The first time ABA was mentioned to us, it came from our paediatrician, and the selling point was that insurance would automatically approve a large number of hours.
I did not know enough to hear that as strange. It sounded like good news. It took me years to work out that what I had been told was not a clinical judgement about my son. It was a statement about what was easy to get approved.
If you are at that appointment now, here is what I would want you to have.
Why the recommendation sounds so certain
It helps to know that the uniformity is structural rather than diagnostic. Most US state autism insurance mandates were written around ABA. A 2020 study of all 51 US jurisdictions found the common pattern includes an annual dollar cap with no restriction on hours or visits, plus a requirement that providers hold BCBA certification.
Your paediatrician has fifteen minutes and needs to send you somewhere today. The pathway that exists, has capacity, and gets approved is the one that gets named. That is not a conspiracy and it is usually not even a strong opinion. It is the path of least resistance, and it can be the right call for your child, but it was not arrived at by ruling out the alternatives.
Questions for the doctor’s office
These are short, fair, and they change what you get back. Pick two rather than firing all of them.
- What else was considered, and why this? This is the question that reveals whether anything else was considered.
- What did you observe in my child specifically that points here?
- What would you recommend if insurance were not a factor? The single most useful question I know. Most clinicians will answer honestly if you make it easy to.
- Who else should assess my child before we commit to a plan?
- Is a referral for speech and OT evaluation reasonable at the same time? Ask for it in writing. A paediatrician referral is what unlocked those services for us, and it is what the insurer eventually had to honour.
That last one matters more than it looks. When we finally got a referral, the carrier tried to contest its validity, and then had to approve what the plan allows. The referral was the lever.
Before you sign anything
A therapy contract is a contract. You are allowed to read it slowly and take it home.
- Hours and how they change. Who decides an increase, and does it need your written agreement?
- Cancellation and attendance policies. What happens when your child is sick or has a bad week? Are there penalties or minimum attendance requirements?
- Notice period to end services, and any fees attached.
- Who is assigned, their qualifications, and what happens when they leave.
- Supervision. Ask for the actual percentage, in writing. The RBT handbook sets a floor of “a minimum of 5% of the hours you spend providing behavior-analytic services each calendar month.” Ask whether they exceed it and by how much.
- Exit criteria. What would completion look like? A plan with no stopping condition is a subscription.
- Recording and observation. Can you watch sessions, and are you permitted to be present?
How to push back without a fight
The framings below got me real answers rather than warnings. The pattern is the same in each: be specific, make it reversible, and ask for a prediction you can check.
Ask for a prediction, not a reassurance
“If we went from 25 hours to 15, what specifically would you expect us to lose, and how would we know within three months?” A general warning is not an answer. A prediction is something you can test.
Propose a trial with a review date
“Can we try this for eight weeks and review it against these measures?” Almost nobody refuses a time-limited trial, and it turns a confrontation into an experiment.
Reallocate rather than reduce
“We would like to move ten of these hours to speech and OT.” That is a different request from wanting less therapy, and much harder to characterise as a parent giving up.
Bring your own data
Write down two weeks of what happens at home. Sleep, eating, refusal, whether your child still does the things they used to enjoy. Clinic data covers the clinic. You are the only person collecting the rest, and it is the half of the picture that nobody else has.
Escalate sideways when the insurer is the obstacle
Direct calls to the carrier produced fast declines for us. What moved things was going through my employer’s HR to the company’s insurance broker, who pressed the carrier. The broker is the carrier’s customer in a way that you are not. Details are in the post on paying for therapy your insurance will not approve.
If you are being told there is no alternative
There is a difference between “this is what we recommend” and “this is all there is.” The second one is rarely true, and it is worth asking directly which one you are being told.
You are also allowed to get a second opinion, to ask for an OT and speech evaluation before committing to anything, and to say that you want to think about it. None of that makes you an obstacle to your child’s progress, though it can feel that way in the room.
The thing I most wish someone had said to me at that first appointment is this: easy approval is not evidence. It tells you about a benefit structure, not about your child.
