- Providing ABA therapy in Durham, Raleigh, Chapel Hill, Greensboro, and Throughout North Carolina.
- Providing ABA therapy in Durham, Raleigh, Chapel Hill, Greensboro, and Throughout North Carolina.
Navigating autism services and insurance coverage can be overwhelming for families. If you’re a parent or caregiver in North Carolina, you may wonder: What is the autism mandate in NC? What protections, services, and benefits does the law provide? This article breaks down North Carolina’s autism law, insurance requirements, education rights, and support programs. We’ll also show how Kids n Heart ABA can help you access the resources your family needs.
What Is the Autism Mandate in NC?
The “autism mandate” in North Carolina refers to state laws requiring insurance companies and public agencies to provide meaningful coverage and support for individuals diagnosed with Autism Spectrum Disorder (ASD).
The core of this mandate is North Carolina General Statute 58-3-192, which ensures that certain health insurance plans must cover the screening, diagnosis, and treatment of autism for eligible individuals.
Key Points of the NC Autism Mandate
- Applies to state-regulated insurance plans (not all employer or self-funded plans)
- Covers individuals diagnosed with ASD under age 23
- Mandates coverage for behavioral health treatment, including Applied Behavior Analysis (ABA) therapy, psychiatric care, speech therapy, occupational therapy, and physical therapy
- Annual coverage caps: Up to $40,000 per year for children under 8, and $30,000 per year for ages 8–23
- Insurance must cover autism testing for children; coverage for adults varies by plan
- Education rights and Medicaid waivers further support children and adults with autism
What Is the Autism Law in NC? (NCGS 58-3-192 & SB 676)
North Carolina’s autism insurance bill, SB 676, was enacted in 2015 and became effective July 1, 2016. This law, codified as NCGS 58-3-192, requires many state-regulated health plans to provide coverage for autism diagnosis and treatment.
Which Plans Must Follow the Law?
- YES: Individual grandfathered plans, fully insured large group plans, fully insured small group grandfathered plans
- NO: Individual non-grandfathered plans, fully insured small group non-grandfathered plans, most self-funded employer plans
What Services Are Covered?
- Adaptive Behavior Treatment (ABA therapy, delivered by licensed providers)
- Psychiatric and Psychological Care
- Speech, Occupational, and Physical Therapy
- Pharmacy Care (medications related to ASD treatment)
Coverage Caps and Age Limits
- Coverage for ABA therapy is capped at $40,000/year for children under 8, and $30,000/year for ages 8–23
- Coverage ends at age 23 for most state-regulated plans
- No dollar or age cap for Medicaid (see waiver programs below)
Does Insurance Cover Autism Testing for Adults?
- For children: State law mandates coverage for autism screening and diagnosis
- For adults: Coverage depends on your specific insurance plan. Some private plans may cover adult testing, but state law does not guarantee this.
Autism Benefits by State: How NC Compares
North Carolina’s autism mandate is considered robust compared to many states, offering:
- Comprehensive coverage for ABA therapy and related services
- Clear annual caps and age limits
- Additional support through Medicaid and waiver programs
- Education rights under federal and state law
However, the law only applies to certain insurance plans. Families with self-funded employer plans may need to check with their HR or benefits administrator for autism coverage details.
Education Rights for Autism in North Carolina
Individuals with Disabilities Education Act (IDEA)
IDEA is a federal law guaranteeing all children with disabilities, including autism, the right to a free appropriate public education (FAPE). In North Carolina, this means:
- Special education services are available from ages 3 to 21
- Individualized Education Programs (IEPs) must be developed within 90 days of identifying a child with autism
- Education in the least restrictive environment (integration with non-disabled peers whenever possible)
- Transition planning for adulthood and independent living
Individualized Family Service Plans (IFSPs)
For children under age 3, North Carolina provides IFSPs to coordinate early intervention services as soon as a child is identified with autism.
What Is the Autism Waiver Program in NC?
North Carolina offers Medicaid waiver programs to support individuals with autism and other developmental disabilities:
Innovations Waiver
- Supports people with autism living independently or with family
- Covers home and community-based services not typically paid for by Medicaid (e.g., respite care, personal assistance, community inclusion)
- No age cap; benefits extend into adulthood
CAP/C Waiver (Community Alternatives Program for Children)
- Helps children with significant medical needs receive care at home instead of in an institution
Is Autism Considered a Disability in NC?
Yes. Autism Spectrum Disorder is recognized as a developmental disability under both federal and North Carolina law. This designation ensures access to:
- Special education services under IDEA
- Disability benefits (such as SSI or Medicaid)
- Workplace protections under the Americans with Disabilities Act (ADA)
- Guardianship provisions for adults unable to make independent decisions
What Benefits Do Autistic Children Get in NC?
Families of autistic children in North Carolina may qualify for:
- ABA therapy and behavioral health treatment (if eligible under insurance or Medicaid)
- Speech, occupational, and physical therapy
- Special education and IEPs
- Medicaid and waiver services for home/community support
- Guardianship protections for transition to adulthood
- Access to autism resource specialists and advocacy groups
How Kids n Heart ABA Can Help
At Kids n Heart ABA, we know navigating insurance, education, and waiver programs can be confusing. Here’s how we make it easier:
- Insurance Navigation: We help families understand which plans are covered under the autism mandate and what services your child can access.
- Comprehensive ABA Therapy: Our Board Certified Behavior Analysts (BCBAs) provide evidence-based, individualized ABA therapy covered by most state-regulated insurance and Medicaid.
- Education Advocacy: We support families in IEP meetings and help coordinate with schools for the best educational outcomes.
- Waiver Support: Our team guides you through Innovations and CAP/C waiver applications so you can maximize your child’s benefits.
- Family-Centered Care: We offer in-home, clinic, and community-based ABA services tailored to your child’s needs.
Explore our full range of autism services and discover how we help families thrive.
Frequently Asked Questions (FAQs)
Is North Carolina a good state for autism services?
Yes. NC offers comprehensive insurance coverage, Medicaid waivers, special education rights, and a strong network of autism resources.
What is the autism waiver program in NC?
The Innovations Waiver and CAP/C Waiver provide Medicaid-funded, home and community-based services for eligible children and adults with autism.
Is autism considered a disability in NC?
Yes. Autism is a recognized developmental disability, qualifying individuals for special education, Medicaid, and other supports.
What benefits do autistic children get in NC?
Eligible children can access ABA therapy, speech/occupational/physical therapy, special education, Medicaid waivers, and more.
Conclusion: Take the Next Step Toward Support
Understanding what is the autism mandate in NC is the first step to unlocking vital resources for your child. With the right information and a supportive team, you can navigate insurance, education, and waiver programs with confidence.
Ready for clarity and support? Contact Kids n Heart ABA for a free benefits review and personalized roadmap to services. Let’s build a brighter future together-one step, one milestone at a time.
What is the autism mandate in NC? It’s your child’s gateway to essential care-and Kids n Heart ABA is here to help you every step of the way.
Sources:
- https://www.asha.org/advocacy/state/info/nc/north-carolina-insurance-requirements-for-autism-spectrum-disorder/
- https://www.autismspeaks.org/advocacy-news/new-law-will-improve-access-evidence-based-autism-therapy-north-carolina
- https://www.autismspeaks.org/north-carolina-state-regulated-insurance-coverage
- https://www.autismsociety-nc.org/accessing-services/
- https://www.autismsociety-nc.org/faqs-related-to-sb-676-autism-health-insurance-coverage/
- https://www.autismsociety-nc.org/wp-content/uploads/Health-Insurance_June2021.pdf
- https://www.dpi.nc.gov/documents/ec/understanding-nc-autism-spectrum-disorder/download
- https://disabilityrightsnc.org/resources/autism-related-services-in-nc/
- https://www.autismsociety-nc.org/wp-content/uploads/Moving-to-NC_Toolkit.pdf
- https://www.autismsociety-nc.org/adult-program-info/
- https://medicaid.ncdhhs.gov/8f-research-based-behavioral-health-treatment-rb-bht-autism-spectrum-disorder-asd/download?attachment
- https://medicaid.ncdhhs.gov/providers/program-specific-clinical-coverage-policies
- https://medicaid.ncdhhs.gov/documents/files/8f-1/open
- https://www.autismsociety-nc.org/autism-diagnosis-adults/
- https://strongstartpsych.com/autism-testing
