Does Insurance Cover ABA Therapy in New Hampshire?
Find out what your New Hampshire plan covers for ABA therapy and what to do if you get a denial.
How ABA Coverage Works in New Hampshire
New Hampshire has a state autism insurance mandate. That means most fully insured health plans sold in the state must cover medically necessary ABA therapy for autism. Fully insured means you buy the plan directly from an insurance company, either on your own or through a small employer.
But there is a big exception. If your employer has 50 or more employees and self-funds its health plan, that plan is governed by federal ERISA law, not the state mandate. Self-funded means the employer pays claims out of its own pocket instead of buying insurance. These plans are not required to cover ABA, though many choose to anyway.
That is why two families at the same company can get different answers. One might have a fully insured plan with full ABA coverage. The other might have a self-funded plan with no ABA benefit at all. The difference is not about your child or your diagnosis. It is about how your employer set up the plan.
The Exact Question to Ask HR and Your Insurer
Before you call an ABA agency, get the facts from your own plan. Start with your HR department or benefits administrator. Ask this exact question: 'Is our health plan fully insured or self-funded?'
Then call the customer service number on your insurance card and ask: 'Does my plan cover applied behavior analysis for autism? If yes, are there any visit limits, age limits, or dollar caps?'
Write down the date, the name of the person you spoke to, and what they said. That note can help if you get a denial later. Also ask for the specific policy language about ABA. Insurers sometimes have a separate medical policy document that spells out the coverage rules.
What a Prior Authorization Needs
Most plans require prior authorization before ABA can start. That means the insurance company reviews your child's diagnosis and treatment plan before they agree to pay. The process usually takes 2 to 4 weeks, sometimes longer.
Your ABA provider will handle most of this, but you need to provide the diagnosis. Your child needs an autism diagnosis from a qualified professional, typically a developmental pediatrician, child psychologist, or psychiatrist. The insurance company will want the diagnostic report, a treatment plan, and sometimes a letter of medical necessity.
Ask your provider for a list of what the insurer requires. Common items include the diagnostic evaluation, a treatment plan with goals, and a statement that ABA is medically necessary and not just educational. Make sure you submit everything on time. Missing a deadline can delay coverage for weeks.
What to Do on a Denial
If your plan denies ABA coverage, you have the right to appeal. The first step is an internal appeal with your insurance company. You usually have 180 days from the denial date to file. The denial letter will tell you the deadline and how to appeal.
In your appeal, include a letter from your child's doctor explaining why ABA is medically necessary. Also include any new information, like a second opinion or updated treatment plan. Keep a copy of everything you send.
If the internal appeal fails, you can request an external review. In New Hampshire, that is a review by an independent third party. The insurance company must follow the external reviewer's decision. Your state insurance department can guide you through this process, and you can find their contact information on the state's website.
New Hampshire Medicaid as a Route
If your family qualifies for New Hampshire Medicaid, ABA coverage is available for children under 21. Medicaid covers medically necessary treatment through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. That includes ABA when a doctor says it is needed.
Your Medicaid plan name is on your member card. Call the customer service number on that card and ask about ABA coverage. You will need a diagnosis and a referral from a provider who accepts Medicaid.
Medicaid can also be a backup if your private plan denies coverage. Some families use Medicaid as a secondary insurance to cover services the private plan does not. Check with your Medicaid plan to see if that is an option for you.
Finding ABA Providers in New Hampshire
Once you know your coverage, the next step is finding a provider. In New Hampshire, the listings for this state are organized by county. The largest concentrations are in Hillsborough County, Rockingham County, and Merrimack County.
When you call an agency, ask if they accept your insurance. Also ask about their waitlist, because some agencies have waitlists of several months. You can also ask if they offer a free consultation to discuss your child's needs before you commit.
New Hampshire listings right now
71 ABA agencies across 8 New Hampshire counties.