What Requirements must be Met for Insurance to Cover Aba Therapy in Utah?

To secure insurance coverage for Applied Behavior Analysis (ABA) therapy in Utah, families must meet several specific requirements across private and public health plans.

Foundational Requirements:

• Formal Diagnosis: A documented autism diagnosis from a qualified professional, such as a physician or psychologist, is mandatory.
• Medical Necessity: Providers must document that the therapy is medically necessary for the child’s development.
• Treatment Plan: A Board Certified Behavior Analyst (BCBA) must create a personalized treatment plan for the insurer to review.
• Prior Authorization: Most insurers require approval before therapy begins to confirm the treatment plan and authorized hours.

Specific Plan Requirements:

• Private Insurance: Under Utah law (SB 57 and SB 95), state-regulated individual and large group plans must cover ABA. Families should verify if their specific plan is fully insured or a small group plan, as the latter may have exclusions.
• Utah Medicaid (CHEC Program): Eligibility is based on income thresholds (typically up to 300 percent of the federal poverty level). Documentation must be submitted through the state portal for children under age 21.
• Tricare: Coverage is available for dependents under age 21 through the Autism Care Demonstration. This requires prior approval and specific forms, such as DD Form 2940.

Additional considerations include age restrictions (generally up to 21 for public plans) and the requirement for services to be supervised by a BCBA and implemented by Registered Behavior Technicians (RBTs).