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Issue 9 |
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👋 Hey there!
How much supervision you bill against direct hours is now a number other people calculate. Under TRICARE's Autism Care Demonstration, a month of direct ABA with no 97155 costs 10% of that child's claims for the whole six-month authorization. Massachusetts Medicaid plans have demanded $942,863 back from one provider over 2024 claims that ran past a 1:10 ratio, and the provider is suing over whether that ratio was ever a payment condition. HHS's public spending file lists paid Medicaid dollars by NPI, code and month through 2024, so anyone can divide your 97155 by your 97153 without asking you. The Massachusetts case may still find the 1:10 line wasn't binding for 2024, and the HHS file shows dollars, not hours. Neither changes the practical step: track paid 97155 against paid 97153 per client and per payer each month, and make up missed supervision inside the authorization period it belongs to. Several dates also fall at the turn of the year. Pennsylvania behavior specialist licenses all expire December 31, the same day TRICARE's annual provider education is due. Healthy Blue's Louisiana members change plans with only 60 days of authorization carried over. And a Medicaid application filed in December can still reach back to September. One filed in January reaches back only to November.
⭐ Featured This Week
California Regional Centers Now Pay Behavior Vendors by the Mile for Excess Driving California DDS Directive D-2025-Rate Reform-007REV:DDS added behavior codes 612, 613, 615, 616 and 620 to its excess-mileage payment. Vendors driving more than the rate model assumes can bill per mile, from $2.97 to $3.07 for analysts, from the month of approval. Read Full Article → 🎧 Listen
✅ BACB Updates
51% Passed the BCBA Exam First Time in 2025. The BACB Now Shows Which Programs. BACB: BCBA Examination Pass Rates for University TraBACB's 2025 university report: 51% of 9,955 first-time BCBA candidates passed. Accredited programs averaged 79.3%, others 53.2%. The ten largest programs, with 54.7% of candidates, averaged 42.9%. Read more → 🎧 Listen
⚖ Legislation Tracker
Healthy Blue Leaves Louisiana Medicaid Dec. 31. Its ABA Auths Carry Only 60 Days. Louisiana Department of Health Informational BulletiHealthy Blue's Louisiana Medicaid contract ends December 31. Members choose a new plan October 15 to November 16. From January 1, 2027, the new plans honor existing prior authorizations for up to 60 days only. Read more → 🎧 ListenTRICARE Recoups 10% of a Child's Six Months of ABA Claims If 97155 Skips a Month TRICARE Operations Manual 6010.62-MUnder TRICARE's Autism Care Demonstration, a month of direct ABA without a supervisor's 97155 costs 10% of that child's claims for the whole six-month authorization. Annual provider education is due by December 31. Read more → 🎧 ListenTennCare Plans Share One ABA Rulebook. UHC Allows 3 Months Without Gains, Wellpoint 6 UnitedHealthcare Community Plan of TennesseeUnitedHealthcare Community Plan of Tennessee says ABA may stop being medically necessary after 3 months without measurable change on a norm-based assessment. Wellpoint Tennessee's guideline says six months. Read more → 🎧 ListenA LEARN Unit Sued MassHealth Over a $943K Supervision-Ratio Clawback Acuity: LEARN Behavioral sues MassHealth over $943KAutism Spectrum Therapies sued EOHHS and seven plans on Sept. 23 over a $942,863 demand for 2024 ABA claims that broke a 1:10 97155-to-97153 ratio. It argues the ratio was never adopted as a rule and cites a 12-month clawback bar. Read more → 🎧 ListenMedicaid Retro Coverage Shrinks Jan. 1. Clients Aged 19 and 20 Face New Checks. CMS CMCS Informational Bulletin: Summary of MedicaidFrom January 1, 2027, Medicaid applications reach back two months, not three. Expansion-group adults, including 19- and 20-year-old EPSDT clients, renew every six months and must show 80 hours a month or an exemption. Read more → 🎧 ListenA House Bill Would Make Every State Electronically Verify Medicaid ABA Sessions H.R. 10618H.R. 10618, introduced September 28, would require states to electronically verify Medicaid ABA from January 1, 2027, capturing service, recipient, date, location, provider, and start and end times. It sits in committee. Read more → 🎧 ListenEvery Pennsylvania Behavior Specialist License Expires December 31 49 Pa. Code § 18.525Pennsylvania behavior specialist licenses expire December 31, 2026. Renewal requires 2 hours of Board-approved child-abuse recognition training and a $75 fee. The license is a qualifying route for IBHS clinical directors and behavior consultant-ABA staff. Read more → 🎧 ListenFrom 2028, an Illinois Speech Pathologist's Diagnosis Can Open ABA Coverage Illinois Public Act 104-0561Under Public Act 104-0561, effective January 1, 2028, an Illinois SLP's autism diagnosis for a child under 3 in Early Intervention can support ABA coverage under commercial plans and Medicaid. A behavior analyst evaluation is still required. Read more → 🎧 Listen
💼 Industry News
Your Medicaid ABA Billing Is Public, by NPI and Month. Reporters Are Using It. HHS Open Data: Medicaid Provider Spending by HCPCSHHS's Medicaid Provider Spending file lists paid dollars by billing NPI, servicing NPI, code and month for 2018–2024, managed care included. The 74 used it to show ABA codes rose from $400M to nearly $2B. Anyone can compute your 97155-to-97153 ratio. Read more → 🎧 ListenFlorida Now Projects ABA Spending at $2.88B, Down From $3.86B. 220 Providers Cut. Office of Governor Ron DeSantis: Results of Florida'Florida now projects FY 2026-27 Medicaid ABA spending at $2.88B, down from $3.86B. More than 220 providers were terminated and 260 restricted or suspended. Every active provider must revalidate credentials and identity. Read more → 🎧 Listen📤 Pass it on Know someone in ABA who should be reading this? We will send them one invitation from you — and nothing else unless they subscribe. Invite a colleague →
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