When your child receives an autism diagnosis, the first wave of questions is emotional. The second wave — often arriving within hours — is financial. Can we afford this? Does our insurance actually cover aba therapy? What happens if it doesn’t?
These questions are completely valid, and you deserve clear answers rather than a paragraph of legal disclaimers and a phone number. What follows is a straightforward breakdown of how insurance coverage works for ABA therapy in Utah, what state law actually requires, and what your realistic options look like depending on your situation.
What Utah Law Requires
Utah passed Senate Bill 95 in 2019, which took effect January 1, 2020. This legislation was significant for Utah families because it removed previous caps on age and therapy hours for state-regulated insurance plans. Prior to SB 95, many plans limited coverage to children under a certain age or capped the number of annual therapy hours — constraints that placed real burdens on families whose children needed intensive support.
Under SB 95, coverage is now based on medical necessity rather than arbitrary limits built into a policy. This means your child’s individualized need, as determined by a Board Certified Behavior Analyst (BCBA), drives the conversation. If ABA therapy is deemed medically necessary, state-regulated individual plans and most employer-sponsored group plans regulated at the state level are required to cover it.
Sources: Utah Legislature SB 95 (2019); Acclimate ABA Therapy Utah Insurance Coverage Guide (2025); Autism Council of Utah Educational Services Resource.
The Self-Funded Plan Exception Most Parents Don’t Know About
Not every employer-sponsored insurance plan falls under Utah’s SB 95 mandate. Large corporations and some employers choose to self-fund their health plans, meaning the company itself bears the cost of employee healthcare rather than paying premiums to a carrier. These plans are governed by federal ERISA law rather than state insurance mandates, so Utah’s SB 95 requirements do not apply to them.
If you are unsure whether your plan is self-funded, you are encouraged to contact your HR department and request a Summary Plan Description (SPD). This document will clarify how your plan is structured and whether ABA therapy is a covered benefit. It is worth asking specifically about autism-related behavioral health services, since some plans categorize coverage differently than a general ABA inquiry might surface.
This is one of the more common points of confusion for Utah families, and knowing which category your plan falls into early in the process can save significant time.
Utah Medicaid Coverage: How It Works
For families who qualify for Medicaid, coverage for ABA therapy is available through a federal provision called the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Under federal law, EPSDT requires that Medicaid programs cover any medically necessary service for children under 21, even if that specific service is not explicitly listed in the state’s Medicaid plan. Because ABA therapy is considered a medically necessary treatment for children with Autism Spectrum Disorder, it falls under this benefit.
To access ABA therapy through Utah Medicaid, your child must have a formal ASD diagnosis from a licensed healthcare provider. That diagnosis needs to establish not only the presence of autism but the medical necessity for ABA-based treatment.
One important nuance: in Utah, both autism diagnostic evaluations and ABA therapy services are classified as carve-out services. This means they are billed directly through Medicaid fee-for-service rather than through a managed care plan, even if your child is enrolled in one. Families can sometimes be caught off guard by this, so it is worth confirming with your provider that they understand how to process these claims correctly.
For most families using Medicaid, out-of-pocket costs are minimal to none. Services require prior authorization and are reviewed approximately every six months to continue coverage.
Sources: Utah Medicaid Provider Manual, Autism Spectrum Services (accessed 2025); Utah DHHS ASD-Related Services Overview; Rogue Behavior Services Medicaid & Autism Therapy in Utah Guide (2025).
Starting the Process
Whether you are navigating private insurance or Medicaid, the process typically begins the same way: with an autism evaluation. A formal diagnosis is the foundation for any insurance authorization request. Without it, coverage requests for ABA therapy cannot move forward.
Once a diagnosis is in place, your ABA provider’s intake team should handle the bulk of the insurance verification and prior authorization process. You are encouraged to ask your provider directly whether they assist with authorizations, and to confirm they are in-network for your specific plan. Out-of-network services may involve higher cost-sharing even when your plan covers ABA therapy in principle.
At Kuska Autism Services, families can complete both the diagnostic evaluation and begin ABA therapy without restarting the intake process at a separate clinic. You can learn more about our therapy program or our diagnostic services to understand how each step works. Having diagnosis and therapy under the same roof means the clinical documentation needed for insurance authorization is already in place when therapy begins. Our team works with families across Davis County, Salt Lake County, and the surrounding areas from our Bountiful and Draper locations. If you are ready to take the next step, you are welcome to get started here or contact our team directly with any questions.
If Coverage Falls Short
For families whose plans do not fully cover ABA therapy, there are supplemental options worth exploring. Utah’s Carson Smith Scholarship and the Utah Fits All Scholarship both provide funding that can be applied toward private autism services, including ABA therapy. The Autism Speaks Family Services Resource Guide maintains an updated list of grants available to families navigating therapy costs.
A Flexible Spending Account (FSA) or Health Savings Account (HSA), if available through your employer, can also be used to pay for ABA-related expenses with pre-tax dollars. Some providers also offer payment plans or can connect families with additional local resources depending on location.
You are encouraged to ask any provider you are evaluating what financial navigation support they offer, since the administrative side of accessing services should not be another obstacle in an already demanding process. If you have questions about how Kuska works with your specific insurance plan, our team is available through our contact page and is happy to verify benefits before your first appointment.
Frequently Asked Questions
Does Utah law require all insurance plans to cover ABA therapy?
Utah’s Senate Bill 95 requires coverage in state-regulated insurance plans and removes prior age and hour caps. However, self-funded employer plans governed by federal ERISA law are not subject to SB 95, meaning coverage in those plans depends entirely on the employer’s own benefit decisions. You are encouraged to review your plan’s Summary Plan Description or contact your HR department to confirm whether ABA therapy is included as a covered benefit.
How do I know if my child qualifies for ABA therapy through Medicaid?
To receive ABA therapy through Utah Medicaid, your child must be under age 21 and hold a formal Autism Spectrum Disorder diagnosis from a licensed healthcare provider. That diagnosis must establish medical necessity for ABA-based services. Because both autism evaluations and ABA therapy are carve-out services in Utah, they are processed through Medicaid fee-for-service regardless of whether your child is enrolled in a managed care plan.
What is prior authorization and why does it matter before therapy begins?
Prior authorization is the process by which your insurance company or Medicaid program reviews and approves ABA therapy services before they begin. Without it, services may not be covered retroactively. Your ABA provider’s intake team should complete this process in coordination with your BCBA, who documents the medical necessity of your child’s individualized treatment plan. Therapy hours, service setting, and the clinical rationale tied to your child’s goals are all part of this documentation.
How many therapy hours will insurance actually cover for my child?
This depends on your child’s individualized assessment rather than a fixed number. Following a comprehensive evaluation by a BCBA, a recommended treatment intensity is established based on your child’s specific goals, learning profile, and your family’s practical considerations. For state-regulated plans under SB 95, coverage is tied to what is clinically indicated rather than a predetermined cap. For Medicaid, authorization is also based on medical necessity and reviewed at regular intervals, typically every six months.
Can an autism diagnosis and ABA therapy be handled by the same provider?
Yes, and having both services under one roof can meaningfully simplify the path to treatment. When the same provider completes the diagnostic evaluation and then coordinates ABA therapy, the clinical documentation needed for insurance authorization is already in place. At Kuska Autism Services, families move from evaluation into therapy without starting over at a different clinic. You can explore our program to learn more about how the process works from assessment through active therapy, or reach out to our team to ask about your specific situation.
Sources: Utah Legislature SB 95 (2019) | Utah Medicaid Provider Manual, Autism Spectrum Services (2025) | Utah DHHS ASD-Related Services | Acclimate ABA Insurance Coverage Guide (2025) | Rogue Behavior Services Medicaid Guide (2025) | Autism Council of Utah Educational Resources