Choosing a Health Plan for a Child in ABA: 7 Things to Check at Open Enrollment

Marketplace enrollment opens November 1, and plenty of employer windows are open right now, so ABA coverage open enrollment decisions are landing on kitchen tables this week. 

I have watched families pick a plan in twenty minutes and spend the following year untangling what it did and did not cover. The seven checks below take about an hour and can keep your child's therapy steady through 2027.

At Blue Jay ABA, we verify benefits for families across North Carolina and Colorado. The same handful of questions separates a plan that supports ABA from one that merely lists it. Settle them before you enroll and the rest of the year gets much quieter.

When ABA Coverage Open Enrollment Starts and Ends in NC and Colorado

Your deadline depends on where your coverage comes from, so start by naming the source. A marketplace plan, an employer plan, and Medicaid each run on a different clock.

Marketplace Plans in North Carolina and Colorado

North Carolina families shop through HealthCare.gov. The HealthCare.gov dates and deadlines page shows Open Enrollment starting November 1 and ending January 15. December 15 is the last day to enroll for coverage that begins January 1, and plans chosen from December 16 through January 15 start February 1.

Colorado's marketplace, Connect for Health Colorado, follows the same calendar for 2027 coverage. It also offers a plan preview tool, so you can compare plans before November 1.

Employer Plans

Employer windows are often shorter than the marketplace window, and many close in November. Ask HR for the exact last day this week. Also ask whether the carrier, network, or ABA benefit is changing for next year.

Medicaid and CHIP

Medicaid and CHIP do not follow open enrollment, and HealthCare.gov notes you can apply at any time. Health First Colorado enrollment is year-round too. If your household might qualify, you can apply while you shop for private coverage.

The ABA Coverage Open Enrollment Checklist: 7 Things to Verify

The first two checks tell you whether a plan can promise ABA at all. The other five tell you whether it will cover your child's ABA in a way your family can sustain.

1. Find Out Whether the Plan Is Fully Insured or Self-Funded

This one question changes what the law can do for you. In a fully insured plan, an insurance company carries the risk and state insurance rules apply, including autism coverage laws. In a self-funded plan, your employer pays claims directly and an insurer or administrator only runs the paperwork.

The North Carolina Department of Insurance explains that self-funded plans are not subject to state insurance laws and are regulated by the U.S. Department of Labor instead. Colorado's Legislative Council staff say the same about mandated benefits. 

They apply to fully insured plans, not to self-funded, union, or federal employee plans. North Carolina's State Health Plan for teachers and state employees is also self-funded.

Self-funded does not mean no ABA coverage, because many large employers cover it voluntarily. It means no state law guarantees it, so the plan document is the only promise you have. Ask HR or member services, "Is this plan fully insured or self-funded?" The summary plan description answers it too.

2. Read the Written ABA Benefit, Not the Brochure

Marketing summaries say "autism services covered." The plan's clinical policy says how much, for whom, and under what conditions. Ask the insurer to send its autism or ABA medical policy along with the Summary of Benefits and Coverage, then look for these items:

• Age limits and annual dollar or hour caps
• Which credentials may supervise and diagnose
• Covered places of service, such as home, clinic, school, community, or telehealth
• Coverage for assessment, treatment, and parent training
• How the plan defines medical necessity
• Exclusions that label ABA "educational" or "custodial"

State law sets the floor for fully insured plans, and the floors differ. North Carolina's autism coverage statute lets plans cap adaptive behavior treatment at $40,000 a year, adjusted for inflation, and limit it to people 18 or younger. 

Colorado removed age and dollar caps for state-regulated plans beginning in 2017. If you are in North Carolina, ask whether your plan applies the cap and what the current figure is.

I remember a family who assumed their employer plan had no ceiling. The cap sat deep in the plan document, and the benefit ran dry in the fall. We rebuilt their son's hours around the remaining dollars while they appealed. Reading the document in November would have saved them months of stress.

3. Confirm Your ABA Provider Is In Network, and Know What Out-of-Network Means

Provider directories lag behind reality. Call the insurer, give the provider's name, address, and tax ID or NPI, and ask whether that exact location is in network for ABA under the plan you are considering. Write down the representative's name and a call reference number.

Then ask what the plan does when no in-network provider has an opening. Some plans offer single-case agreements, which can let a child keep an out-of-network provider at in-network rates. Ask about it by name.

Blue Jay ABA works with Medicaid health plans and many commercial carriers. Our insurance coverage page lists them, including BlueCross BlueShield. We check your plan before the first session.

4. Learn How Prior Authorization and Renewal Work

ABA almost always needs approval before sessions begin, and again at renewal. Ask whether the assessment needs its own authorization and how long review takes. Ask how often the plan re-reviews hours, since many plans review about every six months. Ask what happens if hours are reduced.

Requests usually rest on a diagnosis report, a standardized assessment, and a treatment plan with measurable goals. Our ABA assessment builds the documentation reviewers look for. If a plan denies or trims hours, our guide on how to appeal a denial explains what to gather.

5. Price the Plan on Your Child's Real Year, Not the Premium

A child in regular ABA will likely reach the out-of-pocket maximum. That makes premium plus out-of-pocket maximum a better predictor of your cost than premium alone. Our post on copays and deductibles explains each piece.

Check three details. Are the family and individual out-of-pocket limits separate or combined? Do ABA copays count toward the maximum? Does out-of-network spending count at all? I walk through a full example below.

6. Plan for What Happens if Coverage Changes Mid-Year

Open enrollment is the cleanest time to switch because deductibles reset January 1. A mid-year switch can cost you what you have already paid. Connect for Health Colorado warns that when someone changes individual plans before open enrollment, the new insurer will not honor deductibles and other costs already accumulated.

Outside open enrollment, you can generally change plans only after a qualifying life event, such as moving, losing other coverage, marriage, or a new baby. Needing more therapy is generally not one of them. 

Insurers also leave markets. Cigna has announced it will stop offering individual and family plans in 2027, and affected Colorado customers have a special enrollment period until March 1, 2027.

Authorizations are tied to a plan and a provider, so a new plan usually means a new request. Our posts on authorization transfers and what happens when a parent changes jobs explain how to keep sessions going.

7. Decide Whether Medicaid Belongs in Your Plan

Some children qualify for Medicaid or CHIP, alone or alongside private coverage. NC Medicaid and Health First Colorado both cover ABA for eligible children, and you can apply all year. When a child has both private insurance and Medicaid, Medicaid typically pays after the private plan, so tell your provider about both cards from the first call.

If you are unsure whether your household qualifies, apply and let the caseworker decide. NC Medicaid's own guidance is that applying is the best way to find out.

How to Verify Benefits Without Getting the Runaround

Insurance answers shift with the question you ask and the person you ask. Plain, specific questions tend to get plain, specific answers.

Questions for Your Insurer

• Is ABA covered under my medical or behavioral health benefit, and does that change my cost sharing?
• Is there an age limit, visit limit, or annual dollar cap on autism treatment?
• Is my provider in network at this address under this exact plan?
• Do ABA costs count toward my out-of-pocket maximum?
• Can you send me the autism medical policy in writing?

Questions for HR or Your Benefits Administrator

• Is this plan fully insured or self-funded?
• Will the carrier, network, or ABA benefit change for next year?
• Is there any plan exclusion for autism services I should know about?
• What is the last day to change my election, and which life events reopen it?

Keep a Paper Trail

Write down the date, the representative's name, and the reference number for every call. Ask for key answers by email or through the member portal, and save the Summary of Benefits and Coverage as a PDF. If a claim is denied later, that record is your strongest evidence.

Comparing Two Plans Side by Side: A Worked Example for ABA Families

Here is the comparison I walk families through. The numbers are illustrative, so swap in your own plans' figures.

Run the Numbers for Your Child's Year

Plan B costs $170 more each month and still comes out $2,460 cheaper if your child reaches the out-of-pocket maximum, which is likely with weekly ABA. If your child's hours are low or irregular, Plan A may win. Run both scenarios before you choose.

Decision Rules I Share With Families

• Favor the plan whose written ABA benefit is clear, even when its premium is a little higher.
• Keep your child's provider in network, because a network change can interrupt authorization.
• Look at the out-of-pocket maximum before the deductible.

How Blue Jay ABA Helps You Check Coverage Before You Enroll

You should not need an insurance degree to protect your child's therapy. Our team does this verification every day and explains what we find in plain language.

We verify benefits, build the treatment plan, and manage authorizations for families in Charlotte, Raleigh, Greensboro, and Wilmington. In Colorado we serve families in Denver, Colorado Springs, and Aurora.

Depending on your child's needs, services include home-based ABA, school-based ABA therapy, telehealth ABA, and ABA parent training. If your child does not have a diagnosis yet, our autism evaluation team can help with that first step.

Send us your plan details through our contact form, and we will tell you what we find before your enrollment deadline.

Your Next Step Before Open Enrollment Closes

The strongest ABA coverage open enrollment choice is the plan whose written benefit, network, and yearly cost you have confirmed for yourself. In my experience, families who ask these questions in November spend far less of the next year on hold with insurers. You do not need a perfect plan, only one you understand.

Costs and coverage vary by plan, and nothing here replaces your plan documents. If a plan document leaves you with more questions than answers, call or message Blue Jay ABA at 888-813-2583, and a member of our team will read it with you.

Frequently Asked Questions About ABA Coverage and Open Enrollment

When does open enrollment start for 2027 health coverage?

On HealthCare.gov and Connect for Health Colorado, Open Enrollment for 2027 coverage runs November 1, 2026 through January 15, 2027. Enroll by December 15 for coverage that starts January 1. Employer plans set their own windows, so ask HR for your exact deadline.

Does health insurance have to cover ABA therapy in North Carolina and Colorado?

Fully insured, state-regulated plans must cover autism treatment, including ABA, under each state's autism law. North Carolina allows plans to cap ABA at $40,000 a year, adjusted for inflation, and to limit it to people 18 or younger. Colorado removed age and dollar caps for state-regulated plans in 2017. Self-funded employer plans are not bound by state mandates, so read the plan document.

How can I tell if my employer's plan is self-funded?

Ask HR or member services, "Is this plan fully insured or self-funded?" The summary plan description states it too. A well-known insurer's name on your card does not settle the question, because insurers also administer self-funded plans.

Can I change health plans after open enrollment if my child needs more ABA?

Generally only if you have a qualifying life event, such as moving, losing other coverage, marriage, or a new baby. Needing more therapy is not usually one of them, which is why these checks belong before you enroll. Medicaid and CHIP can be applied for at any time.

Will switching plans change my child's ABA authorization?

Usually yes. Authorizations are tied to a specific plan and provider, so a new plan generally needs a new request. Deductible and out-of-pocket amounts you have already paid may also not carry over to a new insurer.

Sources

• Centers for Medicare & Medicaid Services. (2026). When can you get health insurance? HealthCare.gov. https://www.healthcare.gov/quick-guide/dates-and-deadlines/
• North Carolina Department of Insurance. (2026). Group health insurance. https://www.ncdoi.gov/group-health-insurance
• North Carolina Department of Insurance. (2026). Health plans we do not regulate. https://www.ncdoi.gov/health-plans-we-do-not-regulate
• North Carolina General Assembly. (2015). G.S. 58-3-192, Coverage for autism spectrum disorder. https://www.ncleg.gov/EnactedLegislation/Statutes/PDF/BySection/Chapter_58/GS_58-3-192.pdf
• Colorado General Assembly, Legislative Council Staff. (2020). Colorado health insurance mandates. https://content.leg.colorado.gov/publications/colorado-health-insurance-mandates
• Autism Speaks. (n.d.). Colorado state-regulated insurance coverage. https://autismspeaks.org/colorado-state-regulated-insurance-coverage
• Connect for Health Colorado. (2026). What's new: Changes for plan year 2027. https://connectforhealthco.com/resources/health-insurance-101/whats-new/
• NC Medicaid. (2026). NC Medicaid eligibility. https://medicaid.ncdhhs.gov/eligibility