Ohio's ABA Spend Rose 358% in Five Years. Its Paused Rule Is Back.

Ohio paused its ABA rule in 2025. On July 30, 2026 the Department of Medicaid brought it back at a provider stakeholder session, and led with its own numbers rather than anyone else's.

What Ohio's data says

From ODM's own table, 2020 to 2025:

• Members with an autism diagnosis and any claim: 22,426 → 44,884 (+100%)
• Members with ABA claims: 1,341 → 4,569 (+241%)
• ABA claims: 64,989 → 224,249 (+245%)
• ABA spend: $21,759,461 → $99,573,989 (+358%)

ODM's reading of the gap is stated plainly: growth in members and claims is “commensurate,” but growth in total spend per member is “disproportionate, indication that services are rendered and billed for longer durations of time.”

The second table is the one worth your attention. ODM went looking for ABA billed under behavioral health rehabilitation codes — TBS, CPST and PSR — and found it rising from $39.4M in 2020 to $136.2M in 2025, with ABA's share of those members' spend going from 55.2% to 73.1%. Its list of observations names what it thinks it is seeing: providers billing under both their PT 21 and PT 84 enrollments, the “appearance of service stacking,” and “selective use of TBS service code for higher reimbursement rate.”

The turn: Ohio is citing other states' recoupments

One slide is a list of other states' audit takebacks, presented as the evidence base for the revisions: Indiana ($56.5M state OIG, plus a $2M DOJ recovery across Medicaid and TRICARE), Massachusetts ($17.3M, of which $16.7M for inadequate supervision and $7.3M from the top ten providers alone), Wisconsin ($18.5M), Colorado ($42.6M refunded to the federal government).

ODM also names the budget context — projected shortfalls from the One Big Beautiful Bill Act and House Bill 453. A state writing a rule against that backdrop is not looking for a way to spend more.

What the draft would require

• Provider eligibility (5160-34-01). The “exam eligible RBT” option is removed — the credential is required, not pending. Organization providers must hold accreditation from CARF or the Joint Commission.
• Independence of the diagnosis (5160-34-03). The diagnostic assessment confirming ASD and the referral must be completed by an eligible practitioner “who is independent of (not employed by) the ABA treatment provider.”
• Parent participation is a condition, not a goal. Written consent to participate alongside the child, and a treatment plan carrying a specific goal plus a combined four-hour monthly participation requirement. Evidence that it was met is required at concurrent review.
• Supervision written down. The treatment plan must carry a supplemental supervision plan developed by the BCBA detailing how the assigned RBT will carry it out.
• Billing ABA under community BH codes is prohibited. That is the practice the second table was measuring.
• Non-covered: meals and snack breaks, naps, educational activities. No overlap with Autism or Jon Peterson scholarship funding for the same school-based service, and no duplication of DD waiver services addressing the same goals.
• Group services require a behavioral assessment confirming capacity for group participation, a group-specific plan goal, and a BCBA onsite and immediately accessible if not facilitating.
• Service models are split into Comprehensive (ages 1.5–5, most developmental domains, 1–3 year length of stay) and Focused (all ages, typically 1–20 hours per week, 1–4 year length of stay).

The limits

This is a proposed rule presented at an office-hours session, not a filed one. ODM set no effective date, and the comment route it offered — collective responses, one per billing provider organization — closed at end of business on August 5, 2026, a month ago. Nothing here is in force, and the text can change before filing. The recoupment figures are ODM's characterization of other states' audits rather than Ohio findings, and the utilization tables are ODM's own analysis, published as slides without the underlying methodology.

What you must know or do

• Ohio providers billing ABA under TBS, CPST or PSR: pull those claims now and count what share of your ABA revenue they represent. The draft prohibits the practice outright, and ODM has already measured it at the program level — this is the single change most likely to move your numbers.
• If you hold both PT 21 and PT 84 enrollments: ODM named that pattern specifically alongside “service stacking.” Reconcile what you bill under each before someone else does.
• Owners: start accreditation scoping now. CARF and the Joint Commission are not the ACQ/BHCOE route Indiana took, they take most organizations two to three quarters, and the rule offers no runway once filed.
• If your ASD diagnoses come from a clinician you employ: that referral pathway would stop qualifying. South Carolina made the same move effective July 1, so this is now two states and worth treating as a direction rather than a quirk.
• Everyone: the comment window is closed, so the influence point now is the formal rule filing and its public comment period. Watch the Register of Ohio rather than waiting for a provider bulletin.