---
title: Molina Healthcare of New York ABA coverage (Medicaid Managed Care).
url: "https://carelu.com/payers/molina-healthcare-new-york"
markdown_url: "https://carelu.com/payers/molina-healthcare-new-york.md"
state: NY (New York)
payer: Molina Healthcare of New York
kind: Medicaid managed care plan (MCO)
parent_program: New York Medicaid
description: "How Molina Healthcare of New York (formerly Affinity) handles NY Medicaid ABA — in-house UM with LBA reviewers since the September 2021 eviCore transition, the stale-info traps that transition left behind, and what to verify per case."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

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

_Payer Guide · Molina Healthcare (NY) · Last updated September 2026 · 4 primary sources_

> Ex-Affinity; ABA UM in-house since 9/2021 (formerly eviCore) — the classic stale-info trap.

Molina Healthcare of New York — the plan formerly branded Affinity, including the TotalCare ("TONY") plan code — runs its ABA utilization management in-house, with LBA care-review clinicians evaluating assessments and treatment plans for medical necessity. The history matters operationally: ABA UM moved from eviCore to Molina effective September 1, 2021, with PA code changes following that October, and stale eviCore-era instructions still circulate. One nuance worth knowing at intake: "Affinity" isn't purely legacy branding — Molina still actively markets a co-branded "Affinity by Molina Healthcare" Medicaid Managed Care product for downstate members (Bronx, Brooklyn, Manhattan, Nassau, Orange, Queens, Rockland, Staten Island, Suffolk, Westchester), per Molina's own site, so a family naming "Affinity" may be describing a currently-valid downstate product rather than an outdated card. Molina's bulletin trail indicates ABA is PA-based, but the current process specifics aren't published in materials we could verify — so this guide covers the verified structure and the exact questions to close in the portal.

This plan administers the **New York Medicaid** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [New York Medicaid (NYS DOH / eMedNY) guide](https://carelu.com/payers/new-york-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment** _(ask the plan)_: PA-based per Molina’s bulletin trail, but whether 97151 needs a separate authorization isn’t published — confirm per case with provider services, in writing [1][2]
  - Ask the plan: Molina NY provider services. Ask whether 97151 requires a separate authorization from treatment and for the current NY Medicaid PA code list, in writing per case — and disregard any eviCore-era instruction, which has been stale since 9/1/2021.
- **Prior auth for treatment**: Required — reviewed in-house by Molina’s ABA care-review clinicians (including LBA reviewers) since the 9/1/2021 eviCore transition; route through Molina’s own portal/Availity, never eviCore, and confirm the current PA code list from the NY Medicaid bulletins [1]
- **Autism diagnosis required?**: Yes — state baseline: under 21, ASD/Rett per DSM-5, with the state practitioner referral [3]

## At a glance

- **Plan type:** Mainstream MMC (formerly Affinity; incl. TotalCare "TONY" plan code)
- **UM vendor:** In-house since 9/1/2021 — previously eviCore (stale-info trap)
- **Reviewers:** Molina ABA care-review clinicians (LBA reviewers) assess medical necessity
- **Prior auth:** PA-based per Molina's bulletin trail — current specifics unpublished; verify per case
- **Portal:** Molina provider portal / Availity
- **Clinical criteria:** State baseline (under 21, ASD/Rett); plan-specific overlays unverified

## The eviCore transition — and why old instructions still bite

Until September 1, 2021, Molina NY's ABA authorizations ran through eviCore; since then, assessments and treatment plans are reviewed in-house by Molina's ABA care-review clinicians, including LBA reviewers, with PA code changes effective October 1, 2021. That transition is the plan's defining operational fact: eviCore-era submission instructions, fax numbers, and code lists still surface in old provider packets and search results, and following them sends requests into a void. Anything referencing eviCore for Molina NY ABA is stale — route requests through Molina's own portal/Availity channel and confirm the current PA code list from the plan's NY Medicaid bulletins. [1][2]

## What to verify per case

Molina's current published materials don't answer the operational questions intake needs: whether 97151 requires PA separately from treatment, authorization periods, documentation requirements, hour-cap logic, or rates — and its clinical criteria versus the state baseline are unverified. Until the plan confirms otherwise, work from the state's clinical baseline (under 21, ASD/Rett, complete practitioner referral), submit through the current Molina portal, and confirm PA requirements per case with provider services in writing. Families transferred through the Affinity-to-Molina rebrand may also carry outdated card branding — verify plan identity on every inquiry. [2][3]

## Intake gates

The questions that decide whether a family can start with Molina Healthcare of New York, and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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.
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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.
- **Referral required?**: 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.
- **Prior-auth decision time**: “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]
- **Other insurance (who pays first)**: “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]
- **Telehealth** _(ask the plan)_: 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.

## Delivery and billing rules

Coverage decides whether Molina Healthcare of New York pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: 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]
- **Session-note signature**: 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]
- **Place of service**: 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]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: 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.
- **Daily limits / MUEs** _(ask the plan)_: 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.
- **Bill as provider** _(ask the plan)_: 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.

## What intake should collect for Molina Healthcare of New York

- **Current plan identity:** Affinity and TotalCare ("TONY") cards are Molina now — verify against live eligibility, not the card art.
- **Complete state referral packet:** Under-21 ASD/Rett dx with the full referral payload — the clinical baseline while plan specifics stay unpublished.
- **PA confirmation in writing:** Molina's bulletin trail says PA-based, but specifics are unverified — confirm per case through provider services.
- **Post-2021 submission channel:** Ignore anything referencing eviCore — route through Molina's own portal/Availity.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Molina Healthcare of New York ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00349 (legacy "Affinity Health Plan", active) — see verifyVia — pVerify shows the rebranded "06002 Molina Healthcare of New York (Total Care New York)" with Claim Status support = No, while the legacy "00349 Affinity Health Plan" entry shows full Eligibility+Claim Status = Yes — confirm which ID pVerify actually routes live traffic through today before automating on either.
- **Payer ID (Availity):** 13334 — Availity's list only has "13334 AFFINITY HEALTH PLAN" (legacy branding) — no entry titled "Molina Healthcare of New York" was found. Likely the same underlying connection under old branding, but not confirmed.
- **Payer ID (Change Healthcare / Optum):** 16146 — Confirmed via a strong primary source (Molina's own Provider Quick Reference Guide: "Clearinghouse: SSI/Claimsnet — Payer ID 16146") and cross-listed in Optum's own Institutional Claims Payer List — but Molina's own document names its designated clearinghouse as "SSI/Claimsnet," not explicitly Optum/Change Healthcare, so the cross-listing may reflect interoperability rather than Optum being the primary designated gateway. Verify directly.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none — Molina brought behavioral health in-house effective 1/1/2022, ending a Beacon Health Options delegation
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — explicitly named in Molina's 10/1/2021 provider notice: "The following CPT codes will require prior authorization before the services are rendered: 97151, 97152, 97153, 97155." | — | — | — | — |
| 97152 | Yes | Required — explicitly named in Molina's 10/1/2021 provider notice: "The following CPT codes will require prior authorization before the services are rendered: 97151, 97152, 97153, 97155." | — | — | — | — |
| 97153 | Yes | Required — explicitly named in Molina's 10/1/2021 provider notice: "The following CPT codes will require prior authorization before the services are rendered: 97151, 97152, 97153, 97155." | — | — | — | — |
| 97154 | Not confirmed (see code notes) | — | — | — | — | — |
| 97155 | Yes | Required — explicitly named in Molina's 10/1/2021 provider notice: "The following CPT codes will require prior authorization before the services are rendered: 97151, 97152, 97153, 97155." | — | — | — | — |
| 97156 | Not confirmed (see code notes) | — | — | — | — | — |
| 97157 | Not confirmed (see code notes) | — | — | — | — | — |
| 97158 | Not confirmed (see code notes) | — | — | — | — | — |
| 0362T | Not confirmed (see code notes) | — | — | — | — | — |
| 0373T | Not confirmed (see code notes) | — | — | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Molina NY runs ABA UM in-house since 1/1/2022 (Beacon Health Options previously administered it); a "Codification Matrix" is referenced as the authoritative current PA code list on the plan's website but could not be located as a directly fetchable document this pass — its current ABA-specific content is unconfirmed.

### Contacts

- **Provider services phone:** (877) 872-4716
- **Portal:** [Molina Provider Portal](https://provider.molinahealthcare.com)
- **Fax:** (844) 879-4509 (Main); (866) 879-4742 (UM/prior authorization)

Questions to ask on a verification call:

- Is prior authorization required for 97154, 97156, 97157, 97158, 0362T, and 0373T — the 2021 provider notice only named 97151/97152/97153/97155?
- What are the per-code daily/annual unit caps for ABA services?
- What POS settings are allowed for ABA, and is telehealth reimbursable?
- What billing modifiers does Molina require for ABA claims?
- Which pVerify/Availity/clearinghouse payer ID is currently live for eligibility checks — legacy Affinity Health Plan branding or the newer Molina/Total Care NY branding?
- Is the ABA cost share a copay or coinsurance, charged per-visit or per-day, and does the deductible apply?
- Does Molina support real-time 270/271 eligibility checks for this payer ID?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/06/pVeify-Payer-List-June-26.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23)
- https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/ny/medicaid/D-MHNY-Provider-Letter-Beacon-Transition-FINAL.pdf (accessed 2026-07-23)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://www.molinahealthcare.com/providers/ny/medicaid/comm/-/media/Molina/PublicWebsite/PDF/Providers/ny/medicaid/Prior%20Authorization%20Update_Provider_Notice_for_ABA (accessed 2026-07-23)
- https://www.molinahealthcare.com/providers/ny/medicaid/contacts/contact_info.aspx (accessed 2026-07-23)

## Common questions

### Does Molina Healthcare of New York cover ABA?

Yes — it carries the NY Medicaid ABA carve-in, with assessments and treatment plans reviewed in-house by Molina's ABA care-review clinicians (including LBA reviewers). Its bulletin trail indicates PA-based authorization; confirm current specifics per case.

### Do I still submit Molina NY ABA requests through eviCore?

No — eviCore hasn't handled Molina NY ABA since September 1, 2021. UM is in-house; route requests through Molina's portal/Availity and treat any eviCore-referencing instructions as stale.

### Is Molina the same as Affinity in New York?

Yes — Molina acquired Affinity, and most Affinity branding is legacy card art now covered by Molina. But note: Molina still actively operates a co-branded "Affinity by Molina Healthcare" Medicaid Managed Care product for downstate members, so "Affinity" can also be a currently-valid plan name, not only an old card — verify plan identity either way on any inquiry.

## Primary sources

1. [Molina NY provider notice — ABA prior authorization changes](https://www.molinahealthcare.com/providers/ny/medicaid/comm/-/media/Molina/PublicWebsite/PDF/Providers/ny/medicaid/Prior%20Authorization%20Update_Provider_Notice_for_ABA)
2. [Molina NY Medicaid bulletins index](https://www.molinahealthcare.com/providers/ny/medicaid/comm/bulletin.aspx)
3. [eMedNY ABA Provider Policy Manual (state baseline)](https://www.emedny.org/ProviderManuals/ABA/PDFS/ABA_Policy.pdf)
4. [Molina Healthcare — Affinity by Molina Healthcare (NY Medicaid Managed Care) overview](https://www.molinahealthcare.com/members/ny/hp/affinity/medicaid/overvw/overvw.aspx)
5. [Molina Healthcare of New York Provider Manual — Medicaid Managed Care, PLUS and CHP (2026 Mid-Year Update, June 2026), §7](https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/2026%20Medicaid%20Provider%20Manual%20Mid-Year%20remediated)
6. [eCFR — 42 CFR 438.210(d), timeframe for decisions](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.