Great News for WellCare Health Members!

General Coverage:

WellCare offers coverage for ABA therapy under its behavioral health services for children and adolescents diagnosed with Autism Spectrum Disorder (ASD). Coverage specifics, such as the number of therapy hours and the settings in which therapy can be provided, depend on your specific plan.

Impact of State Mandates:

As WellCare operates within state Medicaid programs and provides Medicare plans, coverage for ABA therapy is often influenced by state regulations. Many states mandate that Medicaid plans provide comprehensive ABA therapy coverage, which typically includes the necessary therapy hours without imposing strict limits.

Plan Variability:

Medicaid Plans:

 Since WellCare primarily offers Medicaid plans, coverage for ABA therapy is generally robust and follows state Medicaid guidelines. However, coverage can vary depending on the specific Medicaid plan you are enrolled in. 

Medicare Plans: 

WellCare’s Medicare plans may have different coverage details for ABA therapy, with some plans offering limited coverage based on specific criteria. It’s essential to check your specific plan to understand the details.

Medical Necessity & Pre-Authorization:

ABA therapy must be considered medically necessary for it to be covered by WellCare. This determination usually involves a formal diagnosis by a licensed healthcare provider. Pre-authorization is often required, meaning WellCare must approve the therapy plan before treatment can begin.

Network Providers & Coverage Limitations:

There may be restrictions on coverage, such as limitations on therapy hours or specific conditions on where therapy can be provided. Ensuring that your ABA provider is within WellCare’s network is crucial to avoid additional costs. Blue Jay ABA is an in-network provider with WellCare, ensuring that you receive high-quality services at an affordable rate.

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

Review Your Policy: 

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

Secure an ASD Diagnosis:

Ensure that your child has been formally diagnosed with Autism Spectrum Disorder (ASD) by a licensed healthcare provider. This diagnosis is necessary for accessing ABA therapy benefits.

Request Pre-Authorization: 

Contact WellCare to initiate the pre-authorization process. You’ll likely need to submit a treatment plan and other relevant documentation for approval before therapy can begin.

Verify Provider Network: Confirm that your ABA therapist is part of the WellCare network. Blue Jay ABA is in-network with WellCare, ensuring you receive top-quality services without unexpected costs.

Understand Coverage Limits: 

Be aware of any limitations on therapy hours, annual caps, or restrictions on therapy settings to make the most of your benefits.

Seek Assistance: 

If you have questions or need help navigating your coverage, don’t hesitate to contact our team or WellCare’s customer service for support.