ABA Medicaid Rule Changes by State

What changed

• Out-of-state BCBAs may no longer enroll as Medicaid providers

  New G.S. 108C-9(e) bars Board Certified Behavior Analysts and Qualified Autism Services Practitioner Supervisors from enrolling as out-of-state providers. Two limits are widely missed: this is an enrollment bar, not a practice or licensure ban, and it applies only to applications submitted on or after April 30, 2026 — it does not speak to analysts already enrolled. NC Medicaid also defines an out-of-state provider as one located more than 40 miles beyond the state border, so clinicians inside that 40-mile band are border providers and are not covered by this bar.

• Telehealth supervision of code 97155 capped at 50%

  The statute limits supervisor observation and direction of a paraprofessional delivered by telehealth to no more than half of that supervisor's services for any single recipient. The draft policy maps this to CPT 97155 and sets the ceiling at 50% of billing per beneficiary — raised from the 20% figure in the earlier draft. The state may grant exceptions for documented medical necessity or access problems, explicitly including poor provider availability in rural and underserved areas.

• Reauthorization frequency is unresolved between statute and draft policy

  For treatment plans exceeding 16 hours per week, the enacted statute requires the plan to be updated and reapproved monthly. The draft policy instead requires reauthorization at least every 90 calendar days — and then contradicts itself, restating the monthly requirement in a later section. Until the final policy publishes, plan against the monthly statutory language rather than the quarterly draft language.

• In-person requirements added for assessment and paraprofessional services

  Supervisor assessments conducted by telehealth are not reimbursable. Paraprofessional services delivered by telehealth are barred outright, subject to the state's exception process. Caregiver training is the exception in the other direction — it may be delivered entirely by telehealth with no in-person component.

• New supervision floors and service ratios

  At least 10% of paraprofessional services must involve supervisor observation and direction. Separately, supervisor services must fall between 10% and 20% of a beneficiary's total, measured over six months, and this ratio applies only to beneficiaries receiving more than 200 paraprofessional hours in that period. Exceeding 20% remains reimbursable with documented medical necessity.

• Paraprofessional credentialing changed in both directions

  Paraprofessionals must hold RBT or ABAT certification after a 120-day grace period from date of hire, but are exempt from Medicaid credentialing itself.

• Three-tier enforcement, escalating to billing suspension

  First and second findings of noncompliance draw recoupment. A third occurrence of noncompliance found to be material and systematic can suspend billing privileges for one to two years.

What changed

• 4,000-hour lifetime cap on comprehensive ABA

  Indiana imposed a lifetime cap of 4,000 hours on comprehensive ABA, tracked with a new UA modifier. A lifetime cap is structurally different from an annual limit — it is not restored by a new plan year, so long-tenured clients approach an absolute ceiling.

• Coverage restricted to beneficiaries under 21

  ABA moves under EPSDT authority, with adult coverage ending after October 1, 2026.

• Telehealth banned across most direct service codes

  Modifier 95 telehealth is no longer permitted for codes 97151, 97152, 97153, 97154, or 0373T.

• Roughly 6% rate cut now, with a further cut scheduled for 2027

  Effective for dates of service on or after April 1, 2026: code 97153 (U1) fell from $17.06 to $16.04, and 97155 at the U3 masters/doctoral tier fell from $27.63 to $25.97. The 97155 U2 tier fell from $21.85 to $20.54. A further reduction is already scheduled for April 1, 2027, taking 97153 to $15.39 and 97155 U3 to $24.93.

• Group codes restratified by group size

  Group service rates were restratified by the number of participants, with code 97154 rising to $9.21 for groups of two.

What changed

• Reimbursement barred when diagnosis and treatment share an owner

  The June bulletin prohibits reimbursement for ABA services provided by a clinic or agency owned by a private entity related to the same private entity that conducted the member's autism evaluation and diagnosis. This is the most operationally significant change in the rewrite and the one least covered elsewhere — it directly affects vertically integrated practices that both diagnose and treat.

• Telehealth eligibility redrawn by code

  Code 97156 becomes permanently telehealth-eligible without prior authorization. Code 97155 becomes permanently telehealth-eligible but requires prior authorization. Code 97151 is no longer allowable by telehealth at all.

• Authorization timing determines which rules apply

  Authorizations approved before July 1, 2026 continue under the prior policy. Any initial or continuing authorization submitted on or after July 1, 2026 must comply with the updated manual.

• Tightened medical necessity, documentation, and enrollment standards

  The rewrite strengthens medical necessity criteria, expands the list of non-covered services, updates provider qualification and enrollment requirements, and adds documentation and plan-of-care requirements.

• Rates are an open question, not a settled one

  Secondary write-ups state the rate structure is unchanged. SCDHHS did not say that. The May bulletin says the updated manual would be posted by July 1, 2026 with corresponding fee schedule updates to follow — an open item. We have found no primary source establishing rates as unchanged and are not repeating the claim.

What changed

• Remote RBT supervision restricted by distance

  Remote supervision of registered behavior technicians is permitted only by a provider located in Georgia, or within 50 miles of the state border. For clinics running centralized remote supervision from outside the region, this is the binding constraint.

• Supervision ratios tied to claims accuracy

  Oversight ratios for RBTs are determined by the provider's claims accuracy, making billing performance a direct input into how much supervision capacity a clinic must staff.

• Additional prior authorization requirements

  DCH proposed added prior authorization requirements for ABA as part of the same high-risk designation.

• Capacity obligations for larger agencies

  Agencies above a certain size face capacity requirements to serve high-acuity members, plus an annual abandoned-care report to DCH. DCH also reiterated the prohibition on member solicitation.

• Separately, CareSource cut Georgia ABA reimbursement to 80% of the fee schedule

  CareSource issued a notice of material amendment to Georgia network providers reducing ABA reimbursement to 80% of the then-current Georgia Medicaid fee schedule, effective May 11, 2026, with a 45-day objection window and termination 90 days after objection. This is a managed care contract action, not state policy, and the specifics come from a private contract letter rather than a published document — CareSource confirmed the substance on the record to trade press but has not published the amendment, the percentage, or the date. Treat the 20% figure as reported rather than official, and note it is Georgia-specific, not a national CareSource action.

• What this is not: the CareSource medical policy being widely cited

  Several write-ups point to CareSource policy GA MCD-MM-0212, effective July 1, 2026, as the Georgia change. That document is a managed care organization's own medical policy, not state policy, and its revision history shows the underlying action was an annual review that moved payment detail into a separate policy and replaced copied manual text with cross-references. It is administrative cleanup. The DCH action above is the substantive change.

What changed

• Code 97153 cut in two stages to $14.45 per unit

  Authorized by the enacted FY 2025-2026 state budget, the rate for 97153 fell to $16.85 per unit on October 1, 2025, then to $14.45 per unit on April 1, 2026 — a 14.2% reduction in the second step and roughly 25% cumulatively from the prior $19.26.

• Only the technician code was reduced

  Codes 97151, 97152, 97155, and 97156 all remain at $19.26 per unit; group codes remain at $3.31 per unit per member. Characterizing this as an across-the-board New York ABA rate cut is inaccurate — it is a targeted cut to the code that carries the most volume.

What changed

• Codes 97153 and 97155 may no longer be billed concurrently

  Effective for dates of service beginning January 1, 2026, DVHA prohibits billing 97153 and 97155 for the same patient at the same time. The state grounds this in a June 2024 AMA clarification that these codes report the patient's face-to-face time, not the clinician's, and estimates concurrent billing had inflated tier hours by approximately 12%.

• Tier rates absorbed the previously withheld value-based payment amount

  Tier hourly rates now include the 1% previously withheld for Value Based Payment.

• ABA determined to fall outside Vermont's supervised billing rules

  DVHA separately determined that ABA does not fall under Vermont's supervised billing rules at all.

What changed

• Pediatricians would need an added specialty designation for referrals to be valid

  The paused rule would require physicians enrolled as Provider Type 31 with Specialty 345 to submit a written request on official letterhead to add ABA Specialty 175 to their enrollment. Without that designation, the autism diagnosis would not be valid for an ABA therapy referral and referrals would be denied.

• No retroactive effect

  The agency stated there is no retroactive date for adding ABA Specialty 175 — the effective date would be the date the specialty is approved and added to the provider's enrollment file. For clinics, that means referral pipelines could not be repaired after the fact.

• CRNPs cannot diagnose for ABA referral purposes

  The same alert stated that certified registered nurse practitioners are not authorized to diagnose autism-related conditions for ABA referrals. This point was not part of the paused implementation and was not widely reported.