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Issue 10 |
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👋 Hey there!
Staying enrolled in Medicaid is becoming work with its own deadlines. Texas said on October 23 that it would notify affected providers on October 31 that they may have to revalidate sooner than their current due date. There are no extensions, and a revalidation counts only once PEMS shows "Closed-Enrolled," not when the application goes in. MaineCare has published the 29 NPIs in its ABA revalidation cohort, whose window opens April 19, 2027; a provider that files no case within 60 days has its claims pended. New York has accepted no new ABA enrollments or changes of ownership since July 27, and its revalidation will fingerprint every owner of 5% or more. Colorado's draft rule would require every technician to be enrolled, with an NPI on the claim, by March 2, 2027. More agencies can now act on that record. Since October 14, CMS can exclude providers from Medicare and Medicaid itself, on grounds that include services "substantially in excess of the needs" of patients. No exclusion by CMS has been reported yet. Since October 15, possibly criminal billing conduct goes to DOJ first, not HHS-OIG. None of the work this asks for is clinical: an email address in PEMS that someone reads, a current mailing address on file with MaineCare, an NPI for every technician, a monthly exclusion check on every employee. Any one of them, missed, can leave claims unpaid. One date is close. Oklahoma's comment period on cutting SoonerCare retroactive coverage closes Monday, November 2. If your practice has carried sessions for a family while their application was pending, that cost is what OHCA's impact statement says it has not identified.
⭐ Featured This Week
Medicaid Prior Auths Have a 7-Day Clock. First Data: 14% Denied, 47% Reversed CMS fact sheet: Interoperability and Prior AuthorizaSince January 1, 2026, Medicaid plans must decide standard prior auths in 7 calendar days, 72 hours if expedited, with a specific denial reason. First posted metrics: Medicaid MCOs denied 14% on average; 47% of appealed denials were overturned. Read Full Article → 🎧 Listen
⚖ Legislation Tracker
Oklahoma's Medicaid Retro Window Shrinks Jan. 1. Comments Close Nov. 2 Oklahoma Health Care AuthorityOHCA's APA WF 26-04 cuts SoonerCare retroactive eligibility from three months to two for children and one for expansion adults, and moves expansion adults to six-month renewals Jan. 1. Comments and the hearing are Monday, Nov. 2. Read more → 🎧 ListenTexas Medicaid Tells Some Providers Saturday to Revalidate Early. No Extensions TMHPTMHP said on October 23 that it would notify affected Texas Medicaid providers on October 31 that they must revalidate early, with due dates from Jan. 1, 2027 to June 5, 2028. No extensions, and only 'Closed-Enrolled' in PEMS avoids disenrollment. Read more → 🎧 ListenWashington Medicaid Would Give You 7 Days, Not 30, to Answer a PA Records Request Washington State Register WSR 26-19-090Washington HCA proposed giving fee-for-service providers seven calendar days, not 30, to answer a prior-auth request for more information before the service is denied. Comments closed Oct. 27, and HCA can now adopt the rule. Read more → 🎧 ListenPhiladelphia's CBH Now Reverses Claims for Other Insurance and Won't Repay Them CBH Provider Bulletin 26-21: Third Party LiabilitySince October 15, CBH reverses claims when it finds other insurance and no longer reprocesses them, even if that coverage has lapsed. Resubmit with the primary's EOB within 90 days of the recovery letter, or dispute. Read more → 🎧 ListenColorado's Draft ABA Rule Puts Every Technician on a Claim by March 2, 2027 Colorado HCPFColorado's draft Medicaid ABA rule would require every behavior technician to enroll and appear by NPI on claims by March 2, 2027. It also sets 25/16/10-hour guidelines, a 60-day assessment window and a 15-day records deadline. First reading December 11. Read more → 🎧 ListenWashington Voids Noncompetes June 30, 2027. Repay-If-You-Leave Clauses Count Washington ESHB 1155From June 30, 2027, Washington voids all noncompetes, old ones included. The amended definition covers clauses making someone repay or forfeit pay for working elsewhere, and patient no-accept clauses. Employers must notify affected staff by October 1, 2027. Read more → 🎧 ListenNew York Froze New ABA Enrollments and Sales in July. Revalidation Letters Come Next NYS Department of HealthNew York stopped new ABA Medicaid enrollments, reinstatements and changes of ownership on July 27, for at least six months. ABA is now high-risk, and Phase 2 revalidation notices, with fingerprints for 5% owners, start this winter. Read more → 🎧 ListenMaineCare's ABA Cohort Revalidates From April 19, 2027. Claims Pend at Day 60 MaineCare Off-Cycle Revalidation Report 1 to CMSMaineCare's off-cycle revalidation lists 29 NPIs in Cohort 4, Adaptive Behavior Services for Children, with a window opening April 19, 2027. Claims pend at day 60 without a case; enrollment ends at day 90. Read more → 🎧 Listen
💼 Industry News
Found Possible Billing Fraud? DOJ, Not HHS-OIG, Now Takes the Disclosure DOJ National Fraud Enforcement Division and HHS-OIGSince October 15, potentially criminal Medicaid billing conduct should be disclosed to DOJ's Health Care Fraud Section first. One filing earns both DOJ and OIG benefits. OIG's protocol no longer accepts crimes, and simple overpayments go to the payer. Read more → 🎧 ListenWashington's Overtime-Exempt Salary Floor Hits $92,196 Jan. 1 at 51+ Employees Washington L&I news release 26-17: Washington's miniFrom January 1, Washington employers with 51 or more employees must pay overtime-exempt staff at least $1,773 a week ($92,196 a year), up from $1,541.70. Employers with 50 or fewer move to $82,976.40. Below the line, salaried BCBAs earn overtime. Read more → 🎧 ListenNebraska Blue's Revised ABA Policy Starts Nov. 15: Office or Telehealth, 25 Hours Blue Cross and Blue Shield of NebraskaFrom November 15, Blue Cross and Blue Shield of Nebraska's ABA policy says services "must be delivered in an office setting or through telehealth," plans should run no more than 25 hours a week, and BCaBA supervision is 25%. Read more → 🎧 ListenCareSource Marketplace Now Sets an ABA Parent-Training Floor: 2 Hours a Month CareSourceSince October 1, CareSource's Marketplace ABA policy in GA, IN, OH and WV requires at least 2 hours a month of caregiver training, up to 18 per six months. Miss the floor and "other authorized ABA units may be reduced." Read more → 🎧 ListenCMS Can Now Exclude Providers From Medicaid Itself, Not Just Through OIG Federal RegisterSince October 14, CMS can exclude providers from Medicare and Medicaid under section 1128(b), the grounds that include services 'substantially in excess of the needs' of patients and kickbacks. OIG keeps its own power. No standards published yet. 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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