North Carolina Medicaid provides coverage for Applied Behavior Analysis (ABA) therapy for children under the age of 21 who have received a formal diagnosis of autism spectrum disorder. This coverage is governed by the North Carolina Department of Health and Human Services (NCDHHS) under Clinical Coverage Policy 11B.

To access these services, families must meet specific eligibility requirements and follow a structured authorization process:

Eligibility and Requirements:

• A formal diagnosis of autism spectrum disorder (ASD) using DSM-5 criteria from a qualified professional is required.
• Services must be deemed medically necessary to improve social, communication, and behavioral skills.
• Prior authorization from the insurer is mandatory before therapy can begin.

Coverage Structure and Limits:

• Medicaid structures coverage through annual hourly caps based on the child’s age. Children aged 0 to 5 may receive up to 40 hours per week, while older children up to age 21 are typically eligible for up to 25 hours per week.
• Reimbursements for sessions generally range from $40 to $100 per hour.
• Managed care options, such as HealthyBlue, require the use of in-network providers and specific prior authorizations.

Getting Started: Families should first obtain a formal diagnosis, then contact their insurer or a provider like Little Achievers ABA to verify benefits. The process involves a functional behavior assessment (FBA) conducted by a Board Certified Behavior Analyst (BCBA) and the development of an individualized treatment plan.