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Medicaid ABA Coverage in New York

Get the steps to start ABA through New York Medicaid, including eligibility, prior authorization, and finding an open provider.

State coverage

Medicaid ABA Coverage in New York

New York Medicaid covers medically necessary ABA therapy for enrollees under 21. This coverage comes through the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which requires states to cover any medically necessary service that corrects or ameliorates a condition.

If your child is on Medicaid in New York, ABA is a covered benefit. You do not need a separate waiver or special enrollment. The coverage applies to all Medicaid managed care plans and fee-for-service Medicaid.

Who Qualifies for ABA

Your child must be under 21 and enrolled in New York Medicaid. You will need a formal autism diagnosis, usually from a qualified professional such as a developmental pediatrician, child psychologist, or psychiatrist. The diagnosis must meet the criteria in the DSM-5.

You also need a treatment plan. The plan is typically written by a Board Certified Behavior Analyst (BCBA) and should include specific goals, the number of hours per week recommended, and the duration of treatment. Medicaid will review this plan to decide if the ABA is medically necessary.

Getting Prior Authorization

In most cases, your ABA provider will handle the prior authorization process. They submit the diagnosis, treatment plan, and supporting documentation to your Medicaid managed care plan. The plan reviews the request and approves or denies it based on medical necessity.

The approval process can take a few weeks. Ask your provider for a timeline and check in regularly. If you are denied, you have the right to appeal. Your Medicaid plan's member services line can explain the appeals process.

Your Medicaid plan name is on your child's member card. Call the number on the card to ask about ABA coverage, prior authorization requirements, and any limits on hours or visits. The exact limits vary by plan, so ask this specific question: "What are the covered hours and visit limits for ABA therapy under my plan?"

Finding an ABA Provider

We list ABA agencies across New York counties. The largest concentrations are in Kings County, Rockland County, and Nassau County. Use the directory to find agencies near you.

When you contact an agency, ask if they accept your child's specific Medicaid plan. Some agencies have contracts with certain managed care plans but not others. Also ask if they have openings for new clients.

If an agency's Medicaid panel is closed, that means they are not accepting new Medicaid patients right now. Ask to be put on a waitlist and check back regularly. You can also contact other agencies on the list or ask your Medicaid plan for a list of in-network ABA providers.

What to Know About Insurance and ERISA

New York has a state autism insurance mandate that requires many health plans to cover ABA. However, this mandate only applies to fully insured plans that are regulated by the state. If your child is on Medicaid, you are covered under EPSDT, not the state mandate.

If you also have private insurance through an employer, note that self-funded plans are exempt from state mandates under federal law (ERISA). Many self-funded plans still cover ABA voluntarily, but they are not required to. Check your plan's benefits or call the number on your insurance card to confirm coverage.

For Medicaid, you do not need to worry about ERISA. Medicaid coverage for ABA under EPSDT applies regardless of whether your plan is fully insured or self-funded.

Starting the Process

Start by getting a formal autism diagnosis if your child does not have one. If they already have a diagnosis, gather the diagnostic report and any previous treatment records.

Next, contact a BCBA to develop a treatment plan. You can find BCBAs through the agencies in our directory or by asking your pediatrician for a referral.

Then, choose an agency that accepts your Medicaid plan and has openings. The agency will submit the prior authorization request to your plan. Once approved, therapy can begin.

Keep copies of all paperwork, including the diagnosis, treatment plan, and authorization approval. This helps if you need to appeal a denial or switch providers.

New York listings right now

797 ABA agencies across 30 New York counties.

Common questions

Does New York Medicaid cover ABA therapy?
Yes, New York Medicaid covers medically necessary ABA for children under 21 through the federal EPSDT benefit. This applies to all Medicaid managed care plans and fee-for-service Medicaid.
What do I need to get ABA covered?
You need a formal autism diagnosis and a treatment plan written by a BCBA. The plan must show that ABA is medically necessary for your child.
How does prior authorization work?
Your ABA provider submits the diagnosis and treatment plan to your Medicaid plan for review. The plan decides based on medical necessity. If denied, you can appeal.
What if an ABA agency says their Medicaid panel is closed?
Ask to be placed on a waitlist and check back regularly. You can also contact other agencies in our directory or ask your Medicaid plan for a list of in-network providers with openings.
Are there limits on ABA hours or visits?
Limits vary by Medicaid plan. Ask your plan directly: "What are the covered hours and visit limits for ABA therapy under my plan?" Do not rely on general figures, as they change.
Does the state autism mandate apply to my child?
If your child is on Medicaid, coverage comes from EPSDT, not the state mandate. If you have private insurance, the mandate applies only to fully insured plans. Self-funded employer plans are exempt under ERISA, though many still cover ABA.

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