Medicaid ABA Coverage in Minnesota
How Minnesota Medical Assistance covers ABA for kids under 21, and the exact steps to get started.
What Minnesota Medicaid Covers
Minnesota's Medicaid program is called Minnesota Medical Assistance. For enrollees under 21, it covers medically necessary applied behavior analysis (ABA) through the federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. That means if a doctor or other qualified professional says ABA is medically necessary, your plan must cover it.
There is no fixed dollar cap, age cap, visit cap, or hour limit written into the state's autism mandate. Those limits change and vary by plan. What matters is what your specific Medicaid plan covers. The exact question to ask your insurer is: "Does my plan cover medically necessary ABA under EPSDT, and are there any prior authorization or utilization review requirements?"
Who Qualifies
To get ABA through Minnesota Medical Assistance, your child must be under 21 and enrolled in Medicaid. You also need a formal diagnosis of autism spectrum disorder (ASD) from a qualified professional, such as a developmental pediatrician, child psychologist, or psychiatrist.
In addition to the diagnosis, your child's provider will need to write a treatment plan that shows ABA is medically necessary. This plan typically includes specific goals, the recommended number of hours per week, and how progress will be measured. Without a current treatment plan, the request will likely be denied.
If your child is already receiving ABA through a private insurance plan and you're switching to Medicaid, you may need to get a new prior authorization. The new plan will review the existing treatment plan and may require updated assessments.
How Prior Authorization Works
Most Minnesota Medicaid enrollees are in a managed care plan. The plan name is on your member card. To start ABA, you or your provider will submit a prior authorization request to that plan. The request must include the diagnosis, the treatment plan, and any supporting documentation.
The plan reviews the request and decides whether to approve it. Approval can take a few weeks, so start early. If the request is denied, you have the right to appeal. The denial letter will explain the appeals process and the deadline to file.
If your child is not in managed care (for example, in a fee-for-service arrangement), the prior authorization process may go through the state directly. Ask your provider or the state's Medicaid office for the correct form.
When an Agency's Panel Is Closed
Some ABA agencies have closed Medicaid panels, meaning they aren't accepting new Medicaid patients. This can be frustrating, but it's not the end of the road. Ask the agency if they keep a waitlist and how long it typically is. Also ask if they can refer you to another provider with openings.
You can also contact your managed care plan's member services. They should have a list of in-network ABA providers and may be able to help you find one with availability. If you're still stuck, ask about a single-case agreement, which lets you see an out-of-network provider at in-network rates.
In the directory, we list the listings for this state. The largest concentrations are in your county's page. Even if one agency is full, others in your area may have openings.
What About Private Insurance
If your child has private insurance, the rules are different. All 50 states have an autism insurance mandate, but that mandate only applies to fully insured plans. If your employer's plan is self-funded, it is governed by ERISA and is not required to follow the state mandate. Many self-funded plans cover ABA anyway, but you need to check your specific plan.
The Affordable Care Act does not require ABA coverage. So don't assume a marketplace plan covers it. Read your plan's summary of benefits or call the customer service number on your insurance card and ask directly: "Does my plan cover applied behavior analysis for autism?"
Minnesota listings right now
100 ABA agencies across 21 Minnesota counties.