Does NCDHHS Cover ABA Therapy?

Yes. NCDHHS covers ABA therapy, under certain conditions.

Understanding the coverage for Applied Behavior Analysis (ABA) therapy under North Carolina Department of Health and Human Services (NCDHHS) is crucial for families and individuals dealing with Autism Spectrum Disorder (ASD). NCDHHS plays a pivotal role in providing healthcare services, including treatments for autism.

NCDHHS and Autism Services

NCDHHS oversees a range of services for individuals with autism, starting from early childhood and extending into adulthood. Here’s how they approach ABA therapy and related services:

Coverage for Children and Adolescents

• Early Intervention Programs: For children up to age 3, services may include evaluation, assessment, and early intervention.
• ABA and TEACCH Programs: These autism-specific treatments are commonly offered until the age of 18 or 20.
• Behavioral Health Treatment for Adults: Starting from July 2021, NCDHHS expanded its services to include Research-Based Behavioral Health Treatment for ASD for individuals over 21 years​​.

Medicaid and Insurance Coverage

• Medicaid Coverage: Medicaid covers autism services, including therapies like ABA, for children under 21, provided the services are medically necessary. This is part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, ensuring comprehensive coverage for children with Medicaid​​.
• Private Insurance Compliance: Major insurers in North Carolina, governed by the NC Department of Insurance, are required to cover autism services for individuals 18 years or younger. The coverage is subject to an annual cap and may include co-pays and deductibles​​.

Navigating NCDHHS Coverage for ABA Therapy

For families seeking ABA therapy for their children with ASD, understanding the coverage specifics and navigating the system is essential:

• Assess Eligibility: For children under 21, check Medicaid eligibility and understand the scope of the EPSDT benefit.
• Understand Insurance Limits: If using private insurance, be aware of the coverage limits and any out-of-pocket costs.
• Explore Adult Services: For individuals over 21, investigate the newly introduced Behavioral Health Treatment options for ASD.

FAQ

Q: How has NCDHHS expanded its autism services for adults?

A: In July 2021, NCDHHS began offering Research-Based Behavioral Health Treatment for Autism Spectrum Disorder for individuals aged 21 and over. This expansion reflects a growing recognition of the need for continued support into adulthood​​.

Q: Are there any specific requirements for Medicaid to cover ABA therapy for children in North Carolina?

A: Yes, Medicaid covers ABA therapy for children under 21 as long as the services are medically necessary. This coverage is a part of the EPSDT benefit, which is dedicated to providing comprehensive healthcare for children with Medicaid​​.

Q: What does the North Carolina law say about private insurance coverage for autism services?

A: North Carolina law requires major insurers governed by the NC Department of Insurance to cover autism services, including ABA therapy, for individuals under 18 years of age. However, coverage is capped annually and adjusted based on the consumer price index, and is subject to co-pays and deductibles​​.

Q: Are there treatments other than ABA therapy recognized by NCDHHS for ASD?

A: While ABA is a well-known treatment for ASD, NCDHHS also recognizes other therapies. Treatments like TEACCH, developed in North Carolina, may be as effective or more so for certain individuals, depending on their specific needs​