ABA therapy costs in Illinois are mostly covered by insurance. This is because Illinois is a state that requires commercial insurance plans to cover ABA therapy. At the same time, this does not mean that ABA therapy is free. The patient owes whatever amount the insurance company does not cover.
Below we explain how much insurance will generally cover and what patients in Illinois typically pay out of pocket for a year of ABA therapy. We also explain what factors affect the cost of ABA.
As a general rule, if you have insurance, it likely covers most of your ABA therapy costs. On average, insurance covers 90-95% of the total expenses. Without that level of help, it is difficult to pay for ABA. Therefore, nearly every child we see for ABA has insurance coverage.
While most commercial insurance plans cover ABA therapy costs, there are some self-funded insurance plans that do not. It is common for union healthcare plans to be self-funded. As self-funded plans, they choose whether or not ABA therapy is covered.
Even though insurance generally covers most of the costs, patients still owe out of pocket expenses in the form of deductibles, copays, or coinsurances.
|Deductibles||The amount one must pay on their own before insurance begins covering a portion of medical costs.
|Copays||A daily or per service fee that a minority of insurance plans charge when you come in for therapy (often $20-$50 if your plan has a copay).|
|Coinsurance||After a plan’s deductible is met, insurance plans often cover 70-100% of the ongoing costs. The amount that they do not pay is the coinsurance amount. This is owed by the patient.|
We refer to the total amount paid for any of these costs as “Out of Pocket Costs”. These are dollars paid by you, not your insurance. Most plans set a maximum amount that you would ever pay out of pocket each year for healthcare expenses. This is called an out of pocket maximum amount.
Children receiving ABA typically receive between 10 and 30 hours of therapy each week. At this level of service, the out of pocket maximum on one’s insurance plan is almost always met. In other words, what most people pay for a year of ABA therapy is equal to their plan’s out of pocket maximum amount.
In Illinois plans generally have an out of pocket maximum between $1,500 and $3,000. It follows that most people pay $1500 – $3000 per year for ABA therapy. This does not include a plan’s monthly premiums.
Importantly, out of pocket maximums can be outside the $1,500 – $3,000 average range. The chart below shows all the out of pocket maximum amounts we see at Westside.
As it shows in the chart, we see plans with out of pockets as low as $500 and high as $10,000+, with a lot of variation in between. This means that some rare patients have paid as low as $500 for a year of ABA and a rare few paid over $10,000.
To estimate what you would pay for ABA therapy, you need to look at your insurance plan’s out of pocket maximum. It follows that the lower your out of pocket amount is the lower that you are likely to owe.
At the start of the year, an insurance plan’s deductibles and out of pocket maximums are not yet met. This is the time of year when insurance plans cover the least amount of costs.
Given that kids receive many hours of ABA each week, both deductibles and out of pockets are met quickly. This usually means costs are briefly high at the start of the year. Shortly after, costs drop to zero when the out of pocket maximum is met.
Below is an example of weekly ABA therapy costs for a child receiving 20-25 hours of ABA therapy on a plan with a $3,000 out of pocket maximum.
The first week is expensive! In this example, it costs the patient almost $1,500. In the next week, the cost decreases to $375. This signifies the deductible being met and insurance starting to cover their portion.
After week 5, the out of pocket maximum amount is met. This brings the weekly cost for the remainder of the year to $0. In total the patient pays $3,000 for ABA for the entire year. As you can see, ABA costs are very front-loaded at the start of the year.
To smooth out the costs over the year, it is important to ask to be put on a payment plan. Westside offers payment plans that help families pay a consistent amount every week for the entire year. In this example, under a Westside payment plan, the family owes $58 per week, and there is no cost shock at the start of the year.
Looking at your plan’s out of pocket amount can give you a good idea of the cost of ABA Therapy, but it does not mean that this amount is entirely accurate. Every insurance plan and child can have different:
Westside analyzes plans to see how it affects an individual’s estimated costs. If you are interested, you may request an analysis of your plan’s ABA coverage by calling (815) 469-1500 ext 1.
For the price of your insurance plan’s out of pocket costs, your child receives 500-1500 hours of 1-on-1 ABA therapy specific to their developmental needs. This type of focused support leads to significant improvements in a child’s learning. This is why many families find the benefits far exceeding the costs.
Assuming one’s out of pocket max will be met through ABA, other medical expenses that a child receives may come at no additional costs. Children with autism often present varied deficits in communication, physical strength, feeding, and sensory processing. While receiving ABA therapy, families often incorporate other therapies (speech, occupational, physical, or feeding therapy) to target specific developmental areas. With an out of pocket that is already met, these adding these therapies may accrue no additional costs to the family.