Copayments, Coinsurance, & Cost Share

Copayments, Coinsurance, and Cost-Sharing Policy

PURPOSE

To establish a uniform policy and procedure for the collection, documentation, and application of copayments, coinsurance, and other cost-sharing amounts required by insurance plans or funding sources. This policy ensures compliance with federal and state regulations, ethical billing practices, and financial transparency for families and stakeholders receiving Applied Behavior Analysis (ABA) services.

SCOPE

This policy applies to all clients receiving ABA services through the Company who are covered under insurance plans or third-party payers requiring cost-sharing responsibilities. This includes Medicaid managed care and private commercial insurance.

POLICY STATEMENT

Clients and/or their financially responsible parties are required to pay any applicable copayments, coinsurance, and deductibles as stipulated by their individual insurance plan or funding source. The agency will verify coverage, inform families of their financial obligations, and collect payments in accordance with applicable laws, contractual agreements, and ethical guidelines.

DEFINITIONS

• Copayment (Copay): A fixed amount set by the insurance plan that the client must pay at the time of service.
• Coinsurance: A percentage of the total allowed amount of the service that the client must pay after deductibles are met.
• Deductible: The amount a client must pay before the insurance plan begins to cover costs.
• Cost-Sharing: Any amount not covered by the funding source and designated as the client's responsibility.

PROCEDURE

1. Insurance Verification and Confirmation of Patient ID

   The organization shall verify each client's eligibility and active coverage status prior to the initiation of services, at regular intervals during the authorization period, and before the submission of claims. Eligibility verification shall be completed through the secure provider portal, electronic verification system, or other approved verification method established by the insurance payer or managed care organization with which the client is affiliated. Verification activities shall include confirmation of active coverage dates, member identification information, authorization requirements, payer-specific limitations, coordination of benefits, and any applicable service restrictions related to behavior analysis services. Documentation of the eligibility verification process, including the date of verification, name or identification of the staff completing the verification, payer source utilized, and relevant confirmation details, shall be maintained in the client record in accordance with organizational policy, payer requirements, and applicable state and federal regulations.

   Following verification, the Billing Department will also determine copay, coinsurance, and deductible responsibilities. Families will receive information detailing their cost-sharing obligations.

2. Collection of Payments

   • Copays must be paid on the day of service or in accordance with a prior arrangement made with the company.
   • Invoices for coinsurance and deductible balances will be sent monthly.
   • Accepted payment methods include credit/debit cards, checks, and electronic bank transfers. Cash payments must be coordinated directly with the company.
   • Payment arrangements may be available.

3. Non-Payment

   Accounts past due by 30 days will receive a first reminder notice. The company will make active efforts to collect the monies owed.

Financial Hardship Policy

Families may request consideration for financial hardship, subject to the terms and limitations set forth by the payer. Some insurance plans do not permit waiver or reduction of copayments; these restrictions will be strictly observed. Each request will be reviewed on a case-by-case basis by the Billing and Compliance Department.

Note: For Medicaid clients, providers are prohibited from billing clients directly for Medicaid-covered services, in accordance with 42 CFR § 447.15. Copayments may not be collected unless expressly permitted by the Medicaid plan.

COMPLIANCE AND AUDITING

The Billing Department will conduct internal reviews quarterly to ensure copay collection aligns with payer contracts.

REFERENCE IN PAYMENT CONTRACT

All clients and/or their financial representatives must acknowledge responsibility for copayments, coinsurance, and other cost-sharing amounts in the Payment Contract for Services, which references this appendix.