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ABA therapy insurance and Medicaid

Most private plans and Medicaid pay for ABA after a child is diagnosed with autism and the plan approves the hours. What the big insurers and each state's Medicaid say is laid out here.

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Medicaid ABA coverage state by state

StateProgrammeAge limitDetails
TexasTexas Medicaid (STAR, STAR Kids and STAR Health)Children and young adults age 20 and younger.Texas Medicaid and ABA
ArizonaAHCCCS (Arizona Health Care Cost Containment System), Arizona's Medicaid programThere's no age limit. AHCCCS health plans say any member of any age can get ABA if medical necessity is met.Arizona Medicaid and ABA
North CarolinaNC Medicaid (NC Medicaid Direct, plus NC Medicaid Managed Care health plans)Under the federal EPSDT rule, coverage of medically necessary care in this age group reaches children and young adults under 21.North Carolina Medicaid and ABA
IllinoisIllinois Medicaid (HFS medical card). Most members receive care from one of the HealthChoice Illinois managed care plans.The age range runs from birth through age 20 for children and young adults.Illinois Medicaid and ABA
FloridaFlorida Medicaid (SMMC, which stands for Statewide Medicaid Managed Care, plus fee-for-service).Children and young adults under 21Florida Medicaid and ABA
GeorgiaGeorgia Medicaid and PeachCare for Kids, mainly through Georgia Families care management organizations (CMOs)Children and young adults under 21Georgia Medicaid and ABA

TRICARE and private insurance

  • Yes. TRICARE pays for ABA under the Autism Care Demonstration when the care is clinically necessary and aimed at the core symptoms of autism. Relatives of active duty members, of retirees and of some Guard and Reserve members can qualify.

  • Yes, for autism, once a child satisfies Aetna's medical necessity rules. Aetna considers ABA unproven for any condition besides autism, and what is covered for you rests on your own plan terms.

  • Yes. Excellus BCBS considers ABA medically appropriate for autism, while New York law requires plans to cover treatment for autism.

  • Yes, provided the child's records show that the criteria are met. For autism, ABA is the leading proven treatment, according to Optum.

  • For autism, yes, when every one of Cigna's medical necessity criteria is met. For other conditions, Cigna doesn't cover ABA, and that includes Rett syndrome. If your plan document differs, it always wins.

The rules that shape your coverage

All 50 states have laws that make state-regulated health plans cover autism treatment. The source is Autism Speaks.

Federal ERISA law governs self-funded employer health plans, and those plans aren't required to follow state autism insurance laws. The source is Autism Speaks.

Medicaid's EPSDT benefit means states must cover any medically necessary service, including autism care, for eligible children under 21. Source: the Centers for Medicare & Medicaid Services.

Autism services for children must be covered by Medicaid, according to each child's medical need. CMS said this in a July 7, 2014 bulletin. Source: the Centers for Medicare & Medicaid Services.

Questions for your plan

  1. Does my plan cover ABA for autism, and do any age or dollar limits apply?
  2. Is prior authorization required, and what does the provider have to submit?
  3. Who is allowed to diagnose, and must it be a particular type of doctor or psychologist?
  4. Which ABA providers in my area are in network?
  5. How much do I pay for each session, and how large is my out-of-pocket maximum?

Note the name of the person you spoke with, plus the date. Ask for the denial in writing if the plan says no, so you can appeal it.

ABA therapy that accepts Medicaid and insurance, by city