Is ABA Therapy Covered by Insurance in North Carolina?

By Brad Fenton | 28 June, 2024
Abacus Therapies - Is ABA Therapy Covered by Insurance in North Carolina

Under federal and state legislation, various health insurance plans provide coverage for ABA therapy in North Carolina. In this article, you’ll find all the details about the state and federal insurance plans that cover ABA, learn more about their requirements, including age and coverage limits, and find answers to other frequently asked questions about this topic.

Is ABA Therapy Covered by State Insurance in North Carolina?

Yes, state-regulated insurance plans in North Carolina provide coverage for autism treatment and services, including ABA therapy. This is stipulated in Senate Bill 676, North Carolina’s autism insurance bill, which was signed into law in mid-October 2015 and enacted in July 2016.

According to the state law, autism insurance coverage is provided under the following plans:

  • Individual grandfathered plans (purchased before March 23, 2010)
  • Fully insured large group plans (for employers with 51+ employees)
  • Fully insured small group grandfathered plans (50 or fewer employees)

Besides ABA therapy for children with autism, state-regulated insurance plans cover the following services:

  • Psychological and psychiatric care
  • Occupational, physical, and speech therapy
  • Pharmacy care

Under the North Carolina autism insurance mandate, ABA must be provided by state-authorized therapists, known as Board Certified Behavior Analysts (BCBAs). These therapists are trained to devise personalized programs for autistic children and track their progress during treatment.

If you would like to find out more about BCBAs at Abacus Therapies, what exactly they do and why they have chosen this noble profession, we invite you to read the interviews with Madeleine Smith and Natalie Schad.

Is ABA Therapy Covered by Medicaid in North Carolina?

Since 2014, ABA therapy has been covered by Medicaid in North Carolina.

According to the guidelines issued by the Centers for Medicare and Medicaid Services (CMS), all states must cover autism therapy for persons under the age of 21 — as long as it’s deemed medically necessary. This is true even if the state laws don’t provide coverage for autistic adults.

The insurance is provided as part of Medicaid’s Early and Periodic Screening, Diagnostic, and Testing (EPSDT) program. To qualify for the program, families with autistic children must have Medicaid or be eligible to receive it. While the family’s income typically factors into Medicaid’s decisions, some categories of children may be eligible for the EPSDT program regardless of it.

All requests for Medicaid’s autism coverage must be submitted by a licensed clinician. If the child is under 3, the requests are sent to the North Carolina Department of Health and Human Services’ Division of Child and Family Wellbeing. 

If they are 3 or older, the request is submitted to the child’s Local Management Entity/Managed Care Organization (LME/MCO).

Will Insurance Cover ABA for ADHD in North Carolina?

There is no federal or state law that would require insurance providers to cover the cost of ABA therapy for ADHD. Providers will only cover ABA if the child has a proper autism diagnosis.

People seeking ABA therapy in Charlotte or elsewhere in North Carolina without an autism diagnosis can ask their clinician for an official recommendation, which would explain why this therapy is a medical necessity for their patient. This might be enough for some insurers to provide partial coverage for the treatment, but the decisions are made on a case-by-case basis.

In the absence of mandatory insurance coverage, parents of children with ADHD may look for grants, scholarships, and other types of funding available in North Carolina.

Does North Carolina Have Caps on ABA Coverage?

The maximum coverage for ABA therapy under a state-regulated health insurance plan in North Carolina is $40,000 a year. It is only available to autistic children aged 18 and under.

As for Medicaid’s age limitations and coverage caps, all autistic children and young adults under 21 are eligible for the EPSDT program. This program’s coverage for ABA therapy isn’t capped, but the state may enforce a soft cap or recommend a more cost-effective alternative treatment.

Why Abacus Therapies?

If you’re looking for an ABA therapist in Charlotte, North Carolina, Abacus Therapies can help. Our team of highly qualified therapists has years of experience working with autistic children of all ages. 

In Charlotte, we are already providing individual home and school-based ABA therapy for children that are two years old or older. We’re happy to announce that this fall we’ll be opening our first ABA center here and also provide several options for group ABA therapies for children with autism.  

To help you cover the treatment cost, we’ll also contact your insurance provider, and assist you in preparing the required documentation.

Request a free consultation today, and let us guide you and your child towards a brighter future.