Does WellCare Cover ABA Therapy in North Carolina?

Applied behavior analysis (ABA therapy) is a treatment that can benefit many children who have autism spectrum disorder (ASD). In fact, it’s considered the leading treatment option for children on the autism spectrum.

ABA therapy is a science-based approach to learning that can help children with autism build the social and communication skills with which they often struggle, while also teaching them to modify certain negative behaviors.

Most children who are referred to ABA therapy undergo multiple hours per week of the treatment over a long period of time. The treatment is very intensive and requires a significant time commitment.

Because of the length of time that is necessary for ABA therapy, it can also be quite costly. Luckily, many insurance plans provide coverage for the treatment.

In this article, we’ll discuss whether WellCare covers ABA therapy in North Carolina.

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

Table Of Contents

What is WellCare?

WellCare is an insurance company that provides a wide range of coverage to more than 5.3 million people across the country. Their plans are primarily offered through Medicare, Medicare Advantage and Medicaid.

The company states that it’s committed to providing healthcare that is “quality, affordable and culturally sensitive.”

The company offers a large selection of different plans, each of which has different things that they provide coverage for, and different terms.

Does WellCare Cover ABA Therapy in North Carolina?

Under most of its plans, WellCare offers ABA therapy coverage. Like all other insurance companies in North Carolina, WellCare must abide by the state’s autism insurance bill, which went into effect on July 1 of 2016.

Under the law, all individual grandfathered plans, fully insured large group plans and fully insured small group grandfathered plans must offer coverage for autism-related services. This includes things such as psychiatric and psychological care, physical therapy, speech therapy, occupational therapy, pharmacy care and other behavior treatments, including ABA therapy.

North Carolina’s law states that ABA therapy is limited to individuals who are 19 years old or younger, and there is an annual cap on services of $40,000 a year.

The only type of plans that do not have to adhere to the state’s law are individual non-grandfathered plans and fully insured small group non-grandfathered plans.

This still covers a majority of insurance plans in North Carolina, though it’s important to check with your specific plan to find out whether it provides coverage for ABA therapy and what the limits are.

What is Required to Have ABA Therapy Covered by WellCare in North Carolina?

While the requirements to receive coverage for ABA therapy can vary from one WellCare insurance plan to the next, there are some general guidelines that you can follow.

First, your child needs to receive an official diagnosis of ASD. In most cases, this can be given by a clinical psychiatrist or psychologist, a developmental pediatrician or another professional trained in the field.

Then, your child must officially be recommended for ABA therapy, and it must be stated that the reason is because it’s a medically-necessary treatment. Both the official diagnosis and the recommendation for treatment are usually required to be put in writing and sent to WellCare.

Next, it’s possible that your child’s ABA therapy treatment plan will have to be pre-approved. This often includes picking a provider from a list of in-network locations, and possibly even having a plan submitted for approval.

Once WellCare reviews all of that information and verifies it’s correct and fits under your plan, then they will provide you with the coverage of your specific plan.

Keep in mind that you may need to recertify your child’s ASD diagnosis, whether the ABA therapy is still medically necessary and/or the specific progress your child is showing to have the coverage of their treatment continue.

Again, make sure that you read all documentation about ABA therapy in your specific WellCare health plan, or reach out directly to the company to find out more.

Blue Gems ABA Works with WellCare and Other Insurance Plans

In most cases, WellCare provides coverage for ABA therapy in North Carolina, as most of their plans are subject to the state’s autism insurance law. That being said, it’s always best to double check your specific plan to see what type of coverage you have.

At Blue Gems ABA, we work directly with WellCare and other insurance plans in North Carolina in an effort to make the process as smooth as possible for patients and their families.

To learn more, please contact us today.