Molina Healthcare of New York ABA coverage (Medicaid Managed Care).

Follows the New York Medicaid rule: ABA is covered for members “under 21 years of age with a diagnosis of Autism Spectrum Disorder (ASD) as defined by… (DSM-5) and/or Rett Syndrome.” No minimum age and no adult pathway — the 21st birthday is a hard cliff. Molina publishes no age rule of its own for New York; its clinical criteria versus the state baseline are unverified in the materials we could reach.^[3][2]

Follows the New York Medicaid rule: the referral is valid no more than two years and no maximum age is set on the diagnostic evaluation. Molina publishes no New York recency rule of its own in the materials we could verify.^[3][2]

Ask the plan: Molina NY provider services and the NY Medicaid bulletins index — confirm whether Molina adds a diagnostic recency rule.

Follows the New York Medicaid rule: the diagnosis and referral must come from a NYS-licensed, NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner or physician assistant, following DSM-5 criteria and NYSDOH’s Clinical Practice Guideline on ASD. LBAs and CBAAs sit outside that list — they may not diagnose and may not self-refer. Molina’s published New York material identifies its reviewers rather than its diagnosticians: assessments and treatment plans are reviewed in-house by Molina ABA care-review clinicians, including LBA reviewers, since the September 1, 2021 move off eviCore.^[3][1]

Follows the New York Medicaid rule: no instrument is mandated. What the state requires with the referral is the “DSM-5 Diagnostic Checklist for ASD diagnoses” plus the severity level when the referral comes from an ASD-diagnosing provider; the treatment plan need only record the assessment methodology used and, “as appropriate, identify standardized assessment used (e.g., adaptive behavior scales, symptom inventories, aggression ratings) and results.” No Molina-specific instrument requirement was located for New York.^[3][2]

Ask the plan: Molina NY provider services — confirm whether the in-house LBA reviewers expect named instruments.

Follows the New York Medicaid rule: the member “must be referred for ABA services by a NYS-licensed and NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant,” the referral is “valid for no more than two years,” and it must carry age, the ASD/Rett diagnosis, date of initial diagnosis, co-morbid diagnoses, symptom severity level, a statement the patient needs ABA, and the DSM-5 Diagnostic Checklist. Molina’s bulletin trail indicates ABA is prior-authorization-based, but the current process specifics are not published in materials we could verify. The one operational certainty is the routing: anything referencing eviCore for Molina New York ABA is stale — utilization management moved in-house effective September 1, 2021, with PA code changes following that October, so route requests through Molina’s own portal or Availity.^[3][1][2]

Ask the plan: Molina NY provider services — confirm per case, in writing, whether 97151 requires PA separately from treatment and what the current PA code list is.

“For Medicaid, Molina’s decision must be made as fast as the Member requires or within three (3) business days of receipt of necessary information but no more than fourteen (14) days of the request.” Expedited requests: “within seventy-two (72) hours of receipt of the expedited request.” Continued-service (concurrent) requests — reauths and unit increases — are decided within one business day of the necessary information (expedited: “no more than 72 hours”). Either clock “may be extended by an additional fourteen (14) days” at the member’s or provider’s request or when Molina needs more information. Federal rules now cap standard Medicaid managed-care decisions at 7 calendar days for plan rating periods starting on or after January 1, 2026, which is tighter than the manual’s 14. No ABA reauth submission lead time is published.^[5][6]

“Medicaid is always the payer of last resort… If third-party liability can be established, Provider must bill the primary payer and submit a primary explanation of benefits (EOB) to Molina for secondary Claim processing,” and “Primary carrier payment information is required with the Claim submission.” The one pay-and-chase carve-out: “Molina will pay claims for prenatal care and EPSDT and then seek reimbursement from third parties” — ask billing whether an ABA claim is treated as EPSDT before relying on it. If Molina paid before learning of other coverage, it sends an overpayment letter with the other policy’s details. The manual does not say whether Molina’s own ABA prior authorization is still required when it is secondary — confirm with Provider Services before starting on the primary plan’s approval alone.^[5]

Not published. Molina’s retrievable New York materials cover the eviCore transition and the bulletin index; no ABA telehealth policy was located, and the state manual answers telehealth only for supervision.^[2][3]

Ask the plan: Molina NY provider services or the NY Medicaid bulletins index at molinahealthcare.com — confirm telehealth code eligibility and POS in writing.

Follows the New York Medicaid rule, which the state applies to FFS and managed care alike: “an LBA can supervise no more than six CBAAs/unlicensed individuals at a time,” “LBAs are required to supervise unlicensed individuals for a minimum of five percent of the hours the unlicensed individual spends providing behavior analysis services each calendar month,” and “supervision must include at least two face-to-face, real-time contacts per month” with the LBA observing service delivery in at least one. Supervision may run over synchronous audio-and-video where on-site is impractical. 97155 counts toward the 5% “only when the LBA joins the patient and the unlicensed individual during a treatment session to direct the unlicensed individual/technician in implementing a new or modified treatment protocol.” CBAAs need direct supervision, and the supervisor “should assess each patient’s/client’s progress at least every 6 months… and review and sign treatment notes and reports prepared by the CBAA supervisee.” Molina publishes no supervision rule of its own for New York; note that its in-house reviewers include LBAs, so a supervision plan that meets the state rule is what a Molina reviewer will be reading against.^[3][1]

Follows the New York Medicaid rule: the LBA supervisor must “review and sign treatment notes and reports prepared by the CBAA supervisee,” and documentation of supervision itself “should be recorded in the patient file.” Clinical documentation must carry the treatment plan with assessment and goals, the goal data, total hours of service per week by who delivered them, and the location(s) of services. Records are kept “for a minimum of six years and, for minors, until the patient turns 22 years of age.” No Molina-specific New York documentation or signature rule was located.^[3][2]

Follows the New York Medicaid rule: “LBAs and CBAAs may work in any legally authorized setting. Examples of such settings include private practice, settings where patients/clients reside full-time or part-time, clinics, hospitals, residences, and community settings” — but “NYS Medicaid does not reimburse for ABA services in a school setting.” The treatment plan must record the location(s) of services. No Molina-specific New York setting rule was located; the state’s school bar is the operative constraint.^[3][2]

Not published. Molina’s New York bulletin trail covers the eviCore transition and PA code changes rather than claim edits, and the state manual is silent on 97153 with 97155.^[2][3]

Ask the plan: Molina NY provider services and the NY Medicaid bulletins index — confirm in writing before billing the overlap.

Not published — authorization periods, unit ceilings, hour-cap logic and rates are all absent from the Molina New York materials we could verify. The state sets no per-day ceiling either.^[2][3]

Ask the plan: Molina NY provider services — confirm authorization periods and any unit limits per case in writing.

Not published. At the fee-for-service layer New York is explicit: LBAs bill “using the LBA’s National Provider Identification (NPI) number for the ‘Billing’ provider and/or ‘Supervising’ provider,” with “the NPI number of the CBAA that provided the ABA service… reported as the ‘Rendering’ provider on each claim”; for unlicensed aides and LBA limited-permit holders the supervising LBA’s NPI fills all three roles. CBAAs cannot bill directly and enroll as OPRA providers. Molina states no New York managed-care claim convention we could verify — and given the eviCore-era instructions still circulating, confirm the current submission channel and claim format with Molina rather than an old provider packet.^[3][1]

Ask the plan: Molina NY provider services — confirm the current portal/Availity route, the PA code list, and the rendering/supervising NPI convention.