinsurance may apply before or after the deductible is met.
- Out-of-pocket maximum: The most you may pay in a plan year for covered, in-network services. Premiums, non-covered services, and most out-of-network costs usually do not count toward this limit.
- In-network vs. out-of-network costs: If your preferred ABA provider is out of network, review whether the plan covers those services and what additional costs may apply.
The Summary of Benefits and Coverage (SBC) is a good starting point, but it may not include every ABA-specific detail. For more information, review the full plan document, such as the Evidence of Coverage, Certificate of Coverage, or Summary Plan Description.
Use a Side-by-Side Plan Checklist
Use this worksheet to compare up to three plans. Fill in each row as you verify information from plan documents and Member Services.
Do not compare plans based only on premium if important network, ABA benefit, or authorization questions are still unanswered.
Keep a Record of Member Services Calls
For each call, note:
- Date and phone number
- Representative’s name
- Reference number
- Exact question asked
- Answer provided
If a verbal answer conflicts with a plan document, ask the plan to identify the specific benefit provision or document that applies and request written clarification when possible.
Confirm Answers Before Making a Selection
Open enrollment decisions are often made with imperfect information. Provider directories may be outdated, plan documents can be complex, and verbal answers may not always be complete.
Before choosing a plan:
- Confirm network participation, ABA coverage, authorization requirements, and cost sharing using the plan’s own documents and Member Services.
- Ask specific questions rather than accepting a general statement that “ABA is covered.”
- Verify network status directly with the ABA provider.
- If an answer is unclear or conflicts with a plan document, ask the plan to identify the specific benefit provision or document that applies and request written clarification when possible.
- Ask the new plan whether an existing ABA authorization will be honored during the transition or whether a new authorization is required before services continue. Transition-of-care rules vary by plan.
BridgeCare does not choose a health plan for families. The enrollment decision remains with the family and, when applicable, the employer or Marketplace.
After enrollment, BridgeCare can help verify ABA benefits, network status, and authorization requirements for the selected plan.
Comparing Plans for the New Coverage Year?
BridgeCare can help families:
- Verify whether a specific plan includes ABA benefits
- Confirm provider network status
- Review authorization requirements
- Explain next steps before services begin
Contact BridgeCare with the exact plan name or insurance card details.
Benefit verification does not guarantee payment or authorization, which depend on the specific plan and clinical review.
