Does NJ FamilyCare cover ABA therapy? A guide for New Jersey parents

If your child has NJ FamilyCare, the short answer is yes: ABA (applied behavior analysis) therapy is a covered benefit for children with autism. Many families don't find this out until months after a diagnosis, so here is how it works and what to do first.

Who is covered

NJ FamilyCare is New Jersey's Medicaid and CHIP program. Since April 1, 2020, it has covered ABA therapy for members from birth up to age 21 who have an autism spectrum disorder diagnosis. The benefit comes through a federal rule for children on Medicaid called EPSDT, which says children must get the treatment that is medically necessary for them.

Which health plan you have matters

Most families on NJ FamilyCare are enrolled in one of these health plans, and that plan is the one that approves and pays for ABA:

• Aetna Better Health of New Jersey
• Fidelis Care
• Horizon NJ Health
• UnitedHealthcare Community Plan
• Wellpoint (formerly Amerigroup New Jersey)

Your plan's name is on your child's insurance card. Each plan has its own forms and its own list of approved (in-network) providers, so the ABA provider you choose must work with your child's plan.

What you need

1. An autism diagnosis. A doctor or psychologist in your plan's network evaluates your child and writes a report. It helps a lot when the report recommends ABA therapy.
2. An ABA assessment. Your plan approves an assessment by a Board Certified Behavior Analyst (BCBA), who meets your child, talks with you and writes a treatment plan with goals and weekly hours.
3. Approval of the treatment plan. The BCBA sends the plan to your health plan. Once it is approved, therapy can start.

Your ABA provider handles steps 2 and 3, including the paperwork with your plan. Your job is mostly to share the diagnosis report and insurance card, sign the intake forms, and be home for the assessment.

How to get started

1. Find your plan name and member ID on your child's NJ FamilyCare card.
2. If your child doesn't have a diagnosis yet, call your plan's member services number (on the back of the card) and ask for in-network providers who do autism evaluations. Our guide How to get an autism diagnosis in New Jersey walks through it.
3. Choose an in-network ABA provider and send them the diagnosis report and a picture of the insurance card.
4. Sign the intake forms and schedule the assessment at home.

Questions parents ask us

Does my child have to be a certain age?

The NJ FamilyCare ABA benefit covers members under 21. Younger children often see the biggest gains, so it is worth starting as soon as you can, but older children and teens qualify too.

Can therapy happen at home?

Yes. Little Haven provides ABA in your home, where your child already feels comfortable and where everyday routines like meals, play and bedtime happen.

What if my plan is not on your list?

Little Haven works with Horizon NJ Health, Aetna Better Health of New Jersey, Fidelis Care and Wellpoint, and with EmblemHealth / GHI (NYC PPO). If your child has a different plan, call us anyway. We'll tell you honestly whether we can help and point you in the right direction if we can't.

My child also has private insurance. Which one is primary?

If your child has private insurance through a parent's job and also NJ FamilyCare, the private plan is usually billed first and NJ FamilyCare second. Tell us about both, and we'll sort out the order with you.

Sources: Autism New Jersey, NJ FamilyCare autism benefit: getting started; NJ Division of Medical Assistance and Health Services, health plans under contract. Coverage rules can change; your health plan's member services can confirm your child's benefits.