Does Health First Colorado (Medicaid) Cover ABA? How to Start

If your child has Health First Colorado, Colorado’s Medicaid program, you may be wondering whether it pays for ABA therapy. The short answer: yes, for children who qualify and when the therapy is medically necessary. Here’s who qualifies, what paperwork you’ll need, and the steps to get started.

For a wider look at insurance, including private plans and Colorado’s autism law, see our guide Does Insurance Cover ABA Therapy in Colorado?

The short answer

Health First Colorado covers ABA through its Pediatric Behavioral Therapies benefit. This is part of EPSDT, the program that covers medically necessary care for children and young people in Medicaid. All behavioral therapy has to be approved before treatment starts, through a step called prior authorization.

Who qualifies for Health First Colorado ABA

According to the state’s billing manual for this benefit, a child can get these services if they:

• Are under 21
• Are enrolled in Health First Colorado
• Have a documented qualifying diagnosis (for example autism, developmental delay, intellectual disability, or another developmental or behavioral condition), or are under 3 and at risk for delay
• Have a signed referral from a primary care doctor or pediatrician
• Have needs that affect daily life, like taking part in age-appropriate activities, learning, communication, or safety

Does my child need an autism diagnosis?

No. The state says behavioral therapy is available to all children enrolled in Health First Colorado when the service is medically necessary, not only children with autism. Your child still needs a qualifying diagnosis or condition, and a recommendation for therapy from an evaluation by a medical provider.

What paperwork is needed

Your ABA provider puts together the request and sends it to the state. According to the state’s pages, it includes:

• A signed referral from your child’s doctor or other ordering provider, with the diagnosis and the reason for therapy
• Results of an assessment your ABA provider completes with your child
• A treatment plan with goals and the hours requested

The most helpful things you can do: keep your child’s diagnosis paperwork handy, and ask your child’s doctor for the referral or prescription early. When you reach out, it helps to have your insurance card, any diagnosis paperwork, and a signed referral from your child’s doctor.

How to get started: step by step

1. Make sure your child is enrolled. If not, you can apply online through PEAK, by phone at 1‑800‑221‑3943, by mail, or at your county office. If your family’s income is too high for Health First Colorado, the state mentions the Children’s Buy-In Program as a possible option.
2. Talk to your child’s doctor about a diagnostic evaluation (if your child doesn’t have one yet) and a referral or prescription for ABA. With Health First Colorado, a child does not need to have a formal diagnosis from a licensed psychologist or other diagnostician in order to start ABA.
3. Call an ABA provider that accepts Health First Colorado. Attain SLB accepts Health First Colorado and has no waitlist.
4. The BCBA assesses your child and writes a treatment plan.
5. The provider submits a Prior Authorization Request (PAR). Licensed clinical reviewers check whether the services are medically necessary by reviewing the treatment plan. You and the provider both get a letter with the decision.
6. Once approved, therapy starts. An approval lasts up to six months. To continue, your provider submits a new request every six months.

What does it cost?

The state’s billing manual says providers may not bill Health First Colorado members for covered services, and that payment from Health First Colorado must be accepted as payment in full. If you have questions about your child’s coverage, ask us before therapy starts.

At Attain, caregiver training is available, and free for families with Medicaid.

Where therapy can happen

The state’s billing manual lists home, office (clinic), school, and community settings, plus telemedicine for some services. Attain offers ABA at our clinic for ABA therapy in Fort Collins, in-home ABA anywhere in Colorado, or a mix, with after-school and full-day sessions. Our telehealth is mainly parent coaching.

If the request is denied

Before a request is denied or partly denied, the state says the requesting provider is able to discuss the decision with a reviewer (a “peer-to-peer” review). After a denial, your provider can ask for a reconsideration or send a new request with more information. You can also appeal in writing to the Office of Administrative Courts within 30 calendar days of the date on your denial letter.