Does Carolina Complete Health Cover ABA Therapy in North Carolina?

A diagnosis of autism spectrum disorder (ASD) often comes with a recommendation to get applied behavior analysis, or ABA therapy. That’s because it’s considered the gold standard treatment option for children on the autism spectrum.

Following targeted strategies that are rooted in scientific evidence, ABA therapists can help children with autism improve their communication, social and daily living skills. They can also help to modify certain behaviors that are disruptive, negative and/or harmful.

ABA therapy is intensive, often requiring many hours per week for a sustained period of time. This can cause quite the financial burden on families.

Luckily, many insurance plans in the state of North Carolina require ABA therapy to be covered. Below, we’ll discuss whether Carolina Complete Health covers ABA therapy in North Carolina, and what you need to do to qualify.

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What is North Carolina’s Autism Insurance Law?

In October 2015, North Carolina passed its autism insurance bill, called SB 676, and it went into effect in mid-2016. It mandates that all state-regulated insurance plans provide meaningful coverage for individuals with autism.

The state’s law applies to all individual grandfathered plans, fully insured large group plans and fully insured small group grandfathered plans. Only non-grandfathered plans are exempt from the law.

Per SB 676, North Carolina insurance companies must cover ABA therapy; psychiatric and psychological care; pharmacy care; and physical, occupational and speech therapy.

To be eligible for services, individuals must be less than 19 years old. State law also caps mandated coverage at $40,000 per year.

Insurance carriers can provide more or additional coverages if they choose, but must not provide less.

Does Carolina Complete Health Cover ABA Therapy?

Carolina Complete Health does provide coverage for ABA therapy in North Carolina. The managed care organization is a joint venture between Centene Corporation and the North Carolina Medical Society.

People who are subscribed to one of its health plans will be happy to know that Carolina Complete Health actually covers individuals up to the age of 21. This is an extended benefit, since the state only requires coverage up to 19 years of age.

Of course, you should still make sure that your specific insurance plan does provide coverage for ABA therapy services. It’s also good to know the exact coverage limits so that you can plan for any related out-of-pocket expenses.

What Do You Have to Do to Get ABA Therapy Covered?

Like most insurance plans, Carolina Complete Health has specific requirements in place if you want to qualify for ABA therapy.

First, your child must have an official ASD diagnosis. This must come from a trained professional who’s qualified to give such a diagnosis, such as a developmental pediatrician or clinical psychiatrist.

In addition, the provider must recommend ABA therapy services for your child. Carolina Complete Health will likely require that your provider write a letter of medical necessity for ABA therapy.

At this point, you must find a local ABA therapy company that is covered under your health insurance plan. They must create a treatment plan for your child, which might need to be pre-approved by the insurance company before coverage will kick in.

Finally, your child can start to receive their necessary ABA therapy services, and those services will be covered by your insurance company. From time to time, Carolina Complete Health may require re-authorization of the ABA therapy services, based on continuing medical necessity.

Blue Gems ABA Works with Most Insurance Companies in North Carolina

ABA therapy can be very intensive, requiring a significant time and financial commitment. Luckily, North Carolina mandates insurance coverage for ABA therapy and other autism-related services.

At Blue Gems ABA, we accept most health insurance plans in North Carolina, helping families get the necessary services their child with ASD needs, at an affordable price. We are experienced in working directly with Carolina Complete Health, and can help you navigate the process of getting your child’s ABA therapy approved and/or re-approved.

To learn more, please contact us today.