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For Immediate Release

May 30, 2014

State Health Plan to Offer Autism Treatment Coverage

RALEIGH, N.C. – The State Health Plan Board of Trustees voted unanimously today to offer a leading treatment for autism spectrum disorder to Plan member families. 

The treatment, known as applied behavioral analysis (ABA), is a systematic and structured strategy for addressing challenging behavior problems often found in individuals with autism spectrum disorder.

“This coverage is the right thing to do,” said State Treasurer Janet Cowell, Chair of the Board. “It offers the opportunity to change the lives of children, young adults and families living with autism spectrum disorder. The benefit fulfills the mission of the State Health Plan to be a leader on health issues in the state.”

"I want to compliment your staff on very thoughtful consideration over the last six months and I believe they have put together a very thoughtful benefit design," Lorri Unumb, Vice President for State and Government Affairs for Autism Speaks, told the Board at today’s Board session. "A lot of families across North Carolina are watching and looking forward to good news from today."

Under the benefit, which will begin January 1, 2015, coverage will be provided for applied behavior analysis when:

  • The member is younger than age 26, and
  • The member is diagnosed with autism spectrum disorder by a licensed physician (MD or DO) or a licensed doctoral level clinical psychologist (PsyD or PhD) utilizing results from a face-to-face evaluation and a clinically recognized, validated tool accepted by the Mental Health Care Manager, and
  • Treatment is determined by the Mental Health Care Manager to be medically necessary.

Coverage for ABA will be limited to a maximum of $36,000 per benefit year and will be only available in-network. In addition, coverage is subject to copay, deductible and coinsurance as applicable.

For more information, see the presentation from the Board meeting: http://www.shpnc.org/library/pdf/board-materials/may-2014/6ABA.pdf​

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The North Carolina State Health Plan for Teachers and State Employees provides health care coverage to more than 670,000 teachers, state employees, retirees, current and former lawmakers, state university and community college personnel, state hospital staff and their dependents.