In North Carolina, accessing Applied Behavior Analysis (ABA) therapy through insurance involves meeting specific state mandates and provider requirements.

General Eligibility and State Mandates: North Carolina Session Law 2014-100 requires private group health plans with 15 or more employees to cover ABA therapy for individuals up to age 18 or until high school graduation. Eligibility requires a formal Autism Spectrum Disorder (ASD) diagnosis based on DSM-5 criteria from a qualified professional.

Medicaid Requirements (Policy 11B): Medicaid covers ABA for children under age 21. Key requirements include:

• A formal autism diagnosis.
• Prior authorization from the state.
• Service hour caps: Up to 40 hours per week for children ages 0-5 and up to 25 hours per week for those ages 6-21.

Private Insurance (e.g., Blue Cross Blue Shield): Plan requirements often include network verification and prior authorization. Coverage typically depends on the specific plan’s clinical necessity guidelines.

Authorization and Documentation: To secure approval, families must typically provide:

• ADOS-2 results and a formal diagnosis from a physician.
• A Functional Behavior Assessment (FBA) completed by a Board Certified Behavior Analyst (BCBA).
• An individualized Treatment Plan or Behavior Intervention Plan (BIP).
• Proof of residency and developmental history records.

Most providers also require biweekly parent training as a condition of ongoing service delivery to ensure consistent care.