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Does North Carolina Medicaid Direct Cover ABA Therapy?

Children with autism spectrum disorder (ASD) often require extensive health-care services. This might include everything from evaluation, assessment and diagnostic services to treatment such as applied behavior analysis (ABA therapy).

Since 2016, North Carolina has mandated that all major insurers governed by the NC Department of Insurance must provide coverage for autism-related services. This was an important milestone for children with ASD and their families, as these services can often be intensive and, as a result, expensive.

Not all health insurers or health insurance plans must adhere to this law, though, and what services are covered or how much is covered can vary greatly from one plan to the next.

In this article, we’ll discuss whether North Carolina Medicaid Direct covers ABA therapy.

Learn more about insurance coverage for ABA therapy

Table Of Contents

What is North Carolina Medicaid Direct?

North Carolina Medicaid Direct is the state’s health insurance program for beneficiaries of NC Medicaid not enrolled in the NC Medicaid Managed Care program. The program helps families coordinate care for many services, including for autism, intellectual disabilities, serious mental illnesses and more.

Many different people qualify for North Carolina Medicaid Direct, and a full list can be found at its website here.

There are certain services that the plan provides that many other standard programs don’t, which gives needy families the care they and their family members need.

Does North Carolina Medicaid Direct Cover ABA Therapy?

Many families who have children with ASD turn to Medicaid programs in North Carolina for help. Those who have this type of coverage can rest assured knowing that ABA therapy is covered under the North Carolina Medicaid Direct program.

In fact, Medicaid programs typically provide more coverage than many private insurance companies do.

In North Carolina, Medicaid programs must provide coverage for autism-related services for children 21 years old and younger. Private insurers are only required to provide coverage for children 18 years old and younger.

Medicaid programs in North Carolina have even offered expanded coverage for adults older than 21 since July of 2021 so that they can get any ongoing services they may need.

In addition, there is an annual cap on autism-related services of $40,000 for most private insurance plans, while Medicaid plans don’t have a specific cap.

Feature Private Insurance in NC NC Medicaid Direct
Autism Coverage Mandate Yes (some insurers) Yes (required)
Age Limit Up to 18 years Up to 21 years (and beyond since July 2021)
Annual Cap on Autism Services $40,000 No specific cap
ABA Therapy Covered? Varies by plan ✅ Yes
Diagnosis Requirement Varies ✅ Required
Medical Necessity Letter Required? Varies ✅ Required
Ongoing Re-Authorization? Varies ✅ Every ~6 months
Appeals Process for Denial? Yes ✅ Detailed appeal process available

What is Required to Get ABA Therapy Covered by North Carolina Medicaid Direct?

There are two main requirements North Carolina Medicaid Direct has to provide coverage for ABA therapy.

The first is an official diagnosis of ASD. This can be given by any professional trained and licensed to do so, which could include clinical psychiatrists, psychologists and developmental pediatricians, among others.

The second requirement is having a letter from a doctor or other professional that says ABA therapy is medically necessary for the child. This letter often must be sent to North Carolina Medicaid Direct before the treatment will be approved.

Once these two requirements are met, families often must visit a provider who is approved by the state. In many cases, the actual ABA therapy treatment plan must also be reviewed and approved initially, with ongoing re-authorizations every six months or so possible as well.

Remember, there are many different plans within North Carolina Medicaid Direct, so make sure to check the details of yours to figure out what services are covered and what you need to do to ensure you receive the proper coverage.

Step Requirement Notes
1 ASD Diagnosis Must be by licensed professional (e.g., psychologist, developmental pediatrician)
2 Medical Necessity Letter Letter must be from a provider explaining need for ABA
3 Use Approved Provider Must be a state-approved ABA provider
4 Submit for Initial Approval Includes treatment plan
5 Reauthorization Likely needed every 6 months
6 Appeal if Denied Review denial letter and file formal appeal

What Happens if My Child’s ABA Therapy Coverage Was Denied?

At times, North Carolina Medicaid Direct may decline coverage for ABA therapy. If this happens, there are some steps you need to follow to ensure you get the coverage you deserve.

First, make sure to review the statement of denial, which will explain in detail why you aren’t receiving the coverage. This will help you prepare your appeal.

Next, consult with your ABA therapy providers to see if there’s anything they can do to help. In some cases, it’s as simple as providing missing documentation or adjusting the wording of documentation.

Once you have done this, you can formally file an appeal letter that details your child’s ASD diagnosis, why ABA therapy is medically necessary to them and any other relevant details.

Blue Gems ABA Works with Many Health Insurance Plans in North Carolina

North Carolina Medicaid Direct provides coverage for ABA therapy in the state. To ensure your child gets this coverage, there are some steps you need to follow, as outlined above.

At Blue Gems ABA, we work with many health insurance plans in North Carolina to make the process easy for families of children with autism. In this way, we help support children as best as we can.

To learn more, please contact us today.

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