Medical Necessity for ABA Therapy in Colorado
Medical necessity for ABA is the test Health First Colorado (Medicaid) or your insurance plan uses to decide whether to pay for applied behavior analysis (ABA) therapy. A prescription, a BCBA’s assessment and a treatment plan with measurable treatment goals must show your child needs it. Budding Futures checks your coverage for free and prepares the paperwork with you.
Definition Updated
What is medical necessity for ABA?
Medical necessity is the test Health First Colorado or a health plan uses to decide whether to pay for a treatment such as ABA: the records must show the child needs it, with a prescription, an assessment and a treatment plan with measurable goals.
Also called medically necessary care. Colorado Medicaid defines it in its program rules.
| Who prescribes | A doctor, nurse practitioner, physician assistant or doctoral psychologist. |
|---|---|
| Who assesses | A Board Certified Behavior Analyst (BCBA), who writes and signs the treatment plan. |
| Who decides | Health First Colorado or your insurance plan. |
| How long it lasts | Health First Colorado approves up to 6 months at a time. |
| If the answer is no | Appeal within 60 days (Medicaid) or 180 days (private plan). |
What does medical necessity mean for ABA?
It means ABA services are needed for your child’s health and daily life, not just helpful. Colorado Medicaid’s own definition includes care that “is clinically appropriate in terms of type, frequency, extent, site, and duration.”
What if ABA is denied as not medically necessary?
A denial is not the end. Read the letter first: it says why and how to appeal.
- Health First Colorado: appeal “within 60 days of the date on the Notice of Action or Notice of Adverse Benefit Determination letter” (member handbook).
- Provider review: the provider can ask Acentra Health for a reconsideration within 10 business days. It “will be performed by a different physician, including an appropriate specialist” (HCPF).
- Private plans: file an internal appeal within 180 days.
- Then external review: Colorado law gives you “four months after receiving notification of the denial” of that appeal (C.R.S. 10-16-113.5).
What are Health First Colorado’s criteria for ABA?
For a child age 20 or younger, Health First Colorado looks for “two or more of the following” (its November 2024 criteria):
- Diagnosis: a condition for which behavioral therapy is recognized as appropriate, including autism spectrum disorder.
- Daily life: ongoing social communication challenges at home, school or in the community.
- Safety: a risk such as self-injury, aggression, property destruction or elopement.
- Skills: a need for support with behavior, learning and play, safety or self-care.
It also needs a standardized assessment, a prescription, a child who is medically stable, and a treatment plan with measurable goals. “The plan must be signed by the BCBA.” Requests for children 20 and under are reviewed under EPSDT, Medicaid’s children’s benefit.
How often is medical necessity checked again?
Health First Colorado approves ABA for up to 6 months at a time. To continue, the records must show “meaningful, measurable, functional improvement changes,” confirmed with data, or explain what got in the way.
How does private insurance in Colorado handle it?
Colorado law says plans “must provide coverage for the assessment, diagnosis, and treatment of autism spectrum disorders for a child,” and that treatment “shall be for treatments that are medically necessary” (C.R.S. 10-16-104). Private plans usually want an autism diagnosis first, then review the BCBA’s plan and progress.
How does medical necessity set the hours?
The BCBA’s assessment leads to the recommended hours in the treatment plan, and the payer approves the hours it agrees are needed. There is no fixed number for every child.
Outside expert, not affiliated with Budding FuturesABA is a highly effective treatment for autism. But it has to be correctly implemented at the highest quality.
Does my child need an autism diagnosis?
Not for Health First Colorado: its benefit covers children with autism “and/or other diagnosis as justified by medical necessity.” Private plans usually need a formal autism diagnosis.
Who decides if ABA is medically necessary?
Your child’s prescriber orders therapy, the BCBA assesses your child and writes the plan, and the payer’s reviewer decides.
What goes in a letter of medical necessity?
For Health First Colorado, an MD, NP, PA or doctoral psychologist signs it. It includes:
- the diagnosis, ideally with its ICD-10 code
- the reason for therapy
- sessions per week and the expected length of therapy
- a standardized assessment from the last 12 months
What does not count as medically necessary?
- Care that is mainly respite or daycare
- Camps, recreational or equine therapy
- Unproven treatments
- “Services rendered by a parent, legal guardian, or legally responsible person”
Quotes come from Health First Colorado, Colorado law, HealthCare.gov and the Council of Autism Service Providers. These are outside sources; they are not affiliated with Budding Futures and did not review this page. This is general information, not legal or medical advice for your child.
Where Can Your Child Get ABA Therapy in Colorado?
How medical necessity relates to ABA with Budding Futures
Budding Futures checks your coverage for free and prepares the paperwork with you, so the BCBA's assessment and plan reach your payer complete.
- Where: Therapy happens at home (in-home ABA therapy), at school under district policy (school-based ABA), and for toddlers as early intervention.
- Who: Rachel Blackburn, BCBA writes every plan, and the same RBT works with your child each week.
- Paperwork: We check your coverage free, file the prior authorization, and ask for a second review if hours are cut.
- Start: Call (720) 613-8837 or send the form; there is no waitlist.
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