Insurance
ABA therapy with Blue Cross Blue Shield
We accept Blue Cross Blue Shield plans in North Carolina, South Carolina (including the Federal Employee Program), New Mexico, and New Jersey. Each Blue plan sets its own ABA rules, so we check your child's benefits for free before anything starts.
Who is eligible
We accept four Blue plans: BlueCross BlueShield of NC, BlueCross BlueShield of SC (including FEP), BlueCross BlueShield of New Mexico, and Horizon BCBS NJ. Your child’s coverage depends on three things:
- Your plan. Employer plans, individual plans, and federal employee plans each have their own benefit booklet. It says whether ABA is covered, how many hours, and what you pay.
- Your state’s autism law. North Carolina and South Carolina both have autism coverage laws for the plans their insurance departments regulate. North Carolina’s covers adaptive behavior treatment such as ABA and may be limited to members 18 or younger. South Carolina’s covers children diagnosed at age eight or younger until they turn 16.
- Medical necessity. Your child needs an autism diagnosis, and ABA has to be medically necessary based on a BCBA’s assessment.
How to start ABA therapy with Blue Cross Blue Shield
- Benefit check. Send us your child’s member ID. We confirm ABA coverage, cost sharing, and whether your plan requires prior review.
- Diagnosis and order. Your child needs a documented autism diagnosis. In North Carolina, a licensed physician or licensed psychologist orders the treatment. BlueCross BlueShield of SC accepts a diagnosis from a psychiatrist, psychologist, neurologist, developmental pediatrician, or another licensed physician experienced in autism.
- Assessment. Our BCBA observes your child, completes standardized assessments, and writes a treatment plan with measurable goals. For BlueCross BlueShield of SC, the assessment must be dated within 45 days of the request.
- Approval. When your plan requires it, we send the treatment plan for review and wait for approval before therapy starts.
- Therapy starts. Sessions begin at home, in our clinic, or in the community, based on the plan.
Once services start
The BCBA tracks progress against each goal and sends updates when your plan asks for them. BlueCross BlueShield of SC expects progress to be documented every six months, and South Carolina law lets a plan request an updated treatment plan from the treating doctor once every six months.
Parents are part of the treatment team. The plan of care lists caregiver goals, and the BCBA coaches you so that new skills carry over to home and the community.
Blue Cross Blue Shield families in your community
Blue Cross Blue Shield ABA therapy FAQs
Many Blue plans cover ABA for autism, but the details depend on your state and your plan. Your benefit booklet lists any visit limits, cost sharing, and prior review rules. Send us your member ID and we check it for you at no cost.
For plans that North Carolina insurance law regulates, yes. State law requires those health benefit plans to cover the screening, diagnosis, and treatment of autism, including adaptive behavior treatment such as ABA. The plan may cap ABA at a yearly dollar amount that the state adjusts for inflation, and may limit it to members 18 or younger. Coverage cannot be denied because the treatment is habilitative or educational.
South Carolina requires group health plans regulated by the state, including the State Health Plan, to cover autism treatment prescribed by the child's doctor under a treatment plan. To qualify, a child must be diagnosed at age eight or younger, and coverage continues until age 16. Behavioral therapy has a yearly maximum that is adjusted for inflation. Individual and small employer plans are not included.
Its ABA policy asks for a confirmed autism diagnosis from a psychiatrist, psychologist, neurologist, developmental pediatrician, or another licensed physician experienced in autism. The BCBA's assessment, including observation in your child's everyday setting, must be dated within 45 days of the request, and parents commit to taking part in the treatment plan goals.
Under North Carolina's autism law, a licensed physician or licensed psychologist orders the treatment, and a qualified professional such as a board certified behavior analyst provides or supervises it. Blue Cross NC also has to approve a prior review for certain services before your plan helps cover the cost; your benefit booklet says whether ABA is one of them on your plan.
It can, with extra documentation. When ABA is planned at school, the BCBA's assessment has to include an observation at school that shows why services are medically necessary there, plus a detailed functional behavior assessment.
Sources
- G.S. 58-3-192, Coverage for autism spectrum disorder (North Carolina General Assembly)
- SC Code § 38-71-280, Autism spectrum disorder coverage (South Carolina Legislature)
- How to request prior review and authorization (Blue Cross NC)
- Applied Behavioral Analysis Services, CAM 387 (BlueCross BlueShield of South Carolina)
Benefit rules change. Your plan documents and your health plan have the final word on your coverage.
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