Oregon Put ABA Utilization Limits on Its Medicaid Cut List, Worth $16 Million

The Oregon Health Authority has listed "service adjustments and utilization management in Applied Behavior Analysis (ABA) services" as one of 35 reduction options in its 2027-29 Agency Request Budget. The line is worth $16.0 million in total funds ($6.45 million General Fund, $9.55 million federal) over the biennium, and OHA marks it as needing federal approval. It's the fifth item on the list.

It isn't a decision yet. It's an option the governor and the 2027 Legislature can take or leave. But it didn't appear from nowhere. Governor Kotek's Advisory Group on Medicaid Sustainability put the same ABA option in its July 7 final report, priced at $8.60 million in state-share savings, and listed it among the options the group "generally found alignment" on.

What OHA says it found

Both documents use the same words. A utilization review "identified outlier utilization trends for ABA services." The number of OHP members receiving ABA "more than doubled from 2023 to 2024" and "included prolonged high-intensity ABA services." The option "would make authorization changes congruent with clinical evidence and review," citing the Health Evidence Review Commission (HERC).

The rule it would enforce is already on the books

This is the part an Oregon provider shouldn't miss. The standard OHA wants authorizations to match is HERC's Guideline Note 75, and it's already in the Prioritized List in force from October 1, 2026 (Line 192, CPT 97151-97158). What it says:

• Ages 1-12, intensive (EIBI): covered for up to six months to start. Continuing depends on progress toward predefined objectives "over and beyond gains that would be expected to arise from maturation alone," measured with a standardized, multimodal assessment no more often than every six months. The note's examples are Vineland, IQ tests, language measures, behavior checklists (CBCL, ABC) and the SRS.
• Intensity: the note says the evidence doesn't set an optimal intensity. Studies ran 15-40 hours a week, and "there is no evidence that increasing intensity of therapy yields improves outcomes."
• Less intensive ABA: used when EIBI isn't indicated, is complete, or progress is insufficient. Six months initially. Effective interventions in the literature ran "a few hours per week to a maximum of 16 hours per week."
• Ages 13 and older: "Intensive ABA is not included on this line." Targeted interventions for problem behaviors that put the member at risk of harm or create significant daily problems are covered, with ongoing coverage tied to progress.

So the savings wouldn't come from a new limit. They'd come from authorizing to a guideline that's already there.

What else is in the option

The advisory group's version adds specifics the OHA line doesn't spell out:

• Putting a requirement for rendering providers to enroll in Medicaid into Oregon Administrative Rules.
• More frequent required updates to functional assessments and treatment plans, and "more robust documentation standards."
• Eligibility criteria that include checks that ABA is "the least restrictive option to address symptoms."
• Recommendations to CCOs on "reasonable service frequency based on functional impact of symptoms, age, and child & family centered goals."

The report lists "attrition of Medicaid ABA providers" as a potential impact on the delivery system, alongside "potential to curb fraud, waste, and abuse."

What isn't settled

The two documents put different numbers on it: $16.0 million total and $6.45 million General Fund in OHA's list, $8.60 million state share in the advisory report. OPB reported it as about $9 million. The report says the governor "is not obligated to adopt or otherwise pursue" any option. Neither document gives an effective date, and OHA says federal approval would be needed. The document is OHA's list of options for a 10% reduction, so being on it doesn't mean an option will be taken.

What you must know or do

• Owners and clinical directors: list your OHP clients aged 13 and older on intensive hours. For each one, check that the treatment plan targets named problem behaviors that put the client at risk of harm or create significant daily problems. That's the only ABA Guideline Note 75 covers at that age.
• BCBAs with EIBI clients aged 1-12: confirm each file has a standardized, multimodal assessment from the last six months that shows gains beyond what age alone would explain. A goal-mastery graph on its own isn't what the note asks for.
• Billers: check that every technician and analyst who renders OHP services is enrolled with OHP as a rendering provider. It's the first program-integrity item named, and the easiest to check.
• Everyone: the next step is the governor's recommended budget. In July, OPB reported she had about five months before it's due to the Legislature. That's the point where this either becomes a proposal or drops off.