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Issue 7 |
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👋 Hey there!
More of what payers check now sits in the clinical record rather than on the claim. CareSource Ohio has refused ABA claims that arrive without the treatment record since September 1. From October 29, Indiana wants a complete FBA behind every behavior a BIP targets, refreshed at each reauthorization. The measures those records rest on are less settled than the rules asking for them. Across two assessments of the same 49 toddlers, agreement on DSM-5-TR severity level was κ = 0.318 and 0.195, and CMS's toolkit calls it best practice to set weekly hours by that level. A review of the BOSCC, a tool built to detect change, found it moved no further than the ADOS in the studies that used both. The payers' requirements still stand. What the research changes is where the case for hours should come from: your own assessment data, written down, rather than a severity level copied from a referral.
⭐ Featured This Week
Indiana Will Require a Complete FBA for Every Behavior a BIP Targets From October 29 Indiana Health Coverage Programs bulletin BT2026162From October 29, Indiana Medicaid wants a complete FBA for each behavior a BIP targets: an indirect assessment from six named tools, graphed with raw responses, plus ABC data and a function statement, refreshed every reauthorization. That's 18 days out. Read Full Article → 🎧 Listen
📚 Research Digest
CMS Wants Hours Set by DSM Severity Level. Clinicians Can't Agree on the Level. Morrier MJCMS's toolkit calls it best practice to set ABA hours by DSM-5-TR severity level — 10, 20 and 30 a week. Agreement on those levels across two assessments of the same 49 toddlers was κ = 0.318 and κ = 0.195. Read more → 🎧 ListenA Tool Built to Catch Change Found a Third of an SD. So Did the ADOS. Howlin et alAcross 19 studies and 789 children, BOSCC scores improved by g = −0.32 in intervention arms and −0.15 in controls. In the four studies that also used the ADOS, both tools moved by almost the same amount: −0.31 and −0.32. Read more → 🎧 Listen
⚖ Legislation Tracker
Medi-Cal Now Names Eight Things a Parent-Training Note Must Contain Medi-Cal Provider ManualMedi-Cal's Behavioral Health Treatment manual now lists eight elements every S5110 or S5111 note must carry, including the names and relationships of the family members trained, and bars billing both codes on the same date for the same service. Read more → 🎧 ListenTexas Opened Its Autism Program to Age 21 in August. HHSC Now Proposes Ending It. Texas HHSCTexas extended its state-funded autism ABA program to anyone under 22 and dropped the 180-hour yearly cap on August 25. HHSC's 2028–29 reduction schedule then listed the program for elimination, $13.7 million over two years. Read more → 🎧 ListenCMS Gave Florida's ABA Task Force 11 Recommendations. Its Report Is Due Dec. 31. Florida ABA Task ForceApproved minutes record CMS's Dr. Caprice Knapp urging Florida's ABA task force to bar telehealth supervision, set supervision ratios, flag 40-hour weeks for audit and end consolidated billing. The task force adopted none of them. Recommendations are due to the Governor by December 31. Read more → 🎧 ListenNC Stops Paying for Uncertified ABA Technicians in Late November NC Medicaid: Updated Reminder: Requirements for ReseNorth Carolina Medicaid won't pay for sessions by technicians without RBT or ABAT certification once their 120-day grace period ends: late November for staff employed August 1. The August 31 bulletin also rewrote the supervision rule. Read more → 🎧 ListenIndiana Ends Peer-to-Peer Reviews for Fee-for-Service Prior Auths November 1 Indiana Health Coverage Programs bulletin BT2026161Indiana Medicaid stops offering peer-to-peer reviews on fee-for-service prior authorization requests November 1; scheduling ends October 31. Denials then go only through administrative review and appeal. A same-day bulletin clarifies ABA referral rules. Read more → 🎧 ListenCalifornia Gives Providers 90 Days to Fix a Denied Claim From January 1 California SB 1049From January 1, 2027, SB 1049 gives California providers at least 90 days from a plan's denial or overpayment notice to submit a corrected claim. Plans and insurers can't deny it as late under any other filing deadline. Read more → 🎧 ListenIndiana Says ABA Clients Can't Be Kept From Napping Because Naps Aren't Billable Indiana Health Coverage Programs bulletin BT2026159Indiana Medicaid's September 29 bulletin bars keeping ABA clients awake because nap time isn't billable. Naps go in the treatment plan schedule per AAP guidance, and lower 97153 use must be documented with nap dates and durations. Read more → 🎧 ListenCalifornia Writes the 2024 Federal Parity Rules Into State Law From January 1 California AB 2011AB 2011, signed September 30, requires California commercial plans and insurers to follow federal parity rules and guidance as they existed on January 1, 2025, including the 2024 final rules. It takes effect January 1, 2027. Read more → 🎧 ListenCalifornia Will Suspend Nonpublic ABA Agencies That Miss a 30-Day Staff Notice California SB 685From January 1, 2027, SB 685 requires California to suspend or revoke a nonpublic agency's certification for listed failures, cuts the staff-change notice from 45 days to 30, and makes death notices due within 24 hours. Read more → 🎧 ListenMontana Medicaid Gives ABA 1,260 Units Per 180 Days. Unused Units Expire. Montana Medicaid Applied Behavior Analysis ServicesMontana's Medicaid ABA manual authorizes an initial 1,260 units (315 hours) per 180 days, expires unused units at day 180, and requires the BCBA to file at least 14 calendar days before continued services start. Read more → 🎧 ListenCalifornia Sent CMS a Medi-Cal BHT Amendment Effective July 1. Approval Is Pending. DHCS State Plan Amendment 26-0033 submission to CMSDHCS submitted State Plan Amendment 26-0033 to CMS in September, asking for a July 1, 2026 effective date. It revises Medi-Cal BHT language on utilization management and fraud controls. DHCS projects no added cost. Read more → 🎧 Listen
💼 Industry News
Colorado Lists 10 Interventions That Need Extra Justification in ABA Treatment Plans Health First Colorado Provider Bulletin B2600542Colorado's September Medicaid bulletin names ten intervention types, including ACT, social stories and sensory diets, that draw added review in pediatric behavioral therapy plans. Each needs a measurable target, assessment link and progress measure. Submit PARs 14–21 days early. Read more → 🎧 ListenAlaska Raised ABA Rates About 41% on July 1. Parent Training Now Pays Like 97155. Alaska DOHAlaska Medicaid's autism fee schedule effective July 1, 2026 raised 97153 from $22.63 to $31.95 and 97155 from $29.78 to $41.97. Family guidance (97156) more than doubled to $41.97, matching 97155. Check July–September remittances. Read more → 🎧 ListenRegence's ABA Policy Changes November 1: One Provider at a Time, No 0373T Stacking RegenceFrom November 1, Regence's ABA policy BH18 limits members to one authorized ABA provider at a time, bars billing 0373T with 97153 or 97155, and requires written justification for group treatment and for each modality's weekly hours. Read more → 🎧 ListenA Medi-Cal Plan Says Unenrolled ABA Groups Risk Termination After About October 29 Health Plan of San Joaquin/Mountain Valley Health PlHealth Plan of San Joaquin/Mountain Valley's April 29 alert requires ABA groups to be Medi-Cal enrolled through PAVE. Groups that can't show enrollment efforts within six months, about October 29, risk termination. Read more → 🎧 ListenPhiladelphia's CBH Raised Rates 5% and 3%. IBHS and ABA Got Neither. Community Behavioral Health: Provider NoticePhiladelphia's CBH raised standard rates 5% on July 1 and negotiated rates 3% on October 1, excluding Regionalized IBHS and IBHS-ABA. The Regionalized IBHS bonus cap falls from 15% to 10%, starting with November's payout. Read more → 🎧 ListenCommunity Care Wants a Taper Plan Before It Renews Center-Based ABA Community Care Behavioral Health: ABA One-to-One CenSince July 8, Community Care's Pennsylvania Medicaid guidelines require every continued-stay plan for center-based ABA to include a plan to taper hours. Full days for convenience don't qualify, and school-age graduates can't return for summer without a new order and assessment. Read more → 🎧 ListenCareSource Ohio Won't Accept an ABA Claim Without the Treatment Record CareSource: Applied Behavior Analysis for Autism SpeSince September 1, CareSource Ohio Medicaid requires the member's treatment record to be submitted before any ABA claim: “Claims will not be accepted without accompanying treatment documentation.” H0036 isn't paid when an ABA code fits. Read more → 🎧 ListenIllinois Makes Its Health Care Deal Notice Permanent and Reaches PE Owners January 1 Illinois Public Act 104-0782From January 1, 2027, Illinois's 30-day Attorney General notice for health care deals no longer sunsets and reaches anyone owning or controlling the parties, including private equity. Provider organizations contracting for 20+ providers are covered. 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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