Does Insurance Cover ABA Therapy in North Dakota?
Find out if your North Dakota plan covers ABA therapy and exactly what to ask to get a clear answer.
How Coverage Works in North Dakota
North Dakota has a state autism insurance mandate. It requires state-regulated health plans to cover medically necessary ABA therapy for children with autism. But that mandate does not apply to every plan.
The key split is between fully insured plans and self-funded plans. Fully insured plans are regulated by the state, so the mandate applies. Self-funded plans are governed by federal ERISA rules, not state law, so the mandate does not bind them. Many self-funded plans still cover ABA, but they are not required to.
That is why two families at the same employer can get different answers. One might have a fully insured plan and the other a self-funded one. The coverage decision depends on how the employer set up the plan.
The Exact Question to Ask HR
Before you call an ABA agency, find out one thing: is your health plan fully insured or self-funded? Ask your HR department or benefits administrator this exact question: 'Is our health plan fully insured or self-funded under ERISA?'
If the plan is fully insured, the state mandate applies. If it is self-funded, the plan decides its own coverage rules. Either way, you still need to check your specific plan documents for ABA benefits.
You can also call the member services number on your insurance card and ask: 'Does my plan cover applied behavior analysis for autism? What are the limits and requirements?' Write down the date, the representative's name, and what they tell you.
What Prior Authorization Needs
Most plans require prior authorization before ABA therapy starts. That means the insurance company reviews the medical necessity before they agree to pay. The process usually starts with a diagnostic evaluation from a qualified professional, like a developmental pediatrician or a psychologist.
Your ABA provider will typically submit the request. It includes the diagnosis, the treatment plan, and the number of hours they recommend. The insurer may ask for more information, so be ready to follow up.
Ask your insurer: 'What documentation do you need for ABA prior authorization? How long does the review take?' Some plans have a specific form, like a prior authorization request form, that must be used. Ask for the exact form name and where to send it.
What to Do on a Denial
If your claim is denied, you have the right to appeal. The denial letter will explain the reason and the deadline to appeal. That deadline is often 180 days, but it varies by plan. Do not miss it.
Start the appeal by asking your ABA provider for a letter of medical necessity. That letter should explain why ABA is needed and how it will help your child. You can also ask your insurer for a copy of the specific policy language they used to deny the claim.
If the first appeal is denied, you may have a second level of appeal, sometimes called an external review. Ask your insurer: 'What is the next step after an internal appeal? Can I request an external review?'
North Dakota Medicaid as an Option
If you qualify for North Dakota Medicaid, ABA therapy is covered for children under 21 when it is medically necessary. This coverage comes through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which requires states to cover necessary services.
Your child must have a diagnosis of autism and a doctor's order for ABA. You will need to find a Medicaid provider that offers ABA. Your Medicaid plan's member services can tell you which agencies are in network.
The plan name is on your member card. Call that number and ask: 'Does my plan cover ABA therapy? What is the process to get it approved?'
Finding an ABA Provider
We list ABA agencies across the counties we cover. The largest concentrations are in Cass County, Ward County, and Stutsman County. The remaining counties have smaller numbers.
When you contact an agency, ask if they accept your insurance. They can verify your benefits and tell you if they are in network. Also ask about their waitlist and how soon they can start services.
If you have a self-funded plan, the agency may still be able to work with you. Many self-funded plans cover ABA even though they are not required to. The agency can check your specific benefits.
North Dakota listings right now
14 ABA agencies across 6 North Dakota counties.