Does Colorado Medicaid Cover ABA Therapy?

Key Highlights

• Colorado Medicaid, known as Health First Colorado, covers ABA therapy for eligible individuals under 21 through the EPSDT program.
• Eligibility requires being under 21, having a formal ASD or related developmental disability diagnosis, and a medical necessity assessment.
• Covered ABA services include behavioral assessments by BCBAs, one-on-one therapy sessions, parent/caregiver training, social skills development, progress monitoring, and telehealth options.
• To apply for Medicaid coverage, families must obtain a diagnosis, get a referral from a healthcare provider, apply through Colorado PEAK or local offices, select an approved Medicaid ABA provider like Little Champs ABA, and begin therapy after approval.
• When both private insurance and Medicaid are available, private insurance pays first; Medicaid covers remaining approved costs with proper documentation.
• Medicaid waivers exist for adults with developmental disabilities, offering behavioral health and community support, but may not always cover ABA therapy.
• Key considerations for Medicaid ABA therapy include prior authorization, coordination with private insurance, and regular progress reviews to maintain coverage.
• Little Champs ABA helps families navigate Medicaid insurance and provides tailored ABA therapy to support children’s growth and development.

Does Colorado Medicaid Cover ABA Therapy?

Yes, Colorado Medicaid—known as Health First Colorado—covers ABA therapy in Colorado for eligible individuals under 21 through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.

Who Is Eligible?

To qualify for ABA therapy coverage under Health First Colorado:

• Age: Under 21 years old.
• Diagnosis: Formal diagnosis of Autism Spectrum Disorder (ASD) or a related developmental disability by a licensed healthcare provider.
• Medical Necessity: An assessment must determine that ABA therapy is medically necessary for the individual’s development and well-being.

What ABA Therapy Services Does Colorado Medicaid Cover?

• Comprehensive Behavioral Assessments: Evaluations by Board Certified Behavior Analysts (BCBAs) to create individualized treatment plans.
• Individual ABA Therapy Sessions: One-on-one sessions focusing on improving communication, social skills, and behavior management.
• Parent and Caregiver Training: Guidance for families to implement ABA techniques at home.
• Social Skills Development: Support in building peer relationships and social interaction skills.
• Progress Monitoring and Adjustments: Regular reviews and updates to therapy plans based on the individual’s progress.
• Telehealth Options: Remote ABA therapy services to increase accessibility.

How to Apply for Colorado Medicaid

If you think your child may benefit from ABA therapy, follow these steps to access coverage:

1. Get a Diagnosis:
   Schedule an evaluation with a licensed healthcare professional who can provide an official ASD diagnosis.

2. Get a Referral:
   A primary care provider (PCP) or specialist must submit a referral stating that ABA therapy is medically necessary for your child’s development.

3. Enroll and Apply:
   You can apply for Medicaid in Colorado through the following methods:

   • Online: Visit the Colorado PEAK website.

   • In Person: At your local county human services office.

   • By Mail: Request a paper application from your county office.

   • By Phone: Call the Member Contact Center at 1-800-221-3943.

4. Find an Approved ABA Provider:
   Choose an approved Medicaid ABA provider, such as Little Champs ABA, that accepts Health First Colorado coverage.

5. Begin Therapy:
   Once approved, your child will start therapy with a personalized treatment plan designed to meet their unique needs.

Coordination with Private Insurance

If you have both private insurance and Medicaid:

• Primary Coverage: Private insurance is considered the primary payer.
• Medicaid as Secondary: Medicaid may cover services not included in your private plan, but you’ll need documentation showing that your private insurance doesn’t cover ABA therapy.

Medicaid Waivers and Key Considerations for ABA Therapy

Colorado Medicaid offers waiver programs for adults with developmental disabilities that provide behavioral health services and support for daily living and community integration, though ABA therapy may not always be included. It’s important to explore these waivers early for continued support as children transition to adulthood.

When using Medicaid for ABA therapy, keep in mind:

• Prior Authorization: Some services require pre-approval before therapy starts, with your provider assisting in this process.
• Insurance Coordination: Private insurance is billed first; Medicaid covers approved remaining costs.
• Progress Reviews: Medicaid mandates regular updates to ensure ongoing therapy effectiveness and approval.

Final Thoughts

Colorado Medicaid’s Health First Colorado program provides essential coverage for ABA therapy to support children under 21 with autism and related developmental disabilities. Knowing the eligibility requirements, covered services, and application process can help families access the therapy their child needs for meaningful progress.

At Little Champs ABA, we not only deliver personalized, compassionate ABA therapy but also assist families in navigating Medicaid insurance and coverage details. If you need help understanding Medicaid benefits or getting started with coverage, our team is here to guide you every step of the way. Contact us today to learn how we can support your family with Medicaid insurance and provide the ABA therapy your child deserves.

Learn more about Medicaid coverage and how we can help.

Frequently Asked Questions

1. Who qualifies for ABA therapy coverage under Colorado Medicaid?

Children under 21 with a formal diagnosis of Autism Spectrum Disorder (ASD) or related developmental disabilities, and a medical necessity assessment, qualify for coverage.

2. How do I apply for Medicaid to cover ABA therapy in Colorado?

Apply through the Colorado PEAK website, local county offices, by mail, or phone. You’ll need a diagnosis, referral from a healthcare provider, and to select an approved Medicaid ABA provider.

3. Can Medicaid cover ABA therapy if I already have private insurance?

Yes. Private insurance is billed first, and Medicaid may cover remaining approved costs. Documentation is needed showing what your private insurance does not cover.

Sources:

1. https://colorado.gov/PEAK
2. https://www.healthfirstcolorado.com/
3. https://www.bacb.com/bcba/
4. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/Waiver-Descript-Factsheet/CO