, , ,

Does Insurance Pay for ABA Therapy in North Carolina?

When a child is diagnosed with autism, it’s important that they get extensive treatment and services to help support them and their families. If the diagnosis is done at a young age, and if appropriate treatment is provided to on a consistent basis, it’s very possible for children with autism to learn the communication and life skills that they need to succeed in life.

Applied behavioral analysis, also known as ABA therapy, has been proven to be one of the most effective treatment methods for children diagnosed with autism spectrum disorder (ASD). Through this treatment, certified and trained therapists administer in-home or in-clinic therapy to children that can be customized to their unique needs.

The personalization, flexibility and uniqueness of ABA therapy are among the factors that makes it so successful, plus the fact that family members and other caregivers can be integrated into the plan to reiterate the skills learned during sessions.

One of the biggest questions that parents often have about the treatment is whether insurance will pay for ABA therapy in North Carolina.

We will discuss that topic in more depth below.

Table Of Contents

Does Insurance Pay for ABA Therapy in North Carolina?

Fortunately, North Carolina does require that meaningful coverage be provided to people who are diagnosed with autism. The state has an autism insurance bill, known as SB 676, that was first passed in October of 2015. The bill officially went into effect in July of 2016.

Under the bill, individual grandfathered plans, fully insured large group plans and fully insured small group grandfathered plans are subject to North Carolina’s autism insurance law.

Individual non-grandfathered plans and fully insured small group non-grandfathered plans are not.

How to Qualify for Insurance Coverage for ABA Therapy

There are some qualifications individuals need to meet in order to qualify for insurance coverage for ABA therapy in North Carolina.

The first is that the individual must get an autism diagnosis from a qualified health-care profession. It must meet the criteria that’s outlined in DSM-5, which is the Diagnostic and Statistical Manual of Mental Disorders. This is a service that Blue Gems ABA offers in North Carolina.

It’s also possible that your insurance company might require prior authorization for ABA therapy. This will ensure that the ABA therapy treatment plan created meets the criteria for being covered.

As always, it’s important to understand what your insurance plan covers for ABA therapy so that you can know all details about what you might need to do to ensure that the services are covered.

The state mandates for autism therapy insurance coverage are great, but only if you understand how to take advantage of them.

How Does Insurance Coverage for ABA Therapy Work?

For most health insurance plans, ABA therapy coverage will work the same as other covered services. You will need to provide all documentation to your insurance company so that the services are pre-authorized — and/or get the help of your ABA therapy services provider to do so.

Then, you’ll just get the services provided to your child, and the insurance company will pay for their share. You might be responsible for some costs associated with the ABA therapy, if it goes above and beyond what your insurance covers or above the state-mandated annual coverage limit.

As your child undergoes ABA therapy, you should get Explanation of Benefits, or EOB, documents. These will outline the services your child received, what your insurance company is covering and what (if anything) you will be responsible to pay.

It’s important to keep detailed records of all of this for your own sake, and to use as evidence should anything from your insurance company not line up. You can match up what’s on your EOBs with the records that you have kept.

If you need any help with this, contact your insurance company directly, and enlist the help of your ABA therapist and company as well.

Blue Gems ABA Provides the Best Services in North Carolina

Parents who have children with autism are fortunate if they live in North Carolina, as the state mandates insurance coverage for ABA therapy, in most cases. This provides essential financial assistance to families and allows children with autism to take advantage of this effective treatment.

Blue Gems ABA is one of the most trusted and experienced providers of ABA therapy in North Carolina. Our team of experts can also conduct autism assessments if you believe your child might have ASD.

Our 3 North Carolina locations aim to help every child dealing with the challenges of autism:

  1. Winston-Salem NC In-Home ABA
  2. Charlotte NC In-Home ABA
  3. Raleigh NC In-Home ABA

We accept most major insurances in North Carolina, which can help to reduce the cost of ABA therapy to you. For more information on what we do and how we can help your child, please contact us today.

For more information, please contact Blue Gems ABA today.

Learn More About Insurance Coverage for ABA Therapy