Accessing Services

Certain insurance plans cover some services for autism. These plans include:

• Group plans from large employers, based in NC but not operating nationally or internationally
• Some “grandfathered” plans that were in effect prior to 2010
• NC State Employees Health Plan
• Private and public employers with voluntary coverage
• TRICARE for active military
• Medicaid and Health Choice (under EPSDT up to age 21)
• Federal civilian employees

As of July 1, 2016, in North Carolina, autism treatments such as Applied Behavior Analysis (ABA) and other evidence-based treatments must be covered under certain health insurance plans for dependents up to age 18. Health plans subject to the law include large group plans (employers with 50+ employees) that are subject to state of NC law, grandfathered plans, and transitional plans. The plans must cover Adaptive Behavior Treatment, which includes ABA and other evidence-based therapies such as TEACCH, Pivotal Response, etc. Medically necessary treatments such as occupational therapy, speech therapy, and physical therapy, as well as psychiatric, psychological, and pharmacy care also are covered. Annual benefits for intensive behavioral services are capped at $40,000. (Co-payments, co-insurance, and deductibles may apply for autism treatment depending on your insurance plan.)

Health-care coverage varies depending on the type of employer and type of plan. We strongly suggest contacting your employer’s Human Resources department directly to learn whether your benefits include coverage of autism treatment.

The State Employees Health Plan sets its own benefit package and had already voluntarily adopted an autism treatment benefit up to age 26, so state employees’ benefits might differ from other plans covered under any new law.

North Carolina’s Medicaid health-care coverage plan has a number of programs and waivers that include health care and treatment services for people with autism. Medicaid health-care coverage is based on disability status, individual or family income, and other factors. You can apply for Medicaid through your local Department of Social Services or start your application process online. Following are some of the ways people with autism can get services under Medicaid.

NC Medicaid Home and Community-Based (HCB) waiver: Children and adults with developmental disabilities such as autism may apply for a slot in an NC Medicaid Home and Community-Based, or Innovations, waiver. Under the waiver, only the income and resources of the individual are counted, so a child with autism whose parents’ income exceeds the guidelines for Medicaid insurance may still be eligible. The first step is to locate the Local Management Entities/Managed Care Organization (LME/MCO) for the county in which the individual resides using this directory. If found eligible, the individual will be placed on the Registry of Unmet Needs until a slot becomes available. A limited number of Innovations waiver slots are available, and individuals may remain on the waiting list for years, so it is important to apply as soon as possible. The LME/MCO should also offer referal for other available and appropriate services (outlined below) while individuals wait for their “waiver slot.”

Medicaid Early Periodic Screening Diagnosis and Treatment (EPSDT): States are required to cover behavioral services for autism for children on Medicaid who are under 21, as well as other interventions. You must find a service provider that is part of an LME/MCO network or willing to become part of a network. Children who are on Medicaid are automatically qualified for EPSDT services; they and their families do not need to sign up for a separate program. For more information, read our detailed guide.

Medicaid State Plan Services: Under Medicaid, individuals with autism should be getting access to physical and mental health-care services including diagnostic assessments, physical therapy, occupational therapy, speech therapy, outpatient and inpatient mental health/psychiatric services, preventative and necessary physical health care, medications, etc. Mental health services may need to be authorized through the LME/MCO, and providers of those services may need to be part of the LME/MCO network.

LME/MCO Non-Medicaid Services and Medicaid “b3” Services: Services vary based on funding and qualifications, but calling the access line of your local LME/MCO will help triage availability for the services for those without other health-care coverage funded through state of NC dollars or funded through b3 (for individuals with Medicaid).

Vocational Rehabilitation (VR) is the state agency that assists people with disabilities in developing job readiness skills, and acquiring and retaining employment. VR may also assist with benefits counseling and assistive technology. To find out about eligibility, contact VR.

Health Savings Accounts: You may be able to set aside pre-tax dollars into an HSA through your employer. This account can be used for health-care expenses such as co-pays, and you may also be able to deduct health-care expenses on your taxes. Please see your employer regarding HSA. The IRS has information on medical tax deductions.

ABLE Accounts: Achieving A Better Life Experience (ABLE) Accounts allow a person with a disability to save for critical expenses while still allowing eligibility for means-tested disability supports and health care. ABLE accounts should start to become available to North Carolina residents in early 2017. Learn more on the website for the NC Office of the Treasurer.

Private pay: Options are available for most services – contact your Autism Resource Specialist for more information.