Paying for an Autism Evaluation: Private Pay, Insurance and What to Ask

Two ways to pay

Families and adults looking for an autism evaluation usually run into two payment models. With insurance, the provider bills your health plan and you pay whatever the plan leaves to you, such as a deductible, copay or coinsurance. With private pay, you pay the provider directly, and the scope and price are agreed between you before the evaluation begins.

Neither model is automatically better. Insurance can lower what you pay out of pocket when an evaluation is covered. Private pay can make the cost clear from the start. The right choice depends on your plan, which providers are available to you and how soon you need answers.

This article is general information. It does not give prices, because prices vary by provider and change over time.

What to know about insurance

HealthCare.gov says all Marketplace plans cover mental and behavioral health services as essential health benefits, and that your specific benefits depend on your state and the plan you choose. It also describes parity protections, which generally mean that limits on mental health services, including deductibles, copayments, limits on visits and requirements to get approval before treatment, cannot be more restrictive than those for medical and surgical care.

That still does not tell you whether a particular autism evaluation is covered, or by which kind of provider. Call the number on your insurance card and ask directly. The National Institute on Aging also notes that telehealth coverage varies from state to state, so if the evaluation is by video, ask your insurer or the provider's billing office whether telehealth is covered for it.

• Is an autism evaluation covered under my plan, and for adults as well as children?
• Do I need a referral or approval in advance?
• Is there a list of in-network providers who do these evaluations?
• How much of my deductible is left, and what would I owe?
• Is a video evaluation covered the same way as an in-person one?

Why some practices do not bill insurance

Some practices offer evaluations on a private-pay basis only. When a practice does not bill insurance, there is no plan approval step and no claim to wait on, and the practice and the person agree on what the evaluation will cover and what it will cost before anything is scheduled.

The trade-off is that you pay the full agreed cost yourself. Some people with out-of-network benefits ask their insurer whether they can submit a claim on their own after paying. Whether that is possible, and how much might come back, depends entirely on your plan, so ask before you count on it.

Your right to a Good Faith Estimate

If you are paying for care yourself, a federal protection may help. The Centers for Medicare & Medicaid Services (CMS) explains that, usually, if you are not using health insurance, a provider must give you a good faith estimate of expected charges if you ask for one or schedule at least three business days ahead.

1. 1Ask before you scheduleCMS says you can ask a provider for an estimate before you schedule care, and they must give it to you within three business days.
2. 2Check what it coversThe estimate should be an itemized list of expected charges, given on paper or by email as you prefer. It covers only that one provider and might not include services scheduled separately or provided by someone else.
3. 3Keep itCMS says you need the estimate if you want to dispute a bill. If you lose it, ask for a new copy, and if you did not get one when you should have, you can submit a complaint.

HSA, FSA and sliding scale questions

HealthCare.gov describes a health savings account (HSA) as an account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses, and a flexible spending account (FSA) as an arrangement through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. Which expenses qualify is set by the rules for these accounts and by your plan, so ask your plan administrator whether a private autism evaluation counts before you rely on it. Ask the provider for an itemized receipt either way.

Many people also feel awkward asking about money. It is a normal part of choosing care.

How we can help

Locascio Wellness offers an adult autism evaluation and a child autism evaluation by secure video. Evaluations are offered only to people who are physically located in Pennsylvania, West Virginia or Arizona during appointments. They are private-pay and are not billed to insurance. The cost is given in writing before anything is scheduled, a sliding scale is available, and you have the right to a Good Faith Estimate. Our what evaluations cost page has the details.

If cost is a worry, say so early. Send the short evaluation request form or set up a free 15-minute consultation on our booking page. If someone else asked for the evaluation, such as a school or employer, ask them what they need first so you pay for the right evaluation.

Therapy is a separate service, and insurance may cover it depending on your plan: therapists on our team offer anxiety therapy and child therapy, and our insurance and fees page explains coverage. If you are in crisis, call or text 988, or call 911. Locascio Wellness does not provide emergency services.