NC Medicaid and ABA Therapy: A Guide for Parents
Yes, NC Medicaid covers ABA therapy for children with autism. The hard part for most families isn’t whether it’s covered, it’s understanding which plan your child is on and what steps come before the first session. This guide walks through it in plain language.
What NC Medicaid calls ABA
In NC Medicaid’s rules, ABA therapy falls under a benefit called Research-Based Behavioral Health Treatment (RB-BHT) for autism spectrum disorder. The details are in NC Medicaid’s Clinical Coverage Policy 8F. You don’t need to read it, but if an insurer or provider mentions “RB-BHT,” that’s ABA.
Which Medicaid plan is your child on?
Most children on NC Medicaid are in one of these:
- A Standard Plan. A health plan that manages physical and behavioral health together. The Standard Plans are AmeriHealth Caritas, Carolina Complete Health, Healthy Blue, UnitedHealthcare Community Plan and WellCare.
- A Tailored Plan. For people with more significant behavioral health needs, intellectual or developmental disabilities, or traumatic brain injury, including children on the Innovations waiver or waitlist. Tailored Plans are run by regional organizations called LME/MCOs.
- NC Medicaid Direct. Some children are in NC Medicaid Direct, the state’s traditional Medicaid program, rather than a health plan.
Not sure? Your child’s Medicaid card names the plan, or you can call the NC Medicaid Contact Center. Our office can also check for you.
LME/MCOs by region
Which LME/MCO serves you depends on your county. In the areas where Empire ABA works:
| Area | Counties | LME/MCO |
|---|---|---|
| Wilmington | New Hanover, Brunswick, Pender, Onslow | Trillium Health Resources |
| Raleigh–Durham | Wake, Durham, Orange, Johnston | Alliance Health |
| Charlotte | Mecklenburg | Alliance Health |
| Around Charlotte | Cabarrus, Gaston, Union, Iredell | Partners Health Management |
County assignments change from time to time, so check the NC DHHS LME/MCO directory for the latest.
What you need before ABA can start
- An autism diagnosis. Medicaid covers ABA for a child with an autism spectrum disorder diagnosis from a qualified professional. If you’re still waiting on an evaluation, see where to get an autism diagnosis in North Carolina.
- A provider in your plan’s network. The ABA provider must be enrolled with NC Medicaid and contracted with your child’s plan.
- An assessment and treatment plan. A BCBA assesses your child and writes a plan with goals and recommended weekly hours.
- Prior authorization. The provider sends the plan to your child’s Medicaid plan, which approves a number of hours for a set period. Authorizations are reviewed and renewed as therapy goes on.
At Empire ABA, our office team handles the authorization paperwork for you. You’ll hear from us at each step, so you’re never left wondering where things stand.
Common questions
Does Medicaid cost anything for ABA?
For most children on NC Medicaid, approved ABA therapy has no cost to the family, but check your child’s plan to be sure. If your child has private insurance and Medicaid, Medicaid usually pays after the private plan. We’ll check your benefits and explain them before therapy starts.
My child has private insurance and Medicaid. Which pays?
Your private insurance is billed first, and Medicaid may cover what’s left. Bring both cards to your first call so we can verify both.
What if my child switches plans?
Changes happen, for example when a child moves to a Tailored Plan. Let us know as soon as you get a letter about a plan change. We’ll check that we’re in network with the new plan and request a new authorization so therapy isn’t interrupted.
How long does authorization take?
It varies by plan. Having the diagnosis report and your insurance details ready when you call speeds things up.
Plans we accept
Empire ABA accepts NC Medicaid, including Alliance Health, Trillium, Partners Health and Vaya Health, and Standard Plans Carolina Complete, Healthy Blue, WellCare, AmeriHealth Caritas and UnitedHealthcare Community Plan, as well as most major commercial plans. See does insurance cover ABA therapy in North Carolina? for more.
Ready to start?
Call your local team in Wilmington, Raleigh–Durham or Charlotte, and have your child’s Medicaid card handy. We’ll take it from there.
