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Does Blue Cross Blue Shield Cover ABA Therapy in North Carolina?

Was your child recently diagnosed with autism spectrum disorder (ASD)? If so, you likely have many questions, including what applied behavior analysis (ABA therapy) is, how you can fit it into the family schedule, and how you will pay for it.

ABA therapy is a science-based approach to learning and behavior that’s considered the gold standard treatment option for children on the autism spectrum. It helps patients build social, communication and daily life skills that they often struggle with, while also helping them modify certain behaviors.

As you may have been told, ABA therapy can be intensive, with some children being prescribed as many as 40 hours per week of the treatment. That’s a major time commitment for any family, and it can be a major financial commitment as well.

If you live in North Carolina, you’re in luck, though: The state mandates meaningful coverage for autism-related services through most insurance companies.

In this article, we’ll discuss whether Blue Cross Blue Shield covers ABA therapy in North Carolina?

Key takeaways
North Carolina’s SB 676 requires meaningful autism-related coverage for most state-regulated insurance plans.
ABA therapy is included under adaptive behavior treatment, along with other therapies and related care.
The minimum requirements include an age limit (under 19) and a $40,000 annual coverage cap.
Most Blue Cross Blue Shield plans in North Carolina generally provide autism-related coverage, but benefits vary by plan.
Families should confirm eligibility, coverage limits, and required steps (like pre-authorization and re-certification) with their specific plan.

Table Of Contents

What is North Carolina’s Autism Insurance Law?

North Carolina’s autism insurance law is called SB 676. It first passed through the state legislature in the middle of October 2015, and it went into effect the following July.

Per the bill, all state-regulated insurance plans must provide meaningful coverage for services related to autism. The types of plans that must adhere to this law include fully insured small group grandfathered plans, individual grandfathered plans and fully insured large group plans.

The only exceptions are fully insured small group non-grandfathered plans and individual non-grandfathered plans. That said, even some of these types of plans do provide meaningful coverage for autism-related services.

There are many different services that the law encompasses. This includes ABA therapy, which falls under the umbrella of adaptive behavior treatment; physical, speech and occupational therapy; and pharmacy, psychological and psychiatric care.

The state does put two limitations in place: Children must be younger than 19 years old, and the annual cap for coverage is $40,000.

Of course, these are just minimums. Insurance carriers may decide to provide coverage that’s above and beyond these limits and requirements, even if they don’t have to adhere to the law.

Requirement Details
Law name SB 676
When it passed Mid-October 2015
When it took effect July 2016
What it requires State-regulated plans must provide meaningful coverage for autism-related services (including ABA under adaptive behavior treatment).
Age limit Child must be under 19 years old.
Annual cap $40,000 per year (minimum required by the state).
Plans required to comply Fully insured small group grandfathered plans, individual grandfathered plans, and fully insured large group plans.
Exceptions Fully insured small group non-grandfathered plans and individual non-grandfathered plans (some may still offer meaningful coverage).

Does Blue Cross Blue Shield Cover ABA Therapy in North Carolina?

Blue Cross Blue Shield is a very large company that operates all across the country. As such, they have many different insurance plans that vary greatly in the types of coverage they provide and how much coverage they provide.

Generally speaking, most Blue Cross Blue Shield plans provide coverage for autism-related services in North Carolina. It’s advisable, though, to check your specific insurance plan to see whether your child is eligible for those services, what the coverage limits are and what you have to do to qualify.

What is the Process for Getting Blue Cross Blue Shield to Cover ABA Therapy?

The process for getting Blue Cross Blue Shield to cover ABA therapy again depends on the specific insurance plan that you have. Most of the company’s plans do follow a very similar process, though.

The first step is often ensuring that your child has an official diagnosis of ASD, and that the diagnosis was given by a certified professional. This is usually a person such as a clinical psychiatrist or developmental pediatrician.

In addition to the diagnosis, the professional must provide what’s called a medical letter of necessity. This letter will state that your child requires ABA therapy because of their ASD diagnosis, and will outline the expected outcomes and recommended timeframe.

After sending these to the insurance company, you must pick an approved ABA therapy provider from the list of clinics in your network.

Even after doing so, you will likely need to get your child’s ABA therapy services pre-approved. Oftentimes, this includes submitting your child’s treatment plan to Blue Cross Blue Shield for approval before the services begin.

You’ll likely also need to have the services re-certified at some point in the future, which typically requires submitting an updated letter of medical necessity, updated ABA therapy treatment plan and notes about your child’s progress toward their goals thus far.

Blue Gems ABA Accepts Blue Cross Blue Shield in North Carolina

Insurance coverage is vital for many families who have children with autism. Luckily, North Carolina mandates coverage for autism-related services such as ABA therapy through most insurance plans.

At Blue Gems ABA, we accept Blue Cross Blue Shield and many other insurance plans in North Carolina. Our team has experience working with insurance carriers to get pre-approval and re-certification of your child’s ABA therapy treatment plan, so you don’t have to carry that weight on your shoulders.

To learn more, please contact us today.

FAQs Answer
Does North Carolina require insurance coverage for ABA therapy? Yes. SB 676 requires meaningful coverage for autism-related services, including ABA as adaptive behavior treatment, for most state-regulated plans.
Which insurance plans have to follow SB 676? Fully insured small group grandfathered, individual grandfathered, and fully insured large group plans must comply. Certain non-grandfathered plan types are exceptions.
What are the limits in the North Carolina law? The minimum requirements include an age limit of under 19 years old and a $40,000 annual coverage cap.
Does Blue Cross Blue Shield cover ABA therapy in North Carolina? Generally, most Blue Cross Blue Shield plans provide autism-related coverage in North Carolina, but benefits and requirements vary by plan.
What documentation is typically needed for BCBS to cover ABA? Many plans require an official ASD diagnosis from a qualified professional and a medical letter of necessity outlining why ABA is needed and expected outcomes.
Is pre-authorization usually required before starting ABA therapy? Often, yes. Many plans require you to submit the ABA treatment plan for approval before services begin.
Will ABA coverage need to be renewed or re-certified? Usually, yes. Re-certification commonly requires an updated letter of medical necessity, an updated treatment plan, and documentation of progress toward goals.