Does AmeriHealth Caritas Cover ABA Therapy in North Carolina?

AmeriHealth Caritas is a managed care organization that provides healthcare services for beneficiaries of Medicaid in North Carolina. The company provides wellness coverage that not only includes medical services, but also behavioral health and other benefits.

Families in North Carolina who have a child with autism spectrum disorder (ASD) might be wondering whether related services are covered under their AmeriHealth Caritas plan. This is especially true if their child has been recommended to have applied behavior analysis, or ABA therapy, treatment.

ABA therapy is the gold standard treatment for children on the autism spectrum, and it’s an intensive treatment that often requires a lot of time. With that, of course, comes a significant financial commitment, which is why insurance coverage is key for many families.

In this article, we’ll discuss whether AmeriHealth Caritas covers ABA therapy in North Carolina.

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Does North Carolina Have an Autism Insurance Bill?

Yes, in October 2015, North Carolina passed its autism insurance bill, which is known as SB 676. That law, which went into effect on July 1 of the following year, requires that state-regulated insurance plans provide meaningful coverage for autism-related services.

Most insurance plans that offer coverage within the state must adhere to this law. That includes all fully insured small group grandfathered plans, fully insured large groups plans and individual grandfathered plans.

The only two types of insurance plans that are exempt are fully insured small group non-grandfathered plans and individual non-grandfathered plans. That being said, even some of those plans do provide coverage for autism-related services, since the mandate is only minimum requirements.

According to the law, autism-related services include adaptive behavior treatment, including ABA therapy; psychiatric, psychological and pharmacy care; and physical, occupational and speech therapy.

Insurance plans must provide this coverage to any individual who is younger than 19 years old, and there is a cap of $40,000 per year of coverage.

Does AmeriHealth Caritas Cover ABA Therapy in North Carolina?

Generally speaking, AmeriHealth Caritas does provide coverage for ABA therapy in North Carolina. It’s always best to check what your specific plan covers, though, as there are many different plans that are offered by AmeriHealth Caritas.

That being said, almost all of the company’s Medicaid plans do provide this coverage, and even many of their non-Medicaid plans do as well. As mentioned, the mandates above are just minimum requirements — meaning that insurance companies can choose to provide coverage above and beyond what is required by the state of North Carolina.

What is Required to Get ABA Therapy Services Covered by AmeriHealth Caritas?

Again, each plan under AmeriHealth Caritas may have slightly different requirements for getting your child’s ABA therapy services covered. There are some general steps you will have to follow, though, no matter what plan you’re on.

The first step is ensuring that your child has an official ASD diagnosis that was given by a certified professional, such as a clinical psychiatrist or developmental pediatrician. Next, this professional must provide a letter of medical necessity that states your child requires ABA therapy as a result of their diagnosis.

From there, you’ll need to choose an ABA therapy provider from a list of approved companies within your AmeriHealth Caritas network.

Most plans will require the services to be pre-certified, which often means they need to receive a copy of your child’s proposed ABA therapy treatment plan. You may need to receive re-certification from time to time, too, which often involves receiving an updated letter of medical necessity, as well as reports from the ABA therapy provider regarding your child’s progress toward their goals.

Blue Gems ABA Works with AmeriHealth Caritas in North Carolina

Juggling your child’s ABA therapy services can be taxing, both from a scheduling and financial perspective. Yet, AmeriHealth Caritas helps to relieve some of that pressure by providing coverage for many autism-related services under most of their plans.

At Blue Gems ABA, we work directly with many insurance companies in North Carolina, including AmeriHealth Caritas. Our experienced team knows what is required to get the therapy covered, and we help remove this burden off your shoulders by walking you through the process.

To learn more, please contact us today.