CurrentOptumPolicy BH 803ABA STM12026

Applied Behavior Analysis (ABA) State Mandates

State-specific mandated coverage rules and requirements for Applied Behavior Analysis (ABA) and related services for Optum behavioral health members across multiple states; affects providers and members in the listed states.

Policy Summary

PayerOptum

PolicyApplied Behavior Analysis (ABA) State Mandates

Policy CodePolicy BH 803ABA STM12026

Change TypeInterim review with material updates

Effective DateJanuary 2026

Next Review Date

Key ActionSubmit required prior‑authorization documentation and a comprehensive evaluation or valid referral per state rules to establish medical necessity.

SourceLink

POLICY UPDATE CHANGES

New ABA State Mandates document to accompany the ABA Supplemental Clinical Criteria.

Updates to KY, NJ and WA state mandate entries.

Kentucky-specific revisions on 12/16/2025.

20+state entries

Up to 25MD hrs (18mo–5y)

Up to 10MD hrs (6–18y)

30MA weekly ceiling

Jan 2026

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

State-Specific Coverage Criteria

Maryland initiation and continuation criteria

Covered when ALL of the following are met (Maryland regulatory criteria):

Maryland ABA initiation and continuation: 1) A comprehensive evaluation of the child by the child's primary care provider or specialty physician identifying the need for treatment of autism spectrum disorder; 2) A prescription from the child's primary care provider or specialty physician that includes specific treatment goals; 3) Annual review by the prescribing primary care provider or specialty physician, in consultation with the ABA provider, that documents benefit to the child, identifies new or continuing treatment goals, and develops a new or continuing treatment plan.see thresholds

Services meeting these criteria will not be denied solely on the number of hours up to state-specified limits; additional hours require medical necessity review.

Kansas CCTS/IIS medical necessity criteria

Covered when ALL of the following are met (Kansas EPSDT criteria for CCTS/IIS):

Kansas EPSDT CCTS/IIS eligibility: Member is age 20 and under; a licensed psychologist or medical doctor has evaluated the member within the last 6 months using a comprehensive diagnostic evaluation to validate the ASD diagnosis; identified deficits in social, communication, language skills, or adaptive functioning form the basis for an individualized treatment plan for no more than 40 hours per week; progress is reviewed monthly by the CCTS provider with formal treatment plan review and renewal at least every six months.age <=20; evaluation within 6 months; treatment basis up to 40 hrs/week; 6-month formal review

Prior authorization will be reviewed after all requested documentation is submitted.

New Jersey ABA eligibility and scope

Covered when ALL of the following are met (New Jersey Medicaid):

New Jersey ABA eligibility: Diagnosis of autism spectrum disorder by a qualified healthcare professional (physician or psychologist); ABA need determined by a qualified healthcare professional such as a BCBA who will assess and develop a treatment plan; services available to children aged 18 months through 21 years based on medical necessity; acceptable qualified healthcare professionals include physicians, psychologists trained/certified in behavior analysis, and BCBAs for treatment planning; a comprehensive diagnostic evaluation is not required to access ABA and diagnosis and treatment planning may be completed by different qualified professionals.age 18 months–21 years

Services may be provided in the school setting provided they are not delivered during normal school hours.

New York enrollment, referral, and provider requirements

Covered when ALL of the following are met (New York Medicaid/Child Health Plus):

New York ABA eligibility and referral: Enrollee is under age 21 and has a DSM-5 diagnosis of autism spectrum disorder and/or Rett Syndrome; referral for ABA services is made by a NYS-licensed and NYS Medicaid-enrolled clinician (physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant); referrals are valid for up to two years and must include age, ASD or Rett diagnosis, date of initial diagnosis, co-morbid diagnoses (if applicable), symptom severity/level of support, statement that the patient needs ABA services, and the DSM-5 diagnostic checklist; services are provided by Licensed Behavior Analysts (LBAs), Certified Behavior Analyst Assistants (CBAAs) under LBA supervision, or other individuals specified by NY law.age <21; referral valid <=2 years

Providers offering services to Medicaid Managed Care enrollees must contact the enrollee's specific MMC plan for coverage, billing, and reimbursement guidance.

Kansas CCTS/IIS services under EPSDT will not be authorized for specific service types or duplicate coverage. Specifically, CCTS/IIS treatment is excluded for speech therapy, occupational therapy, vocational rehabilitation, supportive respite care, recreational therapy, orientation and mobility, services provided in a PRTF or hospital setting, and for any services that are being provided in duplicate through another source or setting. Prior authorization is reviewed only after all requested documentation is submitted and medical necessity must be demonstrated on a case‑by‑case basis for eligible members age 20 and under.

Maryland mandates that ABA services covered for fully insured members are not provided under an Individualized Education Program (IEP) or by fulfilling obligations imposed on public schools under IDEA. In other words, ABA services covered by Maryland regulation are distinct from school IEP services and are not authorized under an IEP, even if the treatment plan identifies the child's school as the location of services.

Maryland expressly states that Applied Behavioral Analysis (ABA) will not be denied on the basis that it is experimental or investigational. Requests that exceed the state‑mandated hourly limits may still require demonstration of medical necessity and will be reviewed under Optum’s standard medical necessity guidelines once mandated benefits are exhausted.

Codes, Limits, and Quantity Rules

Accepted ASD ICD-10 Codes (NJ)ICD-10

F84.0-F84.9

ICD-10 autism spectrum disorder diagnoses (New Jersey accepts these)

inv-09: Maryland weekly ABA hours (ages 18 months–5 years)

Weekly ceilingUp to 25 hours per week for members ages 18 months–5 years

Initiation requirementsComprehensive evaluation by child's PCP or specialty physician identifying need

Prescribing requirementPrescription from PCP or specialty physician that includes specific treatment goals

Annual reviewAnnual review by prescribing provider in consultation with ABA provider documenting benefit, new/continued goals, and treatment plan

inv-10: Maryland weekly ABA hours (ages 6–18 years)

Weekly ceilingUp to 10 hours per week for members ages 6–18 years

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Kansas: Prior Authorization & Medical Necessity

Prior Authorization and medical necessity required for Kansas Medicaid (CCTS/IIS). Services may be covered under EPSDT for members age 20 and under when medical necessity is documented and prior authorization is submitted after all requested documentation. Required documentation includes: a comprehensive diagnostic evaluation validating the ASD diagnosis by a licensed psychologist or MD within the last 6 months; evidence of social, communication, language, or adaptive deficits relative to age norms that justify an individualized treatment plan; and documentation that treatment is limited to no more than 40 hours per week. Progress reviews must be performed monthly by the CCTS provider and the treatment plan and renewal requests must be formally reviewed at least every 6 months.

Member age: 20 and under
Evaluation validating ASD diagnosis within last 6 months by licensed psychologist or MD
Treatment justification: deficits in social/communication/language or adaptive functioning
Maximum: up to 40 hours per week
Monthly progress review by CCTS provider; formal treatment plan/renewal review at least every 6 months

Background and Scope

Applied Behavior Analysis (ABA) is a habilitative and therapeutic service used to treat autism spectrum disorder. State mandates included here set the clinical and administrative expectations for ABA, including requirements for comprehensive evaluation and prescriptive orders, provider qualifications, allowable weekly hours, supervision and review schedules, prior authorization processes, and exclusions. For example, Maryland requires a comprehensive evaluation and a prescription with specific treatment goals, annual review by the prescribing clinician in consultation with the ABA provider, and defines specific hourly thresholds (e.g., up to 25 hours/week for ages 18 months–5 years and up to 10 hours/week for ages 6–18 years). Kansas EPSDT guidance requires validation of diagnosis within six months, individualized treatment planning with progress reviews, and specifies excluded service types and duplicate coverage limitations.

Key Definitions

inv-21: Medically necessary (Virginia definition)

DefinitionMedically necessary means care that is clinically appropriate in type, frequency, site, and duration based on evidence and reasonably expected to: prevent onset; reduce or ameliorate effects; or assist in achieving/maintaining maximum functional capacity

ConsiderationsAssessment considers functional capacity of the individual and age-appropriate functional capacities

Standards basisMust be in accordance with generally accepted standards of care for the mental disorder or condition

inv-22: Down syndrome (Massachusetts commercial definition)

DefinitionDown syndrome: chromosomal condition caused by an error in cell division resulting in an extra whole or partial copy of chromosome 21

Coverage note (MA commercial)

Level-of-Care and Service Setting Rules

Outpatient / community-based ABA

Criteria for outpatient or community-based ABA (state-level enrollment/referral and service-delivery prerequisites):

New York outpatient/community ABA admission: Member under 21 with DSM-5 diagnosis of ASD and/or Rett Syndrome and valid referral from a NYS-licensed and Medicaid-enrolled clinician containing required diagnostic and need information.age <21; referral valid <=2 years

Service provider and setting requirements: Services must be delivered by authorized providers (e.g., LBAs, CBAAs under supervision) and may be provided in settings permitted by state law including private practice, clinics, residences, schools (when not during normal school hours), and community settings.provider must be authorized under state law

MMC enrollees: providers must contact MMC plan for billing/reimbursement guidance.

Supervision, Intensity, and Clinical Criteria

Massachusetts EI supervision and intensity

Massachusetts Early Intervention supervision and intensity requirements (applicable to EI members):

MA EI supervision ratio and presence: Supervision by a Board-Certified Behavior Analyst (BCBA) to a paraprofessional must be provided at a 1:10 ratio (one hour BCBA supervision per ten hours direct service); supervision of paraprofessionals may require both supervisor and direct service provider to be present during home visits.1:10 ratio

ABA services should not exceed 30 hours per week for EI members.

Indiana intensity and individualized planning

Indiana guidance on treatment intensity and individualized planning:

Indiana treatment intensity guidance: Services are intensive and may be provided daily; all determinations are based on individualized treatment plan objectives and the unique needs of the member; intensity should consider the member's ability to participate, benefit, and tolerate services, including concurrent non-behavioral services (e.g., school, speech, occupational therapies); treatment intensity should be increased or decreased based on the member's response and current needs.

Coverage for Specific Conditions and Modalities

ABA for Down syndrome (Massachusetts commercial)

Covered when ALL of the following are met (Massachusetts commercial Down syndrome coverage):

MA commercial Down syndrome ABA coverage: Diagnosis of Down syndrome (chromosomal condition with extra whole or partial copy of chromosome 21); coverage is provided for treatment of Down syndrome including applied behavior analysis (ABA) services as part of covered therapies.diagnosis = Down syndrome

Applies to Massachusetts commercial members effective 01/01/2026.

Supervision Ratios and Weekly Limits

inv-28: ABA services / supervision — ratios and weekly ceilings across states

Supervision ratio1:10 BCBA-to-paraprofessional supervision (one hour BCBA per ten hours direct service)

Massachusetts EI weekly ceilingABA services should not exceed 30 hours per week

Maryland weekly ceilingsUp to 25 hrs/week (ages 18 months–5 yrs); up to 10 hrs/week (ages 6–18 yrs)

Maryland additional hours policyAdditional hours may be authorized if medically necessary; requests reviewed under Optum medical necessity guidelines after mandated benefits exhausted

Document Changes and Review Log

2025-12-16Interim review - Kentucky revision

Interim review updated Kentucky-specific content in the ABA State Mandates document.

2025-11-18Interim review - multiple states updated

Interim review updated select state sections including Kentucky, New Jersey, and Washington.

2025-07-22Interim review - new document createdLatest

New ABA State Mandates document created to accompany the ABA Supplemental Clinical Criteria.

Policy Summary

PayerOptum

PolicyApplied Behavior Analysis (ABA) State Mandates

Policy CodePolicy BH 803ABA STM12026

Change TypeInterim review with material updates

Effective DateJanuary 2026

Next Review Date

Key ActionSubmit required prior‑authorization documentation and a comprehensive evaluation or valid referral per state rules to establish medical necessity.

SourceLink

On This Page

Initiation requirementsComprehensive evaluation by child's PCP or specialty physician identifying need

Prescribing requirementPrescription from PCP or specialty physician that includes specific treatment goals

Additional hoursAdditional hours authorized if medically necessary; requests reviewed under Optum medical necessity guidelines after mandated benefits exhausted

inv-11: Massachusetts Medicaid EI ABA weekly limit

Weekly ceiling (MA EI)ABA services should not exceed 30 hours per week

Supervision ratioBCBA supervision to paraprofessional at 1:10 (one hour BCBA supervision per ten hours direct service)

Supervision presenceSupervision may require both supervisor and direct service provider to be present at the same time during home visits

Denial Risk

Kansas: Exclusions Triggering Non‑Authorization

Kansas exclusions that will prevent authorization. CCTS/IIS treatment will not be authorized where services are duplicative or intended for services covered under other benefit types or settings.

Speech therapy
Occupational therapy
Vocational rehabilitation
Supportive respite care
Recreational therapy
Orientation and mobility services
Services provided in a PRTF/hospital setting
Services already provided in duplicate through any other source/setting

Prior Authorization

Ohio: Telehealth and Prior Authorization Guidance

Ohio Medicaid: ABA may be delivered via telehealth per current guidelines (effective June 2018). If the ABA provider is not enrolled with Medicaid, a single case agreement may be required. Providers should consult Ohio Administrative Code for the list of eligible practitioner types and any applicable prior authorization requirements.

Telehealth delivery permitted for ABA (effective June 2018)
Non‑enrolled providers may require a Single Case Agreement
Check Ohio Administrative Code for eligible practitioners and PA requirements

Documentation Required

Maryland: Required Documentation and Reviews

Maryland: Documentation and review requirements to initiate and continue ABA. A comprehensive evaluation by the primary care provider or specialty physician and a prescription with specific treatment goals are required. The prescribing provider must perform an annual review in consultation with the ABA provider documenting benefit, identifying new or continuing goals, and developing a new or continuing treatment plan.

Comprehensive evaluation by PCP or specialty physician identifying need for ASD treatment
Prescription from PCP or specialty physician including specific treatment goals
Annual review by prescribing provider in consultation with ABA provider documenting benefit, treatment goals, and updated treatment plan

Prior Authorization

Maryland: Hours and Additional Authorization

Maryland: Hours, additional authorization, and provider qualifications. Optum will not deny ABA solely on the number of prescribed hours within specified thresholds: up to 25 hours/week for ages 18 months–5 years and up to 10 hours/week for ages 6–18 years. Additional hours beyond these thresholds may be authorized if medically necessary; after exhausting regulatory-mandated benefits, Optum will apply standard medical necessity review for additional requests. ABA must be provided by appropriately licensed, certified, or authorized providers.

Up to 25 hours/week authorized for members 18 months–5 years
Up to 10 hours/week authorized for members 6–18 years
Additional hours may be authorized if medically necessary; Optum will review requests using medical necessity guidelines after mandated benefits are exhausted
Services must be delivered by licensed/certified/authorized providers per Health Occupations Article or equivalent

Documentation Required

Kentucky: Utilization Review and Treatment Plan / Documentation Requirements

Kentucky: Utilization review and provider documentation/treatment plan requirements for commercial members. An insurer may request utilization review no more than once every 12 months (unless more frequent review is mutually agreed). Upon request, providers must furnish medical records, clinical notes, or other data substantiating medical necessity and clinical improvement. When continued services are anticipated, the insurer may request a treatment plan including diagnosis, proposed treatment type, frequency, anticipated duration, anticipated outcomes as goals, and the frequency the plan will be updated. Treatment plans must contain specific, directly observed, and continuously measured goals addressing cognitive, social, communicative, self‑care, or behavioral domains.

Insurer may request utilization review ≤ once every 12 months unless otherwise agreed
Provider must supply medical records/clinical notes to substantiate medical necessity and clinical improvement upon request
When continued services are anticipated, submit treatment plan with diagnosis, treatment type/frequency/duration, anticipated outcomes/goals, and update frequency
Treatment plan goals must be specific, directly observed, and continually measured addressing ASD‑related domains

Prior Authorization

New York: Referral Documentation and Enrollment

New York Medicaid/Child Health Plus: Referral documentation and provider enrollment requirements. NYS Medicaid members must be referred for ABA by a NYS‑licensed and NYS Medicaid‑enrolled prescriber (physician, psychiatrist, developmental/behavioral pediatrician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant). Referrals are valid for up to two years and should include patient age, ASD or Rett diagnosis, date of initial diagnosis, co‑morbid diagnoses if applicable, symptom severity/level of support (when from diagnosing provider), statement that the patient needs ABA services, and the DSM‑5 diagnostic checklist for ASD.

Referral must be from NYS‑licensed and NYS Medicaid‑enrolled prescriber
Referral validity: up to 2 years
Referral content: patient age; ASD/Rett diagnosis; date of initial diagnosis; co‑morbid diagnoses (if applicable); symptom severity/level of support (if from diagnosing provider); statement of need for ABA; DSM‑5 Diagnostic Checklist for ASD

Coverage provided for treatment of Down syndrome including speech, occupational, physical therapy, and ABA services

Effective dateEffective 01/01/2026 (Massachusetts commercial)

Supervision and visit limits (selected states): Where specified by state mandate: MA EI supervision ratio of 1:10 (one hour BCBA supervision per ten hours direct service) and weekly ceiling up to 30 hours; Maryland limits up to 25 hrs/week for ages 18 months–5 years and up to 10 hrs/week for ages 6–18 years.see state-specific thresholds

Additional hours beyond state-mandated limits require medical necessity review where applicable.

EPSDT / intensive support services

Covered under EPSDT / intensive support services when ALL of the following Kansas-specific criteria are met:

Kansas EPSDT intensive support admission: Member is age 20 and under with an ASD diagnosis validated by a licensed psychologist or MD via comprehensive evaluation within the past 6 months; documented deficits in social, communication, language, or adaptive functioning form the basis for an individualized treatment plan; services provided as CCTS/IIS are limited to no more than 40 hours per week; progress reviewed monthly with formal treatment plan review and renewal at least every six months.age <=20; eval within 6 months; <=40 hrs/week; 6-month formal review

Prior authorization reviewed after submission of all requested documentation.

No quantitative benefit limits implied by this guidance.