Great News for Vaya Health Members!

General Coverage:

Vaya Health covers ABA therapy as part of its behavioral health services for individuals diagnosed with Autism Spectrum Disorder (ASD) by a licensed healthcare provider. Coverage is typically available for individuals under the age of 21, although specific details may vary based on the plan.

State Mandates:

Vaya Health’s coverage is influenced by North Carolina state mandates, which may require comprehensive coverage for ABA therapy without annual caps. These mandates generally apply to fully insured plans, while self-funded plans may have different requirements and limitations.

Plan Variability:

• Medicaid Plans:  Vaya Health operates under North Carolina’s Medicaid program, meaning ABA therapy coverage is usually extensive and aligned with state Medicaid regulations. However, coverage can vary based on specific Medicaid guidelines. Self-Funded Plans: For self-funded plans administered by Vaya Health, ABA therapy coverage might be more variable and could depend on the employer’s decisions regarding benefits.

• Medical Necessity & Pre-Authorization: ABA therapy must be deemed medically necessary, typically determined through an evaluation by a licensed clinician. Vaya Health usually requires pre-authorization to ensure the therapy meets its coverage criteria and to verify the appropriateness of the treatment plan.

Limitations & Exclusions:

Coverage may include limitations such as caps on the number of therapy hours per year or restrictions on the settings where therapy can be provided. It’s important to ensure that your ABA provider is within Vaya Health’s network to avoid additional costs. Blue Jay ABA is a trusted partner with Vaya Health, ensuring accessible and affordable ABA therapy services.

To effectively manage your Vaya Health coverage for ABA therapy, follow these steps:

Review Your Plan: 

Carefully examine your Vaya Health policy to understand the specific coverage details, including any limits or exclusions related to ABA therapy.

Determine Plan Type:

 Identify if your plan is Medicaid-based or self-funded, as coverage can vary depending on the type of plan.

Obtain an ASD Diagnosis: 

Ensure that your child has a formal Autism Spectrum Disorder (ASD) diagnosis from a licensed healthcare provider, as this is a prerequisite for ABA therapy coverage.

Request Pre-Authorization: 

Contact Vaya Health to initiate the pre-authorization process, submit all necessary documentation, and confirm the steps needed to access ABA therapy.

Verify Provider Network: 

Check that your ABA therapist is within Vaya Health’s network to avoid out-of-pocket expenses. Blue Jay ABA is in-network with Vaya Health, offering top-quality ABA services at an affordable cost.

Understand Coverage Limits: 

Be aware of any limitations, such as caps on therapy hours or restrictions on where therapy can be provided, to ensure you can maximize your benefits.

Seek Assistance: 

If you have questions or need further assistance, reach out to our team or contact Vaya Health’s customer service for guidance.