ABA Medicaid Rule Changes by State

What changed

• Code 97153 cut in three stages, from $19.26 to $9.63 per unit

  The first two steps came from the enacted FY 2025-2026 budget: $19.26 to $16.85 per unit on October 1, 2025, then to $14.45 on April 1, 2026. The third came from the enacted FY 2026-2027 budget and took the rate to $9.63 on October 1, 2026. Cumulatively that is a 50% reduction in twelve months. In hourly terms, four units of technician time fell from $77.04 to $38.52.

• Only the technician code was reduced, all three times

  Codes 97151, 97152, 97155, and 97156 remain at $19.26 per unit. Characterizing this as an across-the-board New York ABA rate cut is inaccurate. It is a targeted cut, repeated three times, to the single code that carries the most volume in a comprehensive program. The state's stated rationale is that the change "ensures providers of ABA services are compensated equitably for their training and experience," which reads as a deliberate decision to price unlicensed technician time well below licensed time.

• The arithmetic now collides with technician wages

  At $38.52 per collected hour, a technician paid $25 an hour consumes 65% of the revenue that hour generates before payroll taxes, benefits, supervision time, unbilled cancellations, or any overhead. New York also has one of the highest technician-proxy wage medians in the country, which is why this rate is the one that providers describe as structurally unworkable rather than merely tight.

What changed

• Amerigroup cut technician-delivered ABA 30% for foster children

  Amerigroup, part of the Elevance family, reduced ABA reimbursement by 30% effective September 1, 2026 for the foster care population it covers under Georgia's Medicaid program. Its notice to clinics described the change as intended to better align reimbursement across autism services, and in an email to the state it said it would raise rates for caregiver-training work instead, calling the new structure a more targeted and clinically defensible approach. This is a managed care rate action, not a change to the state fee schedule, and Georgia sets no managed care rate floor for ABA. DCH's position is that where no in-network provider is available, Amerigroup must arrange out-of-network care case by case, which is a right families have to know to invoke.

• 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

• 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. NC Medicaid has since dated the in-state enrollment requirement for supervisors and qualified professionals to August 2, 2026, citing Session Law 2026-1, Sec. 3C.18(c).

• Telehealth supervision of code 97155 capped at 50% per 180-day period

  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 final policy maps this to CPT 97155, billed with the GT modifier, and sets the ceiling at 50% of total 97155 billing per beneficiary per 180-calendar-day period. That denominator matters: it is a rolling-period ceiling, not a per-claim or per-month test. Exceeding it requires written clinical justification in the beneficiary's treatment plan. Telehealth may not be used solely for the convenience of the provider, the beneficiary, or the caregiver.

• Reauthorization is every 90 days above 16 hours per week, every 180 days below it

  The final policy resolves a conflict that ran through every earlier draft. Treatment plans involving more than 16 hours of services per week must be reviewed, modified, and submitted for reauthorization at least once every 90 calendar days, and the initial authorization period for those plans is capped at the same 90 days. Plans involving 16 hours or fewer per week reauthorize at least once every 180 calendar days. Reauthorization must be submitted before the existing authorization expires, so the operational deadline is earlier than the expiration date itself.

• Telehealth removed for paraprofessional services entirely

  Telehealth is removed as a delivery modality for paraprofessional services, which the policy identifies as CPT codes 97152, 97153, and 97154. Assessment delivered by telehealth under 97151 requires clinical justification in the treatment plan. Caregiver guidance runs the other way: 97156 and 97157 are offered by telephonic modality, billed with the KX modifier, when the policy's access criteria are met.

• Supervisor-to-paraprofessional ratio of 10% to 20%, with a 200-hour trigger

  For beneficiaries receiving more than 200 hours of paraprofessional services in a 180-calendar-day period, supervisor-delivered services must fall between one hour per ten hours of service (10%) and two hours per ten (20%). The policy defines the arithmetic explicitly: supervisor hours billed over the period divided by paraprofessional hours billed over that same period, for that same beneficiary. The ratio must be documented in the treatment plan, and any plan requesting a ratio outside the band requires written clinical justification. Clinics below the 200-hour threshold are not subject to the ratio at all, but they are still subject to the separate observation requirement: observation for modification of intervention and technician direction must be provided on an ongoing basis throughout the time services are delivered, with the observing provider either in the same room or on telehealth within the policy's telehealth limits. Note that the earlier draft's flat 10% observation floor does not appear in the final policy as a standalone number.

• Paraprofessionals must hold RBT or ABAT certification, with a grace period

  Qualifying certification means the BACB's Registered Behavior Technician credential or QABA's Applied Behavior Analysis Technician credential. New hires have 120 days from date of hire. Paraprofessionals already employed when the policy took effect have 120 days from August 1, 2026. Until the certification is in hand, the paraprofessional requires direct oversight by a licensed qualified autism services professional whenever they deliver services, which is a staffing cost, not a paperwork one.

• 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 moved under EPSDT authority, and coverage for members turning 21 ended October 1, 2026. Indiana is the clearest example of a state using the EPSDT boundary itself as the cost control, rather than cutting the rate for everyone.

• 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

• 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.