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Item 291.WW.2 of the 2026 Appropriation Act requires the Department of Medical Assistance Services (DMAS) to impose a 20 hour per week limit on Applied Behavior Analysis (ABA) services and to require a diagnosis of Autism Spectrum Disorder (ASD) or, for children age 5 and younger, a provisional diagnosis of ASD to receive ABA services.  DMAS is taking steps to obtain approval from the Centers for Medicare and Medicaid Services (CMS) for these changes.  The effective date for ABA service changes will be announced in a subsequent notice and additional policy guidance will be included in an upcoming update to the DMAS Mental Health Services Manual.

Existing Authorizations and Authorization Process

Please note that no changes will be made to the current authorization process until these changes are approved by CMS and updates to the DMAS Mental Health Services Manual have been finalized.

The following is the language included in the 2026 Appropriation Act:

Item 291.WW.2. The Department of Medical Assistance Services (DMAS) shall impose a 20 hour per week cumulative limit per recipient on services provided under ABA, effective July 1, 2026; such limit can be exceeded based upon documented medical necessity under early and periodic screening, diagnostic and treatment (EPSDT). The department shall require a diagnosis of autism spectrum disorder prior to authorizing ABA services; however, children age 5 and younger may receive a provisional diagnosis for one-year utilizing a protocol designated by DMAS. DMAS shall have the authority to amend the state plan under Titles XIX and XXI of the Social Security Act to effect these changes. DMAS shall provide guidance to ABA providers and facilities on required ABA documentation and shall coordinate with managed care organizations (MCO) to perform periodic pre- and post payment reviews of ABA payments. DMAS shall require specific reporting from each MCO that can be analyzed across MCOs, by region, by provider, and at a statewide level. The requirements in this amendment do not apply to behavior therapy provided by local education agency providers and reimbursed through the fee-for-service Medicaid school-based services program. The department is authorized to promulgate emergency regulations to implement this change within 280 days or less from the enactment of this act. The department shall implement this change upon federal approval and prior to the completion of any regulatory process undertaken in order to effect such change.

To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions. Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest.