Medicaid: Starting Treatment

Qualified Healthcare Professional (QHP) is an insurance term.  Most often, there are two types of Qualified Healthcare Professionals (QHP) involved.  These are often two different people.

• A diagnosing QHP — This is a physician or psychologist who makes a diagnosis of autism and recommends ABA services.
• A treating QHP — This is the Board Certified Behavior Analyst who develops, oversees, and sometimes implements a treatment plan.

Finding qualified professionals:

• Provider Network – Each MCO maintains its own provider network. See the chart below and contact your MCO for next steps.

All families receiving NJ FamilyCare are enrolled* in a Medicaid Managed Care Organization, or MCO.  The MCO is responsible for providing all medically necessary ABA treatment through their provider network.

MCOs currently operating in New Jersey are:
Aetna | Amerigroup | Horizon | United Healthcare | WellCare

Every MCO has different guidelines.  To begin the process, find your MCO’s contact information in the chart below and contact them for their specific autism coverage guidance.

*Note:  There may be a temporary period of Medicaid fee-for-service (FFS) coverage until the MCO enrollment occurs.  For families in this group, the State is responsible for FFS coverage of all medically necessary ABA services. To begin the process, contact Shanique McGowan at 609-433-0264 or shanique.mcgowan@dhs.state.nj.us.

Note:  If your child already has a diagnosis, skip to the “Assessment” tab.

In most cases, a child covered under Medicaid will need a formal autism diagnosis before their MCO will cover ABA. You will need to get a list of diagnostic evaluators (diagnosing QHPs) who are your MCO’s network, secure an appointment, and get an evaluation.

Authorization for diagnosis:

Once you attend your child’s diagnostic evaluation appointment, the MCO authorizes a diagnosing QHP to conduct an evaluation.

If you have fee-for-service Medicaid (see the tab labelled “Managed Care Organization – MCO” above) no prior authorization is required for a diagnostic evaluation until an MCO is assigned.

For more information:
Read about what the diagnosis entails and download Autism New Jersey’s Start Here guide, available in English and Spanish.

Appointment Delays:

Even though waitlists for diagnostic evaluations may be long, there are things you can do to help your child while you wait.

See the “Assessment” tab for the next step.

If your child already has an autism diagnosis, you will need to find a Board Certified Behavior Analyst (BCBA) who is in your MCO’s network. Similar to the search for a diagnostic evaluator, this process should start by contacting the MCO’s member services department or searching the “find a doctor” page on their website. The MCO considers that BCBA the “treating QHP.”

Authorization for assessment:

The MCO then authorizes the treating QHP to conduct an assessment.

If you have fee-for-service Medicaid (see the tab labelled “Managed Care Organization – MCO” above) no prior authorization is required for an ABA assessment until an MCO is assigned.

Assessment:
Once the assessment is authorized, the Treating QHP conducts the assessment and submits a treatment plan to the MCO.

Authorization for treatment: If there are no problems, the MCO approves the treatment plan. See the “Treatment” tab for the next step.

Authorization for treatment: If the MCO approves the treatment plan, your BCBA can begin providing ABA therapy and can submit their bills to your MCO.

Treatment:

• Delivered by – A treating QHP or someone who is supervised by a QHP.  These treating professionals have credentials such as BCBA-D, BCBA, BCaBA, RBT, or another technician.
• Targets – Treatment can include specific skill acquisition and behavior reduction goals with the overall goal of improving communication, social, and adaptive skills.
• Ratio – Treatment can be delivered 1:1 or in small groups.
• Family participation – Parent education is encouraged.
• Location – Treatment may be provided in a therapist’s office, a community setting, or the child’s home.

For more information:
Visit our website for articles about treatment and ABA.