Key Takeaways
- NJ FamilyCare (New Jersey’s Medicaid program) covers medically necessary ABA therapy for members with an autism diagnosis, from 18 months old until their 21st birthday.
- You’ll need an autism diagnosis from a qualified health professional and a script for ABA, and your health plan must approve the assessment and treatment plan.
- GentleCare Therapy is in network with NJ FamilyCare through Horizon NJ Health and UnitedHealthcare Community Plan, and our care coordinators manage the insurance approval process with you.
Does NJ FamilyCare cover ABA therapy? Yes. NJ FamilyCare, New Jersey’s Medicaid and CHIP program, covers medically necessary applied behavior analysis (ABA) therapy for children ages 18 months up to their 21st birthday who have an autism spectrum disorder (ASD) diagnosis. The state added this benefit on April 1, 2020.
If your child has NJ FamilyCare and you’re looking for ABA therapy, this guide explains who qualifies, what paperwork you’ll need, how approval works and how to get started.
Who qualifies for ABA through NJ FamilyCare?
Your child can get ABA therapy through NJ FamilyCare if they:
- are enrolled in NJ FamilyCare/Medicaid,
- are at least 18 months old and have not yet turned 21, and
- have an autism diagnosis from a qualified health professional, such as a physician, psychologist, developmental pediatrician, or neurologist.
A diagnosis your child already has can be used. NJ FamilyCare doesn’t deny services because a condition is “pre-existing”. Your child’s health plan may ask for the full diagnostic evaluation.
What autism services does NJ FamilyCare cover?
Based on medical necessity, for members 18 months old until their 21st birthday with autism, NJ FamilyCare’s autism benefit includes:
- ABA therapy
- Speech, occupational, and physical therapy
- Augmentative and alternative communication (AAC) services and devices
- Sensory integration services
- Developmental, relationship-based approaches such as DIR/Floortime
Services must be medically necessary and generally require pre-approval (prior authorization) by your child’s health plan.
Your NJ FamilyCare health plan matters
Most NJ FamilyCare members get their benefits through one of five health plans (also called managed care organizations, or MCOs). Your plan’s name is on your child’s ID card:
- Aetna Better Health of New Jersey
- Fidelis Care
- Horizon NJ Health
- UnitedHealthcare Community Plan
- Wellpoint (formerly Amerigroup New Jersey)
Your child’s ABA provider must be in network with your specific plan. GentleCare Therapy is in network with NJ FamilyCare through Horizon NJ Health and UnitedHealthcare Community Plan, with additional plan credentialing in progress. Not sure about your plan? Call or text us at (856) 484-5535 and we’ll check for you.
What you’ll need to get started
- Your child’s insurance card, so we can verify ABA benefits.
- A copy of your child’s autism diagnosis (the comprehensive evaluation).
- A script (prescription) for ABA therapy from your child’s doctor. This will need to be a current script that is dated within the year.
- Our intake packet, which our care coordinators will send you.
How approval works, step by step
Here’s what the process looks like at GentleCare. From your first call to your child’s first session with a behavior technician usually takes 4–8 weeks.
- Submit our intake form. Start online or call/text (856) 484-5535.
- Benefits check (about 3–5 days). We verify your child’s ABA benefits with your NJ FamilyCare plan.
- Assessment approval (about 5–14 days). With the intake packet, the ABA script and the diagnosis, we ask your plan to approve an initial assessment.
- Initial assessment (about 15–20 days). A Board Certified Behavior Analyst (BCBA) meets with you and your child and writes an individualized treatment plan, including how many hours of therapy are recommended.
- Treatment plan approval (about 15 days). Your plan reviews the treatment plan and approves the hours.
- Services begin. Once the plan is approved and your child’s team is in place, therapy starts.
Health plans review treatment plans regularly, and your BCBA will update the plan as your child makes progress.
What does ABA cost with NJ FamilyCare?
For children enrolled in NJ FamilyCare (Plans A, B, and C), covered medically necessary ABA services are generally provided at no out-of-pocket cost (no deductibles or coinsurance). Families in CHIP Plan D occasionally have modest co-payments for certain specialized services. Our care coordinators will verify your child’s specific plan tier and benefits before any evaluation or session begins so there are never any surprises.
Where can my child receive ABA?
With GentleCare, ABA therapy can happen at home, in the community (such as daycare or preschool), or at our full-day center program in Gibbsboro, NJ. We provide in-home and community ABA across New Jersey, from South Jersey to Central and North Jersey. Learn more about ABA therapy at GentleCare or tour our center.
Don’t have NJ FamilyCare yet?
You can learn about eligibility and apply at njfamilycare.org or by calling NJ FamilyCare at 1-800-701-0710 (TTY 711). Check the state’s site for the latest details.
A note for Pennsylvania families
GentleCare serves families across Greater Philadelphia too, but we don’t currently accept Pennsylvania Medicaid plans, and we’re not in network with Community Behavioral Health (CBH). We do accept most major Pennsylvania commercial health plans. Call us at (856) 484-5535 to check yours.
Frequently asked questions
Does NJ FamilyCare cover ABA therapy for adults?
NJ FamilyCare’s ABA benefit is for members under 21. After 21, autism services are generally limited to physical, occupational, and speech therapy and communication devices. Adults may find other supports through New Jersey’s Division of Developmental Disabilities.
Do I need a new autism evaluation?
Not always. An existing diagnosis from a qualified professional can be used; your plan will ask for the full evaluation report. We’ll tell you exactly what’s needed when we verify your benefits. We can also support you with following up with the diagnosing doctor for the needed paperwork once you sign a HIPAA release form for us to be in contact with them.
Is there a waitlist?
We currently have immediate openings for in-home and community ABA therapy throughout New Jersey and Greater Philadelphia.
Who can I call with questions about my child’s plan?
Your plan’s Member Services number is on the back of your child’s NJ FamilyCare ID card. For help in New Jersey with autism questions, you can also call the Autism New Jersey Helpline at 800.4.AUTISM.
Sources: NJ Division of Medical Assistance and Health Services (DMAHS), ABA services announcement (effective April 1, 2020); DMAHS, NJ FamilyCare Health Plans; DMAHS Guide to Autism Services; NJ FamilyCare, Choosing a Health Plan. Coverage rules can change, so check with your plan.
About the author: Torrie Martin, MBA, SHRM-SCP, is GentleCare Therapy’s Chief Operating Officer.
How GentleCare can help: Learn more about our ABA Therapy services, or visit our Enrollment page to get started.
