Does UnitedHealthcare Community Cover ABA Therapy in North Carolina?

If your child has autism spectrum disorder (ASD), you might be wondering whether UnitedHealthcare Community plans provide coverage for applied behavior analysis (ABA therapy).

As the leading treatment option for children on the autism spectrum, ABA therapy is prized for its ability to help patients build social interaction and communication skills, while also learning how to modify certain negative behaviors.

At the same time, ABA therapy can be quite intensive, requiring 25 hours or more of treatment every week for most children. This requires not only a significant time commitment, but also a big financial commitment as well.

Luckily, most UnitedHealthcare Community plans cover ABA therapy in North Carolina. In this article, we’ll provide further details about this coverage, including what the state law is and what you need to do to ensure your child’s treatment is covered.

Learn more about insurance coverage for ABA Therapy
Learn more about Insurance coverage for ABA Therapy in North Carolina

Table Of Contents

What is UnitedHealthcare Community?

UnitedHealthcare Community plans provide health insurance coverage for certain beneficiaries of health programs offered through the government, such as Medicaid. They’re designed specifically to help individuals who are underserved, at an economic disadvantage and/or don’t have access to health coverage from an employer.

The company provides Medicaid only plans for people who have disabilities, pregnant women, children and some people who fall into a low-income category. They also offer Dual Special Needs plans (D-SNP) for people who are eligible for both Medicaid and Medicare.

There are many different types of plans offered under UnitedHealthcare Community, so you should know the details of the one you’re subscribed to.

Does North Carolina Mandate Autism-Related Coverage?

Under SB 676, better known as the state’s autism insurance bill, North Carolina does mandate coverage by most health insurance plans that are state-regulated. Only individual non-grandfathered plans and fully insured small group non-grandfathered plans are exempt from this law.

Per the state autism insurance bill, which went into effect on July 1, 2016, state-regulated insurance plans must provide adequate coverage for autism-related services.

This includes evaluation and diagnosis; ABA therapy and other types of treatment; psychological and/or psychiatric care; occupational, speech and/or physical therapy; and pharmacy care, among other services.

Any individual who is subscribed to one of these plans and is under 19 years old is eligible to be covered. Their treatment for autism-related services is capped at $40,000 every year, per the North Carolina law.

What Steps Do You Have to Follow to Have ABA Therapy Covered?

The first step in getting your child’s ABA therapy covered by UnitedHealthcare Community in North Carolina is checking the details of your plan. As mentioned, there are many plans offered through this program, so you need to figure out all the specifics about your plan before you proceed.

Most of the time, you must obtain an official ASD diagnosis from a specialized provider. This can be a developmental pediatrician, clinical psychiatrist or another professional who’s trained in the field and approved by your insurance carrier.

Then, you’ll need to have that provider write a letter of medical necessity that recommends ABA therapy. This is what your health insurance carrier will use to determine whether the treatment will be covered.

You will likely have to select an ABA therapy provider from an approved list of providers under your plan. Once you choose one, you also might need to get your child’s treatment plan pre-authorized before any sessions can start.

After the treatment plan has been approved and your child starts therapy, your insurance carrier may also require ongoing reviews and documentation to re-authorize ABA therapy. This could be progress reports and notes from the ABA therapy provider, a re-assessment from a professional that autism is still present and ABA therapy is still medically necessary, and more.

Because there are precise steps you must follow to get your child’s ABA therapy approved, it’s essential that you keep detailed records of all documents and information you receive from your child’s health-care and ABA therapy teams. This will help make the application and/or appeals process easier.

Blue Gems ABA Works with Most North Carolina Insurers

ABA therapy is the leading treatment for children with autism, but it can be quite intensive. That’s why it’s so helpful to have health insurance that covers your child’s therapy.

At Blue Gems ABA, we work with most health insurers in North Carolina, including UnitedHealthcare Community. In this way, we help make the process of getting your child’s ABA therapy approved as easy as possible.

To learn more, please contact us today.