Navigating insurance coverage for ABA therapy can feel like learning a new language. We’re here to deliver clear, straightforward information about the financial aspects of your child’s care.
Let’s talk about the insurance options that cover ABA therapy in North Carolina, including both state-regulated plans and Medicaid. We’ll explain the requirements, coverage limits, and answer those frequently asked questions that keep parents up at night.
Is ABA Therapy Covered by State Insurance in North Carolina?
Yes, state-regulated insurance plans in North Carolina do provide coverage for autism treatment, including ABA therapy. This coverage was established through Senate Bill 676, North Carolina’s autism insurance mandate, which was signed into law in October 2015 and went into effect in July 2016.
According to this legislation, autism insurance coverage is provided under these state-regulated 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)
Beyond ABA therapy for children on the spectrum, these state-regulated insurance plans typically cover several other autism-related services:
- Psychological and psychiatric care
- Occupational, physical, and speech therapy
- Pharmacy care
Under North Carolina law, ABA therapy must be provided by licensed professionals called Board Certified Behavior Analysts (BCBAs). These specialists are trained to develop personalized programs tailored to each child’s unique needs and to monitor their progress throughout treatment.
If you’re curious about the dedicated professionals who provide ABA therapy, we invite you to learn more about our BCBAs at Abacus Therapies. Our interviews with Madeleine Smith and Natalie Schad offer insights into their approach to therapy and why they’ve chosen this meaningful line of work.
Is ABA Therapy Covered by Medicaid in North Carolina?
Since 2014, Medicaid has covered ABA therapy in North Carolina, making this essential service accessible to more families.
According to guidelines from the Centers for Medicare and Medicaid Services (CMS), all states must cover autism therapy for individuals under 21 years old when it’s deemed medically necessary. This requirement applies even if state laws don’t extend coverage to adults with autism.
This coverage is provided through Medicaid’s Early and Periodic Screening, Diagnostic, and Testing (EPSDT) program. To qualify, families must either have Medicaid or be eligible to receive it. While family income is typically considered when determining Medicaid eligibility, some children may qualify for the EPSDT program regardless of income level.
The process for accessing Medicaid coverage for autism services requires a licensed clinician to submit the request. For children under 3 years old, requests go to the North Carolina Department of Health and Human Services’ Division of Child and Family Wellbeing.
For children 3 and 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?
Currently, there’s no state or federal law requiring insurance providers to cover ABA therapy specifically for ADHD. Insurers typically only cover ABA therapy for children with a formal autism diagnosis.
If your child has ADHD without an autism diagnosis and you believe ABA therapy would be beneficial, you can ask your clinician to provide an official recommendation explaining why this therapy is medically necessary for your child. Some insurance providers may consider providing partial coverage on a case-by-case basis with this documentation.
Without mandatory insurance coverage, families of children with ADHD may need to explore alternative funding options such as grants, scholarships, or other financial assistance programs available in North Carolina.
Does North Carolina Have Caps on ABA Coverage?
Under state-regulated health insurance plans in North Carolina, the maximum coverage for ABA therapy is $40,000 per year. This coverage is available only for children with autism who are 18 years old or younger.
For Medicaid coverage through the EPSDT program, all children and young adults with autism under 21 years old are eligible. Unlike state-regulated plans, Medicaid’s coverage for ABA therapy doesn’t have a hard cap. However, the state may implement a soft cap or recommend more cost-effective alternative treatments in some cases.
Why Choose Abacus Therapies?
If you’re looking for ABA therapy in Charlotte, North Carolina, Abacus Therapies is here to support your family. Our experienced team specializes in working with children of all ages on the autism spectrum, offering both individualized and group-based programs.
In Charlotte, we provide home-based, school-based, and now center-based ABA therapy for children ages two and up. Our newly opened ABA center offers a warm, supportive environment designed to help children build skills, confidence, and meaningful connections.
We also work directly with your insurance provider to help navigate coverage and handle the necessary paperwork, so you can focus on what matters most — your child’s growth and well-being.
Ready to take the next step? Request a free consultation today, and let’s talk about how we can help your child thrive.