Virginia FAMIS Plus ABA Coverage: A Complete Guide for Families

Understanding FAMIS Plus and ABA Therapy in Virginia

If your child has autism and you are covered by Virginia's Family Access to Medical Insurance Security (FAMIS) Plus program, you may be wondering: does my insurance pay for applied behavior analysis (ABA) therapy? The answer is yes, FAMIS Plus typically covers medically necessary ABA services for children with autism. This guide will walk you through what FAMIS Plus is, how ABA coverage works, and the steps to get your child started with therapy.

ABA is a evidence-based therapy that helps children with autism build important skills and reduce challenging behaviors. Because it is often intensive and can be expensive, understanding your insurance coverage is crucial. FAMIS Plus, Virginia's Children's Health Insurance Program (CHIP) for families with incomes too high for Medicaid but still needing help, provides robust coverage for ABA.

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What Is Virginia FAMIS Plus?

FAMIS Plus is a health insurance program for children and teens under age 19 (or up to 21 in some circumstances) from low-income families in Virginia. It is part of the broader FAMIS program that includes separate CHIP and a Medicaid expansion component. FAMIS Plus members receive benefits that are essentially the same as Virginia Medicaid, including comprehensive preventive care, doctor visits, hospital stays, prescription drugs, and mental health services.

Because FAMIS Plus is administered through Virginia's Medicaid agency, its coverage rules for ABA are identical to those of the state's Medicaid program. Since 2019, Virginia Medicaid has required coverage of ABA therapy for children under 21 with an autism spectrum disorder diagnosis. This means FAMIS Plus members have access to the same ABA benefits as children on full Medicaid.

Who Is Eligible for FAMIS Plus?

To qualify for FAMIS Plus, your family must meet income requirements (generally up to 200% of the federal poverty level, though some income disregards apply) and your child must be a Virginia resident and U.S. citizen or qualified non-citizen. Children already enrolled in Medicaid or FAMIS (the separate CHIP plan) may not be eligible for FAMIS Plus. The program is designed for uninsured children who do not have access to affordable employer coverage.

Once enrolled, your child will receive a FAMIS Plus ID card that works like a Medicaid card. It is important to keep this card current and to renew your child's coverage each year.

Does FAMIS Plus Cover Applied Behavior Analysis (ABA)?

Yes, Virginia FAMIS Plus covers ABA therapy for children with autism when it is deemed medically necessary. The benefit is delivered through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which mandates that states provide all medically necessary services to children under 21. ABA must be ordered by a physician or other licensed practitioner, and the therapy must be provided by a Board Certified Behavior Analyst (BCBA) or a team supervised by a BCBA.

What ABA Services Are Covered?

Covered services typically include:

• Comprehensive ABA assessments and functional behavior assessments (FBAs)
• Behavior intervention plans (BIPs) developed by a BCBA
• Direct one-on-one ABA therapy sessions, often provided in-home, at a clinic, or in a school setting
• Parent training and caregiver coaching
• Supervision and monitoring by a BCBA
• Data collection and progress reporting

The exact number of hours and duration of therapy are determined based on the child's individual needs and the recommendations of the BCBA. Prior authorization is typically required, and the provider must be enrolled as a FAMIS Plus/Medicaid provider.

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How to Get ABA Therapy Through FAMIS Plus

Navigating insurance can feel overwhelming, but the process is straightforward. Here are the key steps:

1. Obtain an Autism Diagnosis

Before FAMIS Plus will cover ABA, your child must have a formal diagnosis of autism spectrum disorder (ASD) from a qualified professional, such as a developmental pediatrician, child psychiatrist, or psychologist. The diagnosis must be documented in your child's medical record. If you already have a diagnosis, you can move to step 2.

2. Get a Referral for ABA

Your child's primary care provider or a specialist must write a prescription or referral for ABA therapy. This referral should specify that ABA is medically necessary to treat your child's autism. The provider may also need to complete a medical necessity form for FAMIS Plus.

3. Find a BCBA Provider Who Accepts FAMIS Plus

Not all ABA providers are enrolled with FAMIS Plus/Medicaid. You will need to search for a BCBA-led provider that accepts this insurance. A free service like ABA Therapy Now can match your family with vetted, BCBA-led providers in Virginia who have experience working with FAMIS Plus. We do the legwork for you, so you can focus on your child's care.

4. Schedule an Assessment

Once you have a provider, they will schedule an initial assessment (often a functional behavior assessment) to evaluate your child's strengths and needs. Based on this assessment, the BCBA will create a treatment plan with specific goals and recommended hours of therapy. The provider will then submit this plan to FAMIS Plus for authorization.

5. Begin Therapy

After authorization is approved (usually within 30 days), your child can start ABA sessions. Your provider will work with you to schedule sessions that fit your family's routine, whether in your home, at the provider's clinic, or in the community.

What to Expect from Your FAMIS Plus ABA Coverage

Most families enrolled in FAMIS Plus face no premiums, deductibles, coinsurance, or copays for covered ABA services, as long as they use in-network providers. Virginia's CHIP program has very low cost-sharing, and for many families, ABA is fully covered at no out-of-pocket cost. However, we recommend double-checking with your FAMIS Plus plan and your provider to confirm any potential costs.

There is no specific cap on ABA hours under FAMIS Plus, but the number of hours authorized will be based on medical necessity. The provider will regularly review progress and request authorization for additional hours if needed. Coverage continues as long as the treatment is deemed medically necessary and your child remains eligible for FAMIS Plus.

What If My Child Turns 21?

FAMIS Plus usually covers children up to age 19, but those with disabilities may qualify for continued coverage under Virginia's Medicaid aged-out program up to age 21. For ABA specifically, Virginia Medicaid covers ABA up to age 21, so if your child needs continued therapy, they may transition to full Medicaid. It's important to plan ahead and talk to your caseworker or a benefits counselor.

Finding a Provider: The Importance of a Trusted Match

Choosing the right ABA provider is critical to your child's success. You want a team that is not only skilled but also supportive, communicative, and respectful of your family's values. Because FAMIS Plus has a narrower network than some private insurers, you may find fewer provider options. However, many excellent BCBA-led clinics in Virginia accept Medicaid and FAMIS Plus.

Our free matching service, ABA Therapy Now, connects families with vetted providers who have availability and experience with FAMIS Plus. We pre-screen providers for BCBA supervision, evidence-based practices, and cultural competence. Simply tell us your location and preferences, and we'll share a list of options that fit your needs.

Tips for Families Using FAMIS Plus for ABA

Here are practical tips to make the process smoother:

• Keep all documents organized: Save copies of your child's diagnosis, referral, insurance card, and authorization letters. This helps streamline approvals and renewals.
• Ask about session settings: Some providers offer in-home therapy, which may be more convenient; others have clinic or community-based options. Choose what works for your child.
• Stay in touch with your provider's billing team: They can help verify coverage and handle any authorization issues. It's a good idea to confirm that no unexpected costs arise.
• Consider early intervention: The earlier your child receives ABA, the better outcomes can be. If your child is under age 6, Virginia's Early Intervention program (Part C) may also provide some coordination.
• Don't be afraid to ask questions: You have a right to understand your coverage. Call your FAMIS Plus plan or your provider if anything is unclear.

Common Pitfalls to Avoid

• Assuming all providers are in-network: Always verify that the provider is enrolled with FAMIS Plus before scheduling. Your free matching service can handle this check for you.
• Skipping the prior authorization step: Starting therapy without approval could lead to denied claims. Wait for the authorization to be finalized.
• Ignoring renewal dates: Your child's FAMIS Plus coverage must be renewed each year. Lapse in coverage may interrupt ABA services.

Conclusion

Virginia FAMIS Plus offers a solid path to accessing ABA therapy for children with autism. With no premiums and few out-of-pocket costs, it removes financial barriers and allows families to focus on their child's development. The key is understanding the process: get a diagnosis, a referral, and then find a provider who accepts FAMIS Plus. A service like ABA Therapy Now can simplify the search, connecting you with BCBA-led providers who are ready to help. Take the first step today to give your child the support they deserve.