Medicaid: Starting Treatment
March 03, 2021
Health Insurance and Autism Series.
Essential Information for Families
As of April 1, 2020, NJ FamilyCare covers ABA services for children birth to 21 years, a much anticipated benefit for children on Medicaid. This article provides information about how families can access this benefit for their child.
To understand how to access this benefit, it’s helpful to know who’s who.
Your Healthcare Professional
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.
Managed Care Organization - MCO
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 firstname.lastname@example.org.
Step by Step
Here is a simple breakdown of what to expect in the process.
The first step when seeking Medicaid coverage of ABA therapy is always to contact your MCO. MCO contact information is included at the bottom of this article.
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.
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.
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.
- 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.
MCO Contact Information
|NJ DD dedicated line
O: 973.274.2141 | C: 862.229.4132
O: 973.274.2166 | C: 862.240.2495
Need help? Call Autism New Jersey’s Helpline 800.4.AUTISM or Medicaid’s Office of Customer Service 609.588.8522 or email MAHS.ASDinquiries@dhs.nj.gov.
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Originally posted 4/21/2020