Does Medicaid cover ABA therapy in North Carolina?

This is the same question asked a different way. NCDHHS — the North Carolina Department of Health and Human Services — is the state agency that runs NC Medicaid, not an insurer you hold a card for. Your ABA benefit comes through the Medicaid plan NCDHHS has assigned you to, or through NC Medicaid Direct if you are on no plan. Either way ABA is covered, and the answer above applies.

For most families on NC Medicaid the answer is nothing. Medicaid is built without the deductibles, copays and coinsurance that make commercial coverage hard to predict, and children under 21 are covered under EPSDT. Where a plan does apply any cost-sharing, you get the figure in writing before the first session, not on a bill after it.

The name on your child's card tells you. Healthy Blue, Carolina Complete Health, AmeriHealth Caritas and WellCare are Standard Plans. Alliance Health, Trillium, Vaya Health and Partners are Tailored Plans, assigned by county rather than chosen. If the card names none of these, you are most likely on NC Medicaid Direct. We are contracted with all of them, so call 877-262-2221 and we will confirm it rather than leave you reading the card.

EPSDT — Early and Periodic Screening, Diagnostic and Treatment — covers everyone under 21 on Medicaid. It requires medically necessary treatment to be provided even where limits that apply to adult coverage would otherwise cut it short. In practice it is the reason a child's ABA hours are decided by clinical need rather than by a cap.

There is no set number, and any provider quoting one before meeting your child is guessing. The assessment produces a recommendation — commonly 25 to 40 hours a week for a comprehensive program, and 10 to 25 for a focused one targeting specific skills — and the plan approves a figure against it. You will know the approved number before sessions start.

Most families begin within two to four weeks of their first call. The assessment and the authorization set the pace, and both move faster when the diagnosis report is already in hand.

We appeal it, and we do the work. A denial is usually about documentation or the number of hours requested rather than about whether your child qualifies for ABA at all. North Carolina gives you the right to appeal and to ask that services continue while the appeal is decided. We will also tell you plainly if we think an appeal is unlikely to succeed rather than keep you waiting on one.

Yes. ABA delivered in your child's school is covered on the same basis as therapy at home or in a clinic, and it is often where the skills matter most. See how school-based ABA works.

It ended on April 1, 2023. Children covered by Health Choice moved to NC Medicaid automatically, kept their ID numbers, stopped paying enrollment fees and copays, and gained services Health Choice did not cover, including EPSDT. If you are searching for Health Choice ABA coverage, your child is on Medicaid now and ABA is covered.

Children do move between Standard and Tailored Plans, and families move county. Tell us as soon as you know, ideally before the change takes effect. We re-verify and file with the new plan early enough that sessions carry on through the switch rather than pausing while the paperwork catches up.

Yes, and nothing obliges you to leave their list first. Send us the diagnosis report, we will verify the benefits and file a fresh authorization, and you can decide once you have a real start date from each of us to compare.

Virginia Medicaid is a separate program, run by DMAS through Cardinal Care. ABA is covered there too and we accept it, but the plans and the paperwork differ. See ABA coverage through Virginia DMAS or Cardinal Care.

We accept most major commercial insurance as well, including Aetna, Cigna, United Healthcare and Blue Cross Blue Shield. See the full list of plans we accept, or call us and we will check your specific plan.