To get Applied Behavior Analysis (ABA) therapy covered in North Carolina, families can utilize both private insurance and Medicaid. North Carolina’s Session Law 2014-100 mandates that private insurers cover ABA therapy for individuals with autism up to age 18 or high school graduation, specifically for group health plans with 15 or more employees.

Key steps to secure coverage include:

1. Obtain a Formal Diagnosis: Eligibility requires a formal autism spectrum disorder (ASD) diagnosis from a qualified professional using DSM-5 criteria.
2. Verify Benefits: Contact your insurance provider (such as Blue Cross Blue Shield) to verify in-network status, session limits, and out-of-pocket costs.
3. Navigate Medicaid Requirements: For children under 21, North Carolina Medicaid covers ABA under Clinical Coverage Policy 11B. This involves enrolling in state programs and potentially using managed care options like HealthyBlue.
4. Documentation and Prior Authorization: Most plans require a Board Certified Behavior Analyst (BCBA) to complete a functional behavior assessment and an individualized treatment plan. Necessary documentation often includes ADOS-2 results and behavioral observations.
5. Authorization Approval: Submit the diagnosis, assessment report, and treatment plan for approval, which typically takes between 30 to 60 days.

It is important to note that self-insured plans may opt out of state mandates, and annual hour caps may apply depending on the child’s age and specific plan.