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Issue 5 |
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👋 Hey there!
Four deadlines land on Thursday: TennCare, Vermont, Missouri and the AMA. Three states and a code panel, with nothing in common but your calendar. Maine follows on the 29th. Kansas and Oklahoma move on November 1. If you bill across state lines, that's your next five weeks.
⭐ Featured This Week
Washington's Draft ABA Rule Says Lack of Progress Doesn't Justify More Hours Washington State Health Care AuthorityWashington HCA's draft ABA rules would require 16 items at recertification, let HCA reduce services once behavior stabilizes, and require a client or family signature on every visit note. Informal comments closed August 31; a formal proposal follows. Read Full Article → 🎧 Listen
📚 Research Digest
CDC Survey Puts Autism at 4.5% of Kids. A 12-Cohort Screening Study Found No Rise. Zablotsky BA CDC survey published September 22 found parent-reported autism rose from 3.1% to 4.5% of US children between 2019–20 and 2023–24. A Korean study screening every 7-year-old across 12 birth cohorts found rates flat. Both authors point to detection. Read more → 🎧 Listen
⚖ Legislation Tracker
Kansas Moved Its Autism Diagnosis Rule to November 1 and Narrowed Who Qualifies KMAP General Bulletin 26140From November 1, Kansas Medicaid members 20 and under need an autism diagnosis from a BSRB clinical psychologist or a listed physician type, using DSM criteria and a validated tool like ADOS or CARS. Current clients get two years. Read more → 🎧 ListenMissouri Autism Centers Must Revalidate by October 1. ABA Providers Are Next. Missouri DSS / MMACMissouri clinics enrolled with the Autism Center specialty had to revalidate with MO HealthNet by October 1. Provider type 73 ABA providers get notices from November 1 and must finish by March 2, 2027, or face termination. Read more → 🎧 ListenCategory III Codes Now Arrive Twice as Fast. Deletions Still Land January 1. American Medical AssociationOctober 1 is a double date: codes released on July 1 become effective, and the September Panel's codes release. The October release can slip up to ten days depending on when the fall Panel meets. Read more → 🎧 ListenIllinois Ended Prior Auth for Outpatient Mental Health. Its Plans Split on ABA. Illinois Public Act 104-0028Since January 1, Illinois law bars prior authorization for outpatient mental health care. Molina waives it for ABA assessments and the first 48 units; Meridian keeps it on treatment; CountyCare's notices conflict. Notification deadlines run 24 hours. Read more → 🎧 ListenOklahoma Moves Behavior Analyst Licensing to the Psychologists Board November 1 Oklahoma LegislatureOn November 1, Oklahoma behavior analyst licensing moves from OKDHS to the Psychologists Board under SB 1557. Applicants face a national criminal history check, and the $100 cap on license and renewal fees is gone. Read more → 🎧 ListenMississippi Caps Your Analyst at 10 of the 25 Hours It Mandates. Mississippi House Bill 885The mandate reaches policies issued or renewed on or after January 1, 2016. It is not required beyond age eight, which is not the same as coverage ending at eight, and the insurer pays for the six-month treatment plan review it is entitled to demand. Read more → 🎧 ListenVermont Resets Every Medicaid ABA Prior Auth on New Forms Starting October 1 Department of Vermont Health AccessFrom October 1, Vermont Medicaid ABA prior authorizations need a new request form and an 11-domain Comprehensive Assessment. DVHA says family demographics and a caregiver's ability to participate will influence approvals. Don't update plans early. Read more → 🎧 ListenMaine's ABA Staff Certification Deadline Is October 29. For Some It Has Passed. Maine DHHSMaineCare's new Section 28 gives uncertified direct care staff hired from April 30, 2025 until October 29 or one year from hire, whichever is first, to earn BHP certification. For hires before about September 22, 2025, that date has passed. Read more → 🎧 ListenVirginia Won't Pay for Clinic-Based ABA Unless the Plan Says Why It's in a Clinic Virginia DMAS bulletinVirginia Medicaid doesn't cover clinic-based ABA without a documented clinical reason for the setting in the ISP. Clinic cases need weekly family involvement and 97156/97157. Only LBAs, LABAs and licensed clinical psychologists can supervise unlicensed staff. Read more → 🎧 ListenConnecticut Medicaid Won't Pay for ABA Parent Training by Telehealth Connecticut Behavioral Health PartnershipConnecticut's HUSKY Health says ABA parent training “is not permitted via telehealth and must be conducted in person,” with or without the child. Out-of-state providers must live within 45 minutes of the state line to enroll. Read more → 🎧 ListenNebraska Cut ABA to 20 Hours a Week on July 1 and Stopped Paying for It in Schools Nebraska DHHS Medicaid Provider Bulletin 26-06Since July 1, Nebraska Medicaid limits direct ABA to 6 hours a day and 20 a week unless more is prior authorized. Independent providers can't bill services at school, and supervisors and treating LBAs must each be in person monthly. Read more → 🎧 ListenWisconsin Medicaid Now Denies Incomplete ABA Prior Auths Instead of Holding Them Wisconsin ForwardHealth Update No. 2026-19Since August 17, ForwardHealth denies incomplete prior authorization requests rather than holding them 30 days, and backdates only those submitted within 14 days of the start date. Behavioral treatment requests have a 12-item checklist. Read more → 🎧 Listen
💼 Industry News
Ask for the Hours You Will Actually Deliver. Mississippi's MCO Says So in Writing. CareSource Medical Policy StatementA request for 30 hours from a practice that intends to staff 25 fails the policy on its face. Treatment for symptoms and behaviors not part of the core diagnosis is excluded outright, as is shadowing or companion work in any setting. Read more → 🎧 ListenTexas Medicaid ABA Spending Hit $153.5M. All 16 MCOs Say They Pay $14.50. Texas HHSCTexas Medicaid spent $153.5 million on ABA in fiscal 2025, up from $26.7 million in 2023, per HHSC's September report. All 16 MCOs attested they pay $14.50 per unit for 97153 since September 1, 2025. Read more → 🎧 ListenTennCare's Annual ABA Quality Attestation Comes Due Again October 1 Wellpoint TennesseeTennCare plans require every contracted ABA provider to upload a signed quality attestation “effective October 1, 2025, and annually thereafter.” It asks for telehealth and caregiver-involvement policies, and plans may audit a sample. Read more → 🎧 ListenNew York's ABA Audit Protocol Reaches Back to 2021. It Starts With the Referral. NYS Office of the Medicaid Inspector GeneralNew York's Medicaid Inspector General will audit ABA claims back to August 2021, starting late 2026. A referral older than two years or missing the DSM-5 checklist, or no annual status report to the referrer, disallows the claim. Read more → 🎧 ListenBlueCare Won't Approve an ABA Assessment Until Less Intensive Care Falls Short BlueCross BlueShield of TennesseeBlueCare's TennCare guideline approves an ABA assessment only if less intensive treatment wasn't sufficient and severity was assessed within six months. All three TennCare plans require standardized retesting every two years. Read more → 🎧 ListenTwo Texas Medicaid Plans Left August 31. The Claims Window Shrank to 95 Days. TMHPBaylor Scott & White and FirstCare left Texas Medicaid August 31. TMHP's July notice gave providers 24 months to bill them; its September 2 update says 95 days. Counted from the date of service, sessions before about June 19 are already late. Read more → 🎧 ListenDOJ Says Guidance Alone Can't Be a False Claims Case. It Can Still Prove You Knew. U.S. Department of JusticeDOJ's September 18 Justice Manual revision bars False Claims Act cases resting solely on noncompliance with agency guidance, and urges dismissing meritless qui tams. Awareness of guidance can still prove knowledge, and contract terms still bind. Read more → 🎧 ListenMeridian Recoups 10 Hours of ABA for Every Missing Hour of Supervision Meridian Health Plan of IllinoisMeridian's Illinois Medicaid plan reviews ABA claims after payment for one hour of 97155 supervision per 10 hours of direct treatment. Its own example: 100 hours with 6 supervised means repaying 40 hours of 97153. Read more → 🎧 ListenCMS Named ABA a Top Medicaid Fraud Risk and Posted What Every State Paid CMSCMS's fraud page lists ABA first among Medicaid “high-risk services” and posts CY2025 payments by state: Florida $2.64 billion, with a median of $48,296 per beneficiary. CMS says the variation doesn't by itself indicate fraud. Read more → 🎧 ListenL.A. Care Requires a Parent at Every ABA Session. DHCS Says Plans Can't. L.A. Care Health PlanL.A. Care's Medi-Cal ABA guideline says a parent or caregiver “must be present and available during the totality of the therapy sessions.” DHCS APL 23-010 says Medi-Cal plans “cannot require participation by parents/guardians.” Read more → 🎧 ListenOIG: None of 100 Philadelphia CBH Denials Met the Rules. IBHS and ABA Were 36%. HHS-OIGOIG found none of 100 sampled 2023 Community Behavioral Health prior auth denials met all requirements. IBHS, including ABA, was 36% of 1,102 denials. For all 34 children, CBH skipped a required step. Pennsylvania's templates were also faulted. 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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