Insurance

ABA therapy with SC Medicaid

South Carolina Healthy Connections Medicaid covers ABA therapy for children and young adults with autism through age 20. We check your child's coverage for free and request the prior authorization for you.

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Who is eligible

South Carolina Healthy Connections Medicaid covers autism services, including ABA, for members from birth through age 20. Your child qualifies when they are enrolled in Healthy Connections, ABA is medically necessary, and they have one of the following:

  • an autism spectrum disorder (ASD) diagnosis that meets current DSM criteria,
  • a school special education designation under the autism category, confirmed by a physician involved in your child’s care, or
  • an autism eligibility determination from the state’s Office of Intellectual and Developmental Disabilities, confirmed by a physician.

Under the EPSDT benefit, a child at risk for autism can also be presumptively eligible for ABA. The risk has to be identified through early intervention (IDEA Part C) or documented by your child’s physician in their medical home.

How to start ABA therapy with SC Medicaid

  1. Referral. Your child’s physician can refer you to us, or you can contact us yourself. SC Medicaid accepts self-referrals to autism services providers.
  2. Behavior identification assessment. A BCBA meets your child and you in person to complete the assessment. When ABA will address challenging behaviors, or when more than 15 hours a week of direct therapy is requested, the BCBA also completes a functional behavior assessment.
  3. Plan of care. The BCBA writes an individualized plan of care with goals for your child and specific goals for parent or caregiver participation.
  4. Prior authorization. We send the plan of care, the proof of diagnosis or eligibility, and the assessments for prior authorization. For fee-for-service members, the state’s review contractor decides using standard ABA medical necessity criteria. If your child is in a managed care plan, we follow that plan’s own process.
  5. Therapy starts. Sessions begin once the authorization is approved.

Once services start

For fee-for-service members, each authorization lasts six months. Before it ends, the BCBA sends an updated plan of care and a progress summary to request continued treatment.

Planning for the end of ABA starts on day one. SC Medicaid expects families and other providers to be consulted three to six months before the first change in services, and expects hours to step down gradually, over six months or longer, rather than stop all at once.

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SC Medicaid ABA therapy FAQs

Yes. Healthy Connections Medicaid covers medically necessary autism services, including ABA, for members from birth through age 20, up to the last day of the month of their 21st birthday. The coverage comes through Medicaid's Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.

One of three: an autism diagnosis that meets current DSM criteria; a school special education eligibility under the autism category that a physician involved in your child's care has confirmed; or an autism eligibility determination from the state's Office of Intellectual and Developmental Disabilities, also confirmed by a physician.

Sometimes. Children at risk for autism can be presumptively eligible for ABA when early intervention (IDEA Part C) identifies the risk, or when your child's physician documents it in their medical home.

Not always. SC Medicaid recognizes referrals from a physician or other licensed practitioner, and it also lets members refer themselves to an autism services provider, whether for a diagnostic assessment or for treatment with an existing diagnosis.

For members in fee-for-service Healthy Connections, each ABA prior authorization lasts six months, and your BCBA requests the next one before it runs out. If your child is enrolled in a managed care plan, that plan sets its own authorization rules.

Call the Healthy Connections Member Service Center at 888-549-0820. Children in a managed care plan are covered for autism services too; the plan handles the authorization. You can also share your child's Medicaid ID with our intake team and we will check for you.

Yes. SC Medicaid requires parent or caregiver participation. Your child's plan of care sets specific caregiver goals, and the BCBA works on them with you in family training sessions that follow an evidence-based parent curriculum.

Sources

Benefit rules change. Your plan documents and your health plan have the final word on your coverage.

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