Key Points:
- Utah’s SB 95 mandates ABA therapy coverage in state-regulated plans and removes previous age/hour limits.
- Medicaid in Utah also provides ABA services, but through different programs with their own eligibility rules.
- Not all plans are required to cover ABA; self-funded employer plans and certain waivers may follow different standards.
Navigating insurance coverage for ABA therapy in Utah can be confusing, especially when you’re trying to get timely help for your child. Many parents and caregivers feel overwhelmed trying to decode terms like “state-regulated plan,” “self-funded employer insurance,” or “telehealth ABA.”
The goal of this article is simple: to explain how insurance coverage works for ABA therapy in Utah, clearly, accurately, and thoroughly, so you can make informed decisions and avoid delays in care.
Whether you’re searching for an Applied Behavior Analysis center, exploring in-home ABA, or considering ABA therapy at school, this guide breaks down the process step-by-step and gives you clarity on what Utah laws cover, what they don’t, and how to get started.
Utah’s Autism Insurance Mandate: SB 95 Explained
In 2019, Utah passed Senate Bill 95 (SB 95), which significantly expanded the state’s autism insurance mandate. This bill became effective January 1, 2020.
Here’s what SB 95 changed:
- Removed age caps: Previously, coverage for ABA therapy was limited to children between the ages of 2 and 10. SB 95 eliminated this restriction.
- Eliminated hourly caps: Older laws capped services at 600 hours per year. SB 95 removed this limit for qualifying plans.
- Defined ABA as a medically necessary treatment for Autism Spectrum Disorder (ASD), requiring coverage for it under specific plans.
Plans subject to SB 95 must cover:
- Diagnostic evaluations for ASD.
- ABA therapy supervised by qualified professionals (typically a Board Certified Behavior Analyst or BCBA).
- Related behavioral health services when deemed medically necessary.
What Insurance Plans Are Required to Follow This Law?
Not every health plan in Utah is subject to SB 95. Coverage depends on how your plan is structured and who regulates it.
Plans that must follow SB 95:
- State-regulated individual plans (purchased directly by families).
- State-regulated large group plans (typically employer-sponsored plans, not self-funded).
Plans that may be exempt:
- Self-funded employer plans governed by federal law (ERISA) are not required to follow Utah’s insurance mandates. These plans are often provided by large corporations.
- Medicaid and waiver programs follow different rules, though they often provide coverage through their own policies.
If your plan is self-funded, your employer decides whether or not to include ABA therapy. You can ask your HR department for a Summary Plan Description (SPD) to find out if ABA is included.
How Medicaid Covers ABA Therapy in Utah
Utah Medicaid covers ABA therapy through multiple pathways, each with different eligibility requirements:
1. EPSDT (Early and Periodic Screening, Diagnostic, and Treatment)
Under federal law, Medicaid must cover services that are medically necessary for children under 21. This includes ABA therapy for children diagnosed with ASD.
2. Autism Waiver Program
Previously limited to children aged 2–6, this waiver program provided intensive ABA services in a home or community setting. However, access was capped by enrollment numbers and age restrictions.
3. Recent Expansion (Effective July 2023)
Utah now allows adults with ASD to receive ABA therapy under Medicaid. This was previously restricted, but updates to the law removed the age cap on ABA access for Medicaid participants.
Important: Medicaid coverage is subject to service authorization, medical necessity, and provider qualifications. Families must work with approved providers who understand the Medicaid system.
What ABA Therapy Settings Are Typically Covered?
Depending on your insurance plan, ABA services may be delivered in multiple formats:
In-home ABA
Often covered when a BCBA determines it’s the most appropriate environment for the child. Common under both Medicaid and private insurance when deemed medically necessary.
ABA therapy at school
Insurance may cover ABA therapy in a school setting only if it’s billed through a health plan as medically necessary care—not as part of the student’s education plan. In most cases, school-provided ABA is handled through the education system (IDEA), not insurance.
Telehealth ABA
Many Utah insurers and Medicaid programs allow for supervision, parent training, and some therapy services via telehealth ABA, especially for families in rural areas. However, coverage varies by service type and CPT code.
Applied Behavior Analysis center-based therapy
Most insurance plans cover ABA at a clinical location or applied behavior center for autism as long as the facility and staff are in-network and properly licensed.
What Does Insurance Typically Require for ABA Coverage?
Insurance companies (including Medicaid) usually require several steps before approving ABA therapy:
- Formal ASD diagnosis from a licensed provider (often a developmental pediatrician, neurologist, or psychologist).
- Treatment plan created by a BCBA, including measurable goals and session frequency.
- Pre-authorization: Approval is usually required before therapy begins. Plans often ask for updates every six months.
- Medical necessity documentation: Justifying why ABA is needed and appropriate for the individual child.
Even with coverage, families are often responsible for:
- Copayments or coinsurance
- Meeting deductibles
- Ensuring the provider is in-network
What If My Insurance Doesn’t Cover ABA?
If your current plan does not include ABA coverage:
- Appeal the decision if there’s reason to believe it should be covered.
- Ask your employer to add ABA coverage to next year’s benefits if you’re on a self-funded plan.
- Explore Medicaid or the Autism Waiver if your child qualifies.
- Consider online ABA or telehealth ABA for flexibility and access, particularly if local in-person options are limited.
Some families also explore private pay options while pursuing long-term coverage solutions. Be sure to ask if your ABA provider offers payment plans or assistance with appeals.
What to Ask Your Insurance Company
Before starting ABA therapy, consider asking your insurer:
- Is my plan state-regulated or self-funded?
- Does my plan cover ABA therapy for autism?
Are in-home, school-based, or telehealth sessions covered? - What documentation is needed for pre-authorization?
- Are there any provider networks I must use?
These questions can help you avoid delays and get a clearer picture of coverage for services like in-home ABA, speech support, and more.
Making Informed ABA Therapy Decisions
Accessing ABA therapy for your child involves more than just finding a provider—it means understanding the intersection of laws, insurance rules, and clinical needs. Utah’s laws, especially after the passage of SB 95, have made ABA more accessible for many families. But eligibility, coverage, and out-of-pocket costs can still vary.
Whether you’re pursuing therapy through a private plan, Medicaid, or a hybrid of both, being informed helps you advocate for your child’s right to effective behavioral support. And when choosing between telehealth, in-home, or center-based therapy, knowing what your plan supports ensures fewer surprises.
Ready to start ABA therapy in Utah? Acclimate ABA helps families navigate insurance, from verifying coverage to submitting treatment plans and managing authorizations. Whether you’re looking for in-home ABA, telehealth ABA, or center-based services, we make the process smoother.
Looking for ABA services near me? Acclimate ABA offers comprehensive ABA therapy in Utah, tailored to your family’s needs and supported by your insurance.
Contact us today to schedule a consultation and take the next step toward care.
