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Does Aetna Cover ABA Therapy in North Carolina?

Applied behavior analysis (ABA therapy) is often prescribed for children who are diagnosed with autism spectrum disorder (ASD). As the leading treatment plan for children on the autism spectrum, it’s an evidence-based approach to learning and behavior that helps patients build social, communication and daily life skills with which they may struggle.

ABA therapy can be quite intensive, from both a time and monetary perspective. Some children are prescribed up to 40 hours per week of treatment, based on their specific needs and challenges.

Not only can that cause a strain on time management in a family, but it can also present a financial strain as well.

Luckily, many health insurance plans in North Carolina provide coverage for ABA therapy and autism-related services. In this article, we’ll explore whether Aetna covers ABA therapy in North Carolina?

Key Takeaways
  • Most Aetna plans in North Carolina provide coverage for ABA therapy.
  • State law mandates up to $40,000 annually for eligible plans covering individuals under 19.
  • An official ASD diagnosis and Letter of Medical Necessity are required.
  • Pre-certification is typically necessary before therapy begins.
  • Ongoing reauthorization and progress documentation may be required.

Table Of Contents

Does North Carolina Mandate Coverage for ABA Therapy?

As of July 2016, North Carolina has required most insurance plans that are regulated by the state to provide meaningful coverage for autism-related services. That’s the time when SB 676, the state autism insurance bill, went into effect.

Under the law, all individual grandfathered plans, fully insured large group plans and fully insured small group grandfathered plans must adhere to the law. Only individual non-grandfathered plans and fully insured small group non-grandfathered plans are exempt.

The law states that coverage for adaptive behavior treatment must be given to all people who are younger than 19, and there’s an annual cap of $40,000 every year.

Services that fall under the umbrella of the law include adaptive behavior treatment such as ABA therapy, psychiatric care, psychological care, pharmacy care, and speech, physical and occupational therapy.

Coverage Area Included? Requirements Important Notes
ABA Therapy (Adaptive Behavior Treatment) Yes – Most Plans ASD diagnosis from qualified professional + Letter of Medical Necessity Coverage varies by specific Aetna plan; state law minimum may apply
Age Eligibility Yes (Under 19 under state mandate) Must meet autism diagnosis criteria Some plans may extend beyond minimum age requirement
Annual Coverage Limit Up to $40,000 (state minimum) Applies to qualifying state-regulated plans Some Aetna plans may offer higher limits
Pre-Certification Typically Required Submit treatment plan and provider information Approval required before services begin
Ongoing Authorization Yes Updated Letter of Medical Necessity + Progress Reports May be required annually or per review cycle
In-Network Providers Strongly Recommended Choose provider within Aetna network Out-of-network benefits vary by plan

Does Aetna Cover ABA Therapy in North Carolina?

Many of Aetna’s insurance plans provide coverage for ABA therapy in North Carolina. It’s very important that you check the specific insurance plan you have, though, to not only ensure that it provides this coverage but what the limits are.

While North Carolina has outlined the coverage that state-regulated insurance plans must provide, these are only minimum levels. In other words, your insurance plan may provide services above and beyond these levels if they choose.

There are some Aetna insurance plans that do just this, and even some that aren’t required to provide autism-related coverage that still do. So, again, make sure that you investigate what your plan specifically provides if your child has ASD.

How Do You Get ABA Therapy Covered in North Carolina?

Every insurance plan is different, so it’s best to check what the rules, regulations and procedures are for getting your child’s ABA therapy services covered by Aetna. That being said, there are some general rules that you should keep in mind.

First, Aetna will require that you provide them with an official ASD diagnosis from a certified professional such as a developmental pediatrician or clinical psychiatrist. In addition to the diagnosis, they must provide a letter of medical necessity that states your child requires ABA therapy as a result of their neurodevelopmental disorder.

Once those have been approved, you can search for an ABA therapy provider that is in your Aetna plan’s network. You probably will need to have the services pre-certified, which usually entails providing Aetna with your child’s detailed treatment plan.

After it’s fully approved, your child can begin ABA therapy services.

It’s likely that Aetna will need to re-approve your child’s ABA therapy from time to time. This could happen on an annual basis or on a different timeframe, based on your plan’s requirements.

In most cases, this just requires receiving an updated letter of necessity that states ABA therapy is still required for your child as a result of their ASD, as well as potentially progress reports from the ABA therapy clinic showing your child is attending and making progress toward their goals.

Blue Gems ABA Works with Most Insurance Companies in North Carolina

ABA therapy can be expensive for families who have a child with ASD. Luckily, many insurance plans in North Carolina, like Aetna, provide coverage for ABA therapy and related autism services.

At Blue Gems ABA, we work with Aetna and most insurance companies in North Carolina. Our team is experienced doing so, and we can help you get your child’s treatment plans approved so they are covered by insurance, taking a huge weight off your shoulders.

To learn more, please contact us today.

Frequently Asked Questions
Does Aetna fully cover ABA therapy in North Carolina?

Coverage depends on your specific plan. Many plans meet or exceed the state-mandated minimum coverage levels.

Is there an annual cap for ABA therapy?

State-regulated plans must provide up to $40,000 per year for eligible individuals under age 19.

What documentation is required for approval?

A certified ASD diagnosis and a Letter of Medical Necessity are required, along with a treatment plan for pre-certification.

Will Aetna require re-approval?

Yes. Most plans require periodic reauthorization supported by updated medical documentation and progress reports.