Does Medicaid cover ABA therapy in Virginia? What families need to know
Yes, Virginia Medicaid covers ABA therapy for children under 21 when it is medically necessary, and Virginia law requires many private plans to cover it too. Here is how each one works.
Virginia Medicaid pays for ABA therapy for children and young people under 21 when a provider shows it's medically necessary and the health plan approves it. In-Home ABA Richmond works with Virginia Medicaid health plans and most major insurance, and we check your benefits before your child starts.
- Medicaid: ABA is covered under the EPSDT children's benefit, under age 21, with service authorization.
- Cardinal Care has five health plans. Your card shows which one you have.
- Private insurance: Virginia law requires many plans to cover ABA at any age, with a yearly ABA cap of at least $35,000.
- Plans through a large employer may be self-funded and follow different rules. Ask HR.
Does Medicaid cover ABA therapy in Virginia?
Yes. Virginia's Medicaid agency, the Department of Medical Assistance Services (DMAS), lists "Behavioral Health Therapy including Applied Behavior Analysis (ABA)" among the medically necessary services children can get through EPSDT.
EPSDT stands for Early and Periodic Screening, Diagnostic and Treatment. The agency says it covers children under age 21 enrolled in Medicaid's managed care or FAMIS Plus, so Medicaid members under 21 are the ones eligible for this behavioral health benefit. For ABA eligibility, three rules matter:
- Age: under 21.
- Medical necessity: the health plan decides case by case whether ABA is medically necessary for your child.
- Service authorization: therapy must be approved before it starts. The assessment itself doesn't need one.
Your health plan can tell you whether you owe anything for approved sessions. We help families through every step: we submit the assessment, the treatment plan, the therapy hours the BCBAs and RBTs will deliver, and the progress reports the plan asks for.
The five Cardinal Care health plans for Medicaid ABA therapy
Most members of the Medicaid program are in Cardinal Care managed care. Since July 1, 2025, DMAS lists five health plans. Each one approves ABA for its own members.
- Virginia Medicaid (Cardinal Care)
- Aetna Better Health of Virginia
- Anthem HealthKeepers Plus
- Humana Healthy Horizons of Virginia
- Sentara Health Plans
- UnitedHealthcare of the Mid-Atlantic
- Commercial plans through work
- Marketplace plans
| Cardinal Care health plan | What to do |
|---|---|
| Aetna Better Health of Virginia | Tell us your member ID; we request the authorization |
| Anthem HealthKeepers Plus | Same |
| Humana Healthy Horizons of Virginia | Same. Former Molina members moved here on July 1, 2025 |
| Sentara Health Plans | Same |
| UnitedHealthcare of the Mid-Atlantic | Same |
Not sure which plan you have, or want to switch? The Cardinal Care managed care helpline is 1-800-643-2273 (TTY 1-800-817-6608), listed on the DMAS members page.
A Medicaid change Virginia has proposed
Parents should know about this before they plan their child's hours. In August 2026, DMAS sent the federal government a proposed change to Medicaid's autism services (State Plan Amendment 26-018). The document we read wasn't yet approved.
As proposed, it would limit ABA to young people with an autism diagnosis, or children 5 and under with a provisional diagnosis for up to a year. It would also set a limit of 20 hours a week, which children under 21 could go over when it's medically necessary under EPSDT. The proposed start date is October 1, 2026.
We will update this page when the change is approved or dropped. Until then, the current rule applies: ABA under EPSDT, under 21, authorized on medical necessity. Source: DMAS SPA 26-018 packet.
ABA therapy insurance coverage in Virginia: private plans and the autism law
Virginia has an autism insurance law, Code of Virginia § 38.2-3418.17. It applies to insurance companies and HMOs that sell health plans in Virginia. Here's what it says, in plain words:
- Who is covered: since January 1, 2020, people of any age with autism spectrum disorder.
- ABA is included when it's provided or supervised by a BCBA licensed by the Virginia Board of Medicine.
- A yearly cap: ABA coverage can be limited to $35,000 a year, unless the plan chooses to pay more.
- No visit limits.
- Who orders it: a licensed physician or licensed psychologist, who must be independent of the ABA provider.
- Prior authorization is allowed, and the plan can review the treatment no more than once every 12 months unless both sides agree.
Read the law itself on the Virginia Legislative Information System.
Plans through a big employer
Many large employers pay their workers' claims themselves. These are called self-funded plans, and they often follow federal rules instead of state insurance law. Ask your HR office one question: "Is our plan fully insured or self-funded, and does it cover ABA?" Many self-funded plans cover ABA anyway. We check either way.
What you may pay with private insurance
Expect your plan's usual costs: a deductible, then a copay or coinsurance for each session. Because ABA can mean many hours a week, the out-of-pocket maximum matters a lot. Our cost guide shows how the numbers add up over a year.
Virginia Medicaid vs private insurance for ABA
| Virginia Medicaid (EPSDT) | Private insurance (state law) | |
|---|---|---|
| Ages | Under 21 | Any age (since 2020) |
| Approval | Service authorization, case by case | Prior authorization allowed |
| Who orders ABA | Per your health plan's rules | Licensed physician or psychologist, independent of the provider |
| Yearly limit | No dollar cap today (a weekly hours limit is proposed) | Can be capped at $35,000 a year for ABA |
| Your cost | Ask your health plan | Deductible, copay or coinsurance |
Questions to ask your insurance provider
- Does my plan cover ABA therapy for autism, and in the home?
- Do you need a prior authorization? For the assessment too?
- Is there a yearly dollar limit or an hours limit for ABA?
- What's my deductible, copay or coinsurance for ABA, and my out-of-pocket maximum?
- Is caregiver (parent) training covered as part of ABA?
- Do you cover sessions at daycare or school, or only at home?
Or skip the phone tree: send us your insurance details and we will find out. Book a call, or see how to get started.
Frequently asked questions about Medicaid ABA and insurance
Does Virginia Medicaid cover in-home ABA therapy?
Yes. Virginia Medicaid covers ABA for children under 21 through EPSDT when it's medically necessary and approved by your health plan. It can be delivered in the home.
Do I need a prescription for ABA therapy in Virginia?
For private insurance, Virginia law says ABA must be prescribed or ordered by a licensed physician or licensed psychologist who is independent of the ABA provider. Medicaid plans have their own steps, and we tell you what yours needs.
Is there a Virginia autism waiver for ABA?
ABA for children on Medicaid is covered through the EPSDT benefit, so a child under 21 doesn't need a waiver to get it. Waivers are separate programs for other long-term supports.
Does my child need a new autism evaluation?
Usually not, if the report is recent enough for your health plan. Some plans ask for an updated evaluation after a few years. We check what yours requires.
What if my insurance denies ABA?
Ask for the denial in writing and the reason. Most denials can be appealed, and some are fixed with more information from the BCBA or your doctor. We can help you with the next steps.
Sources read 16 October 2026: DMAS EPSDT and Cardinal Care member pages, DMAS SPA 26-018 packet, Code of Virginia § 38.2-3418.17. This page is general information, not legal advice.