Does Insurance Cover ABA Therapy in Georgia?
Find out if your Georgia plan covers ABA therapy and get the exact questions to ask.
Why coverage varies by plan
Georgia has a state autism insurance mandate. That mandate requires many health plans to cover medically necessary ABA therapy for children with autism. But it does not apply to every plan.
The mandate binds fully insured plans, which are plans where the employer buys coverage from an insurance company. It does not bind self-funded plans, where the employer pays claims directly and hires an administrator. Self-funded plans follow federal ERISA rules instead, and they are exempt from state mandates.
That is why two families at the same employer can get different answers. One may have a fully insured plan and get ABA coverage. The other may have a self-funded plan and get a denial, even though they work for the same company.
Ask HR these two questions
Before you call an agency, find out how your plan is funded. Ask your HR department: 'Is our health plan fully insured or self-funded?' That single answer tells you whether Georgia's mandate applies to you.
Then call the number on your insurance card and ask: 'Does my plan cover medically necessary ABA therapy for autism?' If they say yes, ask for the specific coverage details in writing.
If your plan is self-funded, do not assume you are out of luck. Many self-funded plans cover ABA anyway, even though they are not required to. The only way to know is to ask.
What prior authorization needs
Most plans require prior authorization before ABA starts. That means the insurer reviews the treatment plan and approves it before services begin. The process usually involves your ABA provider submitting documents.
You will typically need a formal autism diagnosis, a prescription or referral from a doctor, and a detailed treatment plan. The treatment plan should include goals, estimated hours per week, and how progress will be measured.
Ask your insurer for the exact prior authorization form name and what documents they require. Ask how long the review takes and what to do if they need more information. Keep copies of everything you submit.
What to do on a denial
If your claim is denied, you have the right to appeal. The denial letter must explain why and tell you the deadline to appeal. Do not miss it.
Start by calling the insurer to ask why it was denied. Sometimes a simple documentation error is the cause. If the denial is based on medical necessity, ask your ABA provider to write a letter explaining why the treatment is needed.
If the internal appeal is denied, you may have the right to an external review by an independent third party. Ask the insurer about this option. Keep a log of every call, including dates, names, and what was said.
Georgia Medicaid as a route
If you qualify for Georgia Medicaid, ABA therapy is covered for children under 21 when it is medically necessary. This is through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.
Your child must be enrolled in Medicaid or a Medicaid managed care plan. The plan name is on your member card. Contact your managed care plan to ask about ABA coverage and how to get prior authorization.
If you are not sure whether you qualify, apply through Georgia's Medicaid agency. The application process is online and takes about 15 minutes. You will need income and household information.
Where to find ABA providers
Once you know your coverage, you can look for an ABA provider that accepts your insurance. In Georgia, the listings for this state include many agencies across the counties we cover.
The largest concentrations are in Fulton County, Cobb County, and Gwinnett County. If you live in a rural county, you may need to travel or look for providers offering telehealth.
When you call an agency, ask if they are in-network with your specific plan. Ask if they have experience with prior authorization for your insurer. Ask about waitlists, because some agencies have them.
Georgia listings right now
727 ABA agencies across 73 Georgia counties.