In-home ABA therapy in North Carolina

ABA needs a diagnosis and a written order

Three steps, in this order. We can request approval once the diagnosis and the order are in hand.

North Carolina's autism mandate covers screening, diagnosis and treatment of autism spectrum disorder as defined by the current DSM or ICD. Treatment has to be ordered by a licensed physician or licensed psychologist, and then provided or supervised by one of the professionals the statute lists, including a Board Certified Behavior Analyst.

NC Medicaid applies the same order requirement. So the sequence in North Carolina is diagnosis, order, then authorization, and we can only start the third step once the first two are in hand.

What the mandate lets a plan limit

Your plan may cap ABA by age and by dollars. Ask your insurer in writing what its current limits are.

The statute allows plans to limit adaptive behavior treatment to individuals 18 years of age or younger, and it sets an annual dollar maximum that started at $40,000 and has been indexed since. Those are limits a plan may choose to apply, so ask your insurer in writing what its current figure is. The screening and diagnosis obligation carries no age limit. Self-funded employer plans sit outside the mandate entirely.

If your child is on NC Medicaid

Medicaid covers ABA for children under 21 and for adults where the evidence supports it. Every plan needs prior approval.

Research-Based Behavioral Health Treatment is covered for children under 21 through EPSDT, and since July 2021 for adults too where the evidence supports it, which makes North Carolina unusual. Every treatment plan needs prior authorization; being under 21 does not remove that requirement.

Plans of 16 hours a week or fewer are authorized for up to 180 days at a time, plans above 16 hours for up to 90 days, and reauthorization follows the same split, so we start each renewal well before the window closes.

If your plan says no

Appeal to your insurer first. Then Smart NC can send your case to an independent reviewer.

Finish the insurer's internal appeal first, then request an external review from Smart NC, the consumer program inside the North Carolina Department of Insurance, within 120 days of the final internal decision. Smart NC assigns an independent review organization; a standard review is decided within 45 days, an expedited one within about four business days, and in urgent cases the expedited external review can run at the same time as the internal appeal.

Smart NC also helps families file the internal appeal itself, at 1.855.408.1212. This process does not cover self-funded plans, which use the federal external review route, or Medicaid, which has its own appeal process.