Does Fidelis Care Medicaid cover ABA therapy for adults?

Fidelis Medicaid covers ABA therapy for members under 21 years old under the EPSDT benefit. Adults over 21 may have limited coverage; you would need to check with Fidelis directly or explore other Medicaid options.

How long does Fidelis take to approve ABA therapy?

Prior authorization typically takes 7 to 14 business days after the provider submits a complete treatment plan. Delays can occur if documentation is missing, so ensure your provider submits everything promptly.

Can I choose any ABA provider with Fidelis Medicaid?

You can choose any provider that is in-network with Fidelis Care Medicaid. Out-of-network providers may not be covered. Always confirm network status before starting services.

What if my child needs more hours than initially authorized?

Your BCBA can request a modification to the treatment plan and submit it for reauthorization. Fidelis will review the updated medical necessity documentation.

Does Fidelis cover in-home ABA therapy?

Yes, Fidelis covers both center-based and in-home ABA therapy as long as it is medically necessary and prescribed by a doctor. The setting depends on your child's needs and provider availability.

What should I do if Fidelis denies coverage?

You have the right to appeal the denial. Your provider can help gather additional documentation. You can also contact Fidelis's member services or the New York State Department of Health for assistance.

Fidelis Medicaid ABA Therapy: Your Complete Guide

In short: Fidelis Care Medicaid covers ABA therapy for members with an autism diagnosis. Your child needs a diagnostic evaluation and a doctor's prescription. Fidelis will then authorize a specific number of hours. Our free matching service can help you find a BCBA-led provider that accepts Fidelis, saving you time and stress.

What Is Fidelis Care Medicaid Coverage for ABA Therapy?

Fidelis Care is one of New York's largest Medicaid managed care plans, serving hundreds of thousands of families across the state. Under New York's Medicaid program, Fidelis is required to cover medically necessary applied behavior analysis (ABA) therapy for members diagnosed with autism spectrum disorder (ASD). This coverage is part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which ensures children under 21 receive comprehensive health care services.

ABA therapy is an evidence-based treatment that uses behavioral principles to improve communication, social skills, and daily living skills while reducing challenging behaviors. Fidelis covers both center-based and in-home ABA services, provided they are prescribed by a licensed physician and delivered by a Board Certified Behavior Analyst (BCBA) or a supervised Registered Behavior Technician (RBT).

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🔗 Related reading: Tiptoe Walking & Autism: ABA Strategies That Work · Local ABA Therapy

Who Is Eligible for Fidelis ABA Coverage?

Autism Diagnosis Requirement

To qualify for ABA coverage through Fidelis Care Medicaid, your child must have a formal diagnosis of autism spectrum disorder from a qualified professional, such as a developmental pediatrician, child psychiatrist, or psychologist. The diagnosis must be documented in your child's medical records.

Age and Medicaid Enrollment

Coverage applies to Fidelis Medicaid members under the age of 21. You must be actively enrolled in a Fidelis Care Medicaid plan. If you are not yet enrolled, you can apply through the New York State of Health marketplace or your local Department of Social Services.

Medical Necessity

Fidelis will only authorize ABA therapy if it is deemed medically necessary. This means the therapy must be prescribed to treat the symptoms of autism, such as deficits in communication or social interaction, or to address behaviors that interfere with daily functioning. A BCBA will conduct an initial assessment to determine the appropriate number of hours per week.

Step-by-Step: How to Get ABA Therapy Through Fidelis

Step 1: Obtain a Prescription

Your child's doctor must write a prescription for ABA therapy. This prescription should specify the diagnosis and recommend ABA as a treatment. Without this, Fidelis will not process a prior authorization request.

Step 2: Find a BCBA-Led Provider

You need to choose an ABA provider that accepts Fidelis Care Medicaid. Many providers have waitlists, so it's wise to start early. Our free matching service can help you find vetted, BCBA-led providers in your area who accept Fidelis. We do the legwork of checking availability and insurance acceptance, so you don't have to.

Step 3: Initial Assessment and Treatment Plan

The provider's BCBA will conduct a functional behavior assessment (FBA) to identify your child's needs. Based on this, they will create a treatment plan with specific goals, proposed hours per week, and duration. This plan is submitted to Fidelis for prior authorization.

Step 4: Prior Authorization

Fidelis reviews the treatment plan to ensure it meets medical necessity criteria. Authorization is typically granted for 3 to 6 months, after which a reauthorization is needed. The provider handles this process, but you may need to provide additional documentation if requested.

Step 5: Begin Therapy

Once authorized, therapy can begin. Sessions may be in a clinic, at home, or in community settings, depending on the provider and your child's needs. The BCBA will supervise RBTs and adjust the plan as needed.

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🔗 Related reading: NC LME-MCO ABA Approval: Step-by-Step Guide for Parents · Nearby ABA Therapy

Costs and Financial Considerations

Under Fidelis Care Medicaid, there are no co-pays, deductibles, or co-insurance for ABA therapy. The cost is fully covered by the plan. However, you must ensure your provider is in-network. Out-of-network providers may not be covered or may require additional approvals. Always confirm with both Fidelis and the provider before starting services.

If you have a private insurance plan through Fidelis (not Medicaid), coverage may differ. This guide focuses on Fidelis Medicaid plans only.

Common Mistakes to Avoid

Waiting too long to start: The authorization process can take weeks. Begin as soon as you have a diagnosis.
Not verifying provider network status: Always confirm the provider accepts Fidelis Medicaid before the assessment.
Assuming all ABA providers are the same: Look for BCBA-led providers with experience in your child's age group and needs.
Ignoring reauthorization deadlines: Your provider must submit updated progress reports to continue coverage.
Not using our free matching service: It saves time and connects you with providers who have current openings for Fidelis members.

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How Our Free Matching Service Helps

Navigating insurance and finding a provider can be overwhelming. Our service is completely free for families. We match you with vetted, BCBA-led ABA providers who accept Fidelis Care Medicaid in your area. We verify availability, insurance acceptance, and provider credentials so you can focus on your child's therapy journey. Simply fill out a short form, and we'll connect you with options tailored to your needs.

Frequently Asked Questions About Fidelis and ABA

We've answered common questions below to help you feel confident about the process.

Fidelis Care Medicaid ABA Therapy Coverage: A Complete Guide for New York Families

Key takeaways

What Is Fidelis Care Medicaid Coverage for ABA Therapy?