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Does HealthyBlue Cover ABA Therapy in North Carolina?

Parents of children with autism spectrum disorder (ASD) have a lot to juggle. Their children often have special needs and support services, and all of that must be incorporated into the family’s daily routine.

Aside from the simple logistics of this, treatment plans for ASD can often be very intensive and, as a result, expensive. For instance, applied behavior analysis (ABA therapy), which is considered the gold standard treatment for children with autism, often requires 25 hours or more of therapy per week.

Many health insurance plans help parents shoulder the burden of this cost by providing coverage that is often mandated by the state.

In this article, we’ll discuss whether HealthyBlue covers ABA therapy in North Carolina, as well as some of the requirements that go along with that coverage.

Learn more about insurance coverage for ABA Therapy
Learn more about Insurance coverage for ABA Therapy in North Carolina

Table Of Contents

What is HealthyBlue?

HealthyBlue is simply the name that’s given to the health insurance plans that are offered through Medicaid in North Carolina. They provide coverage for things such as doctor visits, prescriptions and vision care, as well as other free extras such as smoking cessation and healthy eating programs, and rides to the pharmacy and doctor.

There are various ways that one can become eligible for a HealthyBlue plan in North Carolina, such as if they meet certain resource and income guidelines, are pregnant, under the age of 21, over the age of 65, have a disability, or are a low-income individual or in a low-income family.

Topic Details
Does HealthyBlue Cover ABA Therapy? Yes, subject to plan-specific details
State Mandate Effective Date July 1, 2016
Coverage Age Limit Up to 19 years old
Annual Coverage Cap $40,000
Eligibility Requirements ASD diagnosis, medical necessity letter, approved provider, treatment plan, ongoing reports

Does North Carolina Mandate Coverage for Autism?

On July 1, 2016, North Carolina’s autism insurance bill went into effect. It requires meaningful coverage for various autism-related coverage by any insurance plan that is regulated by the state.

This includes individual grandfathered plans, fully insured large group plans and fully insured small group grandfathered plans. The only types of insurance to which the state law doesn’t apply are individual non-grandfathered plans and fully insured small group non-grandfathered plans.

Under the law, all required plans must provide coverage for ABA therapy; psychiatric and/or psychological care; physical, occupational and/or speech therapy; pharmacy care and more.

The coverage is limited to people who are 19 years old or younger, with an annual cap of $40,000.

Does HealthyBlue Cover ABA Therapy in North Carolina?

The short answer is that yes, HealthyBlue covers ABA therapy in North Carolina. Whether your plan offers coverage, and what type of coverage it offers, depends on the individual plan you are subscribed to.

That’s why it’s always important to read through your plan documents to discover what coverage you’re eligible for. If you have any questions about it, you can also contact an administrator at HealthyBlue to find out more.

Generally speaking, though, HealthyBlue’s insurance plans are subject to North Carolina’s autism insurance law, which means they have to provide coverage for autism-related services.

Requirement Covered by HealthyBlue Notes
ASD Diagnosis ✅ Must be from a qualified professional
ABA Therapy ✅ Subject to plan details and documentation
Age Limit ✅ Covered until age 19
Annual Coverage Cap ✅ $40,000 cap
Documentation Needed ✅ Diagnosis, necessity letter, reports

 How Do You Get ABA Therapy Approved by HealthyBlue?

If your HealthyBlue plan provides coverage for ABA therapy, there are a few steps you have to take. Again, make sure to check the details of your plan so you don’t miss anything.

First, you’ll need to have an official ASD diagnosis from a qualified professional. In many cases, this can include a clinical psychiatrist, a developmental pediatrician or some other professional trained in the process.

Next, you’ll need a letter from this provider that ABA therapy is medically necessary for your child due to this diagnosis. In most cases, this won’t be hard to prove if an ASD diagnosis is given.

Once this is done, you’ll need to select an ABA therapy company from an approved list of providers that are covered by your plan. Sometimes, you may need to have your child’s actual ABA therapy treatment plan drawn up and approved as well.

Finally, you may need to submit ongoing reports about your child’s progress in ABA therapy, revised plans as they make progress and letters stating that it’s still medically necessary for the coverage to continue.

You should always keep detailed documents from your child’s medical providers and ABA therapy team so that you can file a timely and accurate appeal should their treatment plan be denied by HealthyBlue for whatever reason.

Step Requirement
1 Obtain official ASD diagnosis
2 Get letter stating ABA therapy is medically necessary
3 Choose approved ABA therapy provider
4 Submit and get treatment plan approved (if needed)
5 Provide progress reports and ongoing documentation

Blue Gems ABA Accepts Many Health Insurances in North Carolina

Navigating the world of health insurance can be complicated, especially for parents of children with ASD who already have a lot on their plates. You can rest assured, though, that if you have HealthyBlue in North Carolina, your child’s ABA therapy should be covered.

At Blue Gems ABA, we accept many health insurance plans in North Carolina to help make it easier for parents of children with autism to afford this beneficial treatment. We have years of experience working with these companies, too, to help make the application and submission process easy and carefree.

To learn more, please contact us today.