Short answer: yes, in most cases. But which type of Horizon plan you have changes the process, the requirements, and sometimes the outcome. Horizon Blue Cross Blue Shield of New Jersey is the state’s largest health insurer with more than 3.7 million members, and it offers several distinct plan types, each working a little differently when it comes to ABA therapy coverage.
This guide breaks down exactly what Horizon covers, how the two main Horizon products differ, what the authorization process looks like, and what to do if your claim runs into trouble.
The Two Types of Horizon Plans and How They Differ
Most families in NJ holding a Horizon insurance card have one of two very different products:
Horizon BCBS commercial plans — these are fully insured plans purchased through an employer, a marketplace, or directly. They include Horizon HMO Select, Horizon PPO, Horizon Omnia, Horizon Direct Access, and the NJ Direct plans used by state and county employees.
Horizon NJ Health — this is Horizon’s Medicaid managed care product, used by families enrolled in NJ FamilyCare. It works entirely differently from commercial coverage and has its own authorization rules.
Both cover ABA therapy. But the eligibility criteria, cost-sharing, and appeals process are not the same. Knowing which one you have determines the steps you take.
Horizon BCBS Commercial Plans: What They Cover
Under New Jersey Chapter 115, fully insured commercial plans regulated by the state are required to cover medically necessary ABA therapy for individuals under 21 with an autism spectrum disorder (ASD) diagnosis. Horizon’s commercial plans comply with this mandate.
Coverage includes:
ABA therapy delivered or supervised by a Board-Certified Behavior Analyst (BCBA) or Licensed Behavioral Analyst
Initial and ongoing BCBA assessments
Parent training as part of the ABA program
Re-authorization evaluations at the end of each coverage period
Coverage does not include ABA therapy that is not supervised by a credentialed BCBA, or services provided by a provider not recognized in Horizon’s network unless a single-case agreement has been arranged.
The Self-Funded Exception
Not every employer plan is subject to Chapter 115. If your employer is self-funded, meaning they pay claims directly rather than purchasing coverage from Horizon, the state mandate may not apply. Your insurance card will still say Horizon, which is why this confuses so many families.
To confirm, call the member services number on your card and ask: “Is my plan fully insured or self-funded?” If it is self-funded, ask your HR department whether your employer has voluntarily opted into the NJ autism insurance mandate.
Horizon NJ Health (Medicaid): How ABA Coverage Works
If you are enrolled in NJ FamilyCare and your managed care plan is Horizon NJ Health, ABA therapy is covered as a medically necessary service for members under 21 with an ASD diagnosis. This coverage comes through the federal EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) benefit, which requires Medicaid to cover all medically necessary treatments for children.
Key differences from commercial coverage:
There is no annual deductible and typically no copay for ABA therapy under Horizon NJ Health
Prior authorization is still required
Income eligibility requirements apply to NJ FamilyCare enrollment. Children under 19 generally qualify if household income does not exceed 355% of the federal poverty level
For NJ FamilyCare enrollment or to check eligibility, call 1-800-701-0710 or visit njfamilycare.dhs.state.nj.us.
What Horizon Requires Before Approving ABA Therapy
Whether you have a commercial Horizon plan or Horizon NJ Health, the documentation requirements are similar. Per Horizon’s published ABA policy, all ABA codes require prior authorization before therapy begins. Claims submitted without an active authorization on file will be denied.
Here is what needs to be in place before authorization is requested:
A formal ASD diagnosis from one of the following:
Pediatrician or pediatric neurologist
Child psychiatrist or psychologist
Advanced Practice Nurse with autism services in their scope
A prescription for ABA therapy stating it is medically necessary, referencing the autism diagnosis and recommending treatment.
A BCBA assessment and treatment plan including:
A Functional Behavior Assessment (FBA)
Specific, measurable therapy goals
Recommended weekly therapy hours
Clinical justification for the hours requested
Horizon reviews this package and typically issues a decision within 14 to 21 business days of a complete submission. Authorizations are usually granted for six months at a time, after which a re-evaluation is required to continue services.
Common Horizon Plan Types and What to Expect
Different Horizon plans have different cost-sharing structures. Here is a general breakdown:
Horizon HMO Select / Horizon PPO Standard employer plans. Require prior authorization. You will have a deductible, copay, or coinsurance depending on your specific plan. Referrals may be required for specialist services depending on your plan tier.
Horizon Omnia A tiered network plan. Tier 1 providers cost less out of pocket. Verifying whether your ABA provider is a Tier 1 or Tier 2 provider under Omnia can significantly affect your costs.
NJ Direct (SHBP/SEHBP) State employee and teacher plans. Subject to the NJ autism mandate. These plans have their own prior authorization process through Horizon, and ABA is a covered benefit.
Horizon NJ Health Medicaid managed care. No deductible for covered services. Prior authorization required. No cost to the member for medically necessary ABA.
What Happens If Horizon Denies Your Request
Denials under Horizon are not uncommon, and they are not permanent. The most common reasons include:
Insufficient clinical documentation supporting medical necessity
Requested hours exceeded Horizon’s standard initial approval amount
The provider did not meet Horizon’s credentialing requirements
The plan is self-funded and not subject to the NJ mandate
If you receive a denial:
Request the denial letter in writing with the specific reason stated
File an internal appeal within the deadline listed on the denial letter, typically 30 to 180 days
Include updated clinical records, a physician letter, and any supporting research in your appeal
If the internal appeal fails, contact DOBI for an independent external review at 1-800-446-7467
Horizon NJ Health (Medicaid) denials follow a slightly different process. Members have the right to a fair hearing through the NJ Division of Medical Assistance and Health Services. Your provider can assist with this process.
How Therapy Associates Works With Horizon Families
Therapy Associates is in-network with Horizon Blue Cross Blue Shield and Horizon NJ Health. We provide in-home ABA therapy across Northern New Jersey, including Passaic, Bergen, and Essex counties.
When you check your eligibility with us, our team contacts Horizon directly to verify your specific benefits, confirm in-network status, identify your deductible and copay, and flag whether your plan is fully insured or self-funded before you take another step. We handle the prior authorization submission and manage re-authorization at each six-month renewal.
If you are a state or county employee in Northern NJ, we also work with NJ Direct plans under the SHBP/SEHBP benefit structure.
Key Takeaways
Horizon Blue Cross Blue Shield covers ABA therapy for children under 21 with an ASD diagnosis under most of its fully insured NJ commercial plans, as required by Chapter 115. Horizon NJ Health (Medicaid) also covers ABA as medically necessary for eligible members. All Horizon ABA claims require prior authorization before therapy begins. Self-funded employer plans may not be subject to the NJ mandate regardless of having a Horizon card. Denied claims can be appealed internally and, if needed, through DOBI’s independent external review process.
Frequently Asked Questions
Does Horizon BCBS cover ABA therapy for all ages?
Coverage under the NJ mandate applies to children under 21. Adults over 21 may have coverage depending on their specific plan, but it is not guaranteed by state law. Call member services to confirm.
What is the difference between Horizon BCBS and Horizon NJ Health?
Horizon BCBS refers to Horizon’s commercial insurance plans purchased through employers or the marketplace. Horizon NJ Health is Horizon’s Medicaid managed care product for NJ FamilyCare members. Both cover ABA, but cost-sharing, income requirements, and appeal rights differ.
Do I need a referral to start ABA therapy under Horizon?
This depends on your plan type. HMO plans typically require a referral from your primary care physician before seeing a specialist. PPO and direct access plans generally do not. Check your plan documents or call member services.
How often does Horizon require re-authorization for ABA therapy?
Typically every six months. Your BCBA will complete a progress evaluation and submit a continuation request before your current authorization expires to avoid any gap in services.
Is Therapy Associates in-network with Horizon?
Yes. We are in-network with Horizon Blue Cross Blue Shield commercial plans and Horizon NJ Health. We serve families across Northern New Jersey and verify your Horizon benefits at no cost when you reach out.
Final Thought
Having Horizon does not automatically mean the process is straightforward, but it does mean coverage is real and enforceable. The most common obstacle is not the insurer refusing to pay, it is families not knowing what documentation to submit or not realizing their employer plan is self-funded until after a denial. Starting with a benefits verification call or reaching out to an in-network provider who handles this daily removes most of that uncertainty before it becomes a problem.
If you have Horizon and want to know exactly what your child’s coverage looks like, reach out to Therapy Associates and we will have a clear answer for you within 24 to 48 hours.
