---
title: "New York Medicaid ABA coverage: the intake guide."
url: "https://carelu.com/payers/new-york-medicaid"
markdown_url: "https://carelu.com/payers/new-york-medicaid.md"
state: NY (New York)
payer: New York Medicaid (NYS DOH / eMedNY)
kind: State Medicaid program
description: "How NYS Medicaid covers ABA — no prior authorization at the fee-for-service layer (a 2-year practitioner referral is the gate), the 2023 managed-care carve-in where every major plan does require PA, the phased 25% cut to 97153, LBA-only billing, and the 5% supervision rule."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# New York Medicaid ABA coverage: the intake guide.

_Payer Guide · New York Medicaid · Last updated September 2026 · 17 primary sources_

> Under 21, ASD/Rett; FFS has NO prior auth (referral only) — but most kids sit in MCOs that do.

New York Medicaid covers ABA for members under 21 with autism spectrum disorder or Rett syndrome — a young benefit (first billable in 2021, nine years after the state's commercial mandate) with a split personality. At the fee-for-service layer, administered through eMedNY, there is no prior authorization at all: the entire front door is a practitioner referral valid for up to two years. But since January 1, 2023 the benefit is carved into every mainstream Medicaid Managed Care plan, most children sit in one of those ~13 plans, and every major plan does impose its own prior authorization. In practice, "does this family need a PA?" is answered by which card they carry — which makes plan identification the first intake question in New York.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: FFS: NO prior authorization — the gate is a practitioner referral (valid ≤2 years). MMC plans set their own PA, and every major plan requires it [1]
- **Prior auth for treatment**: FFS: none stated — referral-gated, with treatment-plan updates every 6 months. MMC: each plan runs its own assessment + treatment PA [1]
- **Autism diagnosis required?**: Yes — under 21 with ASD (DSM-5) and/or Rett syndrome (F84.0, F84.2); not available for adults 21+ or other diagnoses [1]

## At a glance

- **Covers ABA?:** Yes — under 21, ASD (DSM-5) and/or Rett syndrome; no waiver pathway, no adult coverage
- **FFS prior auth:** NONE — a practitioner referral (valid ≤2 years) is the only gate
- **MMC prior auth:** Plan-by-plan — all major MCOs require PA (see the per-plan guides)
- **Diagnosis recency:** Referral valid no more than 2 years (the state's de facto recency rule)
- **Rates (per 15 min):** 97153: $14.45 (eff. 4/1/2026, after a phased 25% cut) · 97151/97155/97156: $19.26
- **Licensure:** NYSED Licensed Behavior Analyst (LBA) — only LBAs enroll and bill
- **Settings:** Home, clinic, community — NOT reimbursable in schools
- **Staff screening:** No RBT or state background-check mandate for technicians — screening flows from OMIG/LEIE/SAM exclusion checks, plus Justice Center checks only in OMH/OPWDD/OCFS-certified settings

## The FFS front door: a referral, not a prior authorization

Nothing in the current FFS ABA Policy Manual (updated October 1, 2025) requires prior authorization or prior approval — for the assessment or for treatment. The gate is a referral from a NYS-licensed and NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant (LBAs cannot diagnose or self-refer). The referral is valid for no more than 2 years and must carry a specific payload: the member's age, the ASD and/or Rett diagnosis with date of initial diagnosis, co-morbid diagnoses, severity level, a statement of need for ABA, and the DSM-5 Diagnostic Checklist. Once services start, the treatment plan must be updated at least every 6 months and shared with the referring provider. For intake, that means a complete referral packet is the whole authorization battle on FFS — chase its required elements at first contact, because an incomplete referral is the only thing standing between the family and a booked assessment. [1][5][14][15]

One forward-looking caveat: the Governor's FY 2026-27 Executive Budget proposed an ABA "Centers of Excellence" (CoE) designation framework whose criteria were still undefined as of mid-2026. Two budget-summary sources on the enacted SFY2026-27 budget (signed 5/28/2026) describe only the ABA rate-methodology reform as surviving into the enacted budget, with no CoE program mentioned — but that read comes from secondary budget-highlights write-ups, not primary bill text, so treat "CoE didn't survive" as unconfirmed rather than settled. Still worth watching for an implementation notice from DOH/OMH before assuming either outcome. [1][5][14][15]

## The 2023 carve-in: where most families actually are

Effective January 1, 2023, ABA was carved into the mainstream Medicaid Managed Care benefit package — and since most children are enrolled in MMC, most New York ABA runs through a plan, not through eMedNY. The state's own manual is blunt about what that means: providers serving an MMC member "must contact the MMC member's specific MMC plan for coverage, billing, and reimbursement guidance." Unlike the FFS layer, every major plan imposes prior authorization, each with its own machinery — Fidelis's Centene-style clinical policy, UnitedHealthcare's Optum portal, Anthem's Availity form, Healthfirst, MetroPlus, EmblemHealth, and Molina all have dedicated guides below. [4][1][16]

The carve-in also runs through the regional upstate plans per the eMedNY directory (v2026-2, April 1, 2026): Excellus BCBS (Central NY, Rochester, Southern Tier), MVP Health Plan and CDPHP (Capital Region and Hudson Valley), and Independent Health and Highmark Western & Northeastern NY (Western NY), plus the HIV-SNPs (Amida Care, MetroPlus Partnership) and HARP variants — each now has its own dedicated guide below. Per the state's July 2026 Medicaid Managed Care enrollment report, the five regional plans carry real scale, not a rounding error: Excellus (179,533 statewide members), MVP (165,151), CDPHP (80,854), Independent Health (60,812, Erie County only), and Highmark Western & Northeastern NY (45,881) — roughly 532,000 members combined. One trap: Aetna Better Health appears in the NY directory only as a Partial LTC (MLTC) plan — it is not a mainstream children's Medicaid plan and not an ABA payer in NY Medicaid. [4][1][16]

## Rates: a single statewide schedule — and a 25% cut to 97153

The FFS fee schedule is flat: one statewide rate per code, no credential tiers, no modifiers, no geographic variation. Assessment (97151) and the QHP codes (97155 protocol modification, 97156 family guidance) pay $19.26 per 15-minute unit; group codes 97154/97157/97158 pay $3.31 per unit per member. The story is 97153, technician-delivered direct treatment — the volume code of every ABA practice. The FY 2025-26 enacted budget authorized a phased 25% cut applied only to 97153: $19.26 → $16.85 effective October 1, 2025 → $14.45 effective April 1, 2026. A NYSABA/CASP survey reported 74% of Medicaid ABA providers would leave the program if the second tranche took effect; the FY 2026-27 Executive Budget nonetheless layered on roughly $28.5M in further cuts. Two modeling notes: MMC plans negotiate their own rates (the state schedule is the FFS reference, not binding on plans), and any margin model built on pre-cut 97153 rates is now ~25% wrong. [2][3][5]

## Licensure, supervision, and the operational rules

New York is one of the strictest licensure states in the country: only NYSED Licensed Behavior Analysts (LBAs) can enroll in Medicaid and bill — a BCBA credential alone is not sufficient. Certified Behavior Analyst Assistants (CBAAs) enroll as non-billing (OPRA) providers and bill through their supervising LBA, and unlicensed technicians may deliver scripted 97153 sessions billed under the LBA's NPI. Effective October 1, 2025, that supervision has teeth: LBAs must supervise unlicensed technicians for at least 5% of the technician's service hours each calendar month, with at least 2 face-to-face real-time contacts per month (one observing service delivery), and no LBA may supervise more than 6 CBAAs/unlicensed individuals at a time — rules that apply to FFS and MMC alike, and that turn supervision capacity into a hard cap on census. Other operational rules worth wiring into intake: ABA is not reimbursable in a school setting (home, clinic, and community are fine); records must be kept at least 6 years and, for minors, until the patient turns 22 (10 years for MMC providers); and ABA-via-telehealth was under formal state evidence review in mid-2025 — supervision of technicians may already occur via synchronous audio/video. [3][1]

## Staffing & credentialing: who you can hire, and what they must clear

New York has no RBT mandate. The FFS manual defines the technician tier simply as an "unlicensed individual" — someone not licensed, certified, or registered by the state as an ABA provider — with no credential, training-hour, age, or education requirement attached. What the state regulates instead is scope: an LBA may not delegate any task within the ABA scope of practice, even under direct supervision, so technicians only execute the scripted treatment-plan activities the LBA wrote, record data without interpreting it, prepare the setting, and write factual session notes. The middle tier is unique to New York: the Certified Behavior Analyst Assistant (CBAA), a NYSED credential under Education Law Article 167 requiring a bachelor's degree (in ABA, or a related field plus ABA certificate coursework), 1,000 hours of supervised experience, and passage of both the NYCBAA and NY Autism exams. And if you staff with RBTs anyway — many agencies do — the BACB's own floor travels with the credential: 18+, high-school education, the 40-hour training and competency assessment, and a passed criminal background check plus abuse-registry check no more than 180 days before the certification application. [1][7][8][9][10][11][6][12][13]

On background screening, the ABA Policy Manual itself imposes no employee-level background-check, fingerprinting, or registry requirement — the obligations arrive from adjacent rules, keyed to what your agency is. At provider enrollment, NY Medicaid screens applications at the federal limited/moderate/high risk tiers and collects the $750 federal application fee (2026) from certain provider types (waived if already paid to Medicare or another state's Medicaid/CHIP within 12 months); enrollment fingerprinting attaches only at the high-risk tier, so confirm your risk category with provider enrollment. Justice Center pre-employment checks — Staff Exclusion List check first, then a fingerprint-based criminal background check via IdentoGO, fully completed before the hire has regular unsupervised contact with recipients — bind programs under Justice Center jurisdiction (OMH- and OPWDD-operated/certified programs, OCFS residential programs for children), not a standalone LBA practice billing Medicaid FFS; but an agency that also runs OPWDD-certified services (e.g., community habilitation) carries the full four-check stack: SEL, CBC, an MHL 16.34 check, and the OCFS child-abuse SCR check. Every agency, whatever its settings, should screen staff against the three exclusion databases OMIG names — the NYS Medicaid exclusion list, the federal OIG LEIE, and SAM.gov; OMIG doesn't publish a check frequency, so set a recurring cadence in your compliance plan. [1][7][8][9][10][11][6][12][13]

The supervisor credential is the LBA, and New York is explicit that BCBA certification alone "is not sufficient" to practice — it's only a pathway to licensure, which requires a master's from a NYSED-registered ABA program (or substantial equivalent), the exam (BCBA satisfies it), supervised experience, good moral character, minimum age 21, NYSED-approved child-abuse-reporting coursework, and a $300 fee. The supervision math covered above — 5% of each technician's monthly service hours, two face-to-face contacts, the six-supervisee cap — is what turns those credentials into a staffing model. Plans then layer on their own stacks: Optum/UHC Community Plan requires network LBAs to hold active BCBA certification plus the NY license plus a NY Medicaid ID (CBAAs need their own Medicaid ID), along with professional liability insurance and a virtual-visits attestation for telehealth supervision; Healthfirst stretches record retention to 10 years for MMC providers (vs. the state's 6-year/age-22 floor). No NY Medicaid plan we checked requires RBT certification for technicians. [1][7][8][9][10][11][6][12][13]

## Intake gates

The questions that decide whether a family can start with New York Medicaid (NYS DOH / eMedNY), and what they have to bring.

- **Age limit**: Under 21. ABA “will be covered for NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) members under 21 years of age with a diagnosis of Autism Spectrum Disorder (ASD) as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and/or Rett Syndrome.” No minimum age is set, and there is no waiver pathway and no adult coverage — so the 21st birthday is a hard coverage cliff worth flagging at intake for any member 19 or older. [1]
- **Diagnosis recency**: New York regulates the referral’s age, not the evaluation’s. “Referrals for ABA services are valid for no more than two years” and must carry the “date of initial diagnosis” — but the manual sets no maximum age on the diagnostic report itself, so an older evaluation can still support a fresh referral. Once services start, “LBAs will update the treatment plan at least every 6 months or as needed,” and initial plans and updates “should be shared with the referring provider.” Managed-care plans layer tighter clocks on top (Fidelis runs a 2-year evaluation window plus a 60-month validated-tool rule; MetroPlus requires annual re-validation), so the card decides the operative recency rule. [1]
- **Who may diagnose**: “The NYS Medicaid 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,” and those referring providers “should follow the criteria for diagnosing ASD found in the DSM-5 and outlined in the NYS Department of Health’s publication, Clinical Practice Guideline on Assessment and Intervention Services for Young Children with Autism Spectrum Disorders.” LBAs and CBAAs are outside that list — NYSED bars them from diagnosing the condition ABA is provided for and from prescribing or ordering ABA — which is why no New York case should open without a separate diagnosing clinician in the file. [1][17]
- **Diagnostic tools required**: No instrument is mandated. What the state requires with the referral is the “DSM-5 Diagnostic Checklist for ASD diagnoses,” plus the “symptom severity level/level of support (if referral is from an ASD-diagnosing provider).” On the ABA side the manual asks only that the treatment plan record the “assessment methodology (e.g., antecedent-behavior-consequence log, behavioral observation/sampling, functional behavior assessment, self-monitoring/self-report, inventory, etc.)” and, “as appropriate, identify standardized assessment used (e.g., adaptive behavior scales, symptom inventories, aggression ratings) and results of assessment.” Named-instrument requirements in New York are a managed-care overlay, not a state rule. [1]
- **Referral required?**: Required — and at the fee-for-service layer it is the entire authorization gate, because nothing in the current manual requires prior approval. The referral must come from a NYS-licensed, NYS Medicaid-enrolled physician, psychologist, psychiatric NP, pediatric NP or PA; it is “valid for no more than two years”; and it must carry seven elements: age of the patient, the ASD or Rett Syndrome diagnosis, date of initial diagnosis, co-morbid diagnosis if applicable, symptom severity level/level of support, “statement the patient needs ABA services,” and the DSM-5 Diagnostic Checklist. An incomplete referral is the only thing standing between an FFS family and a booked assessment. [1]
- **Prior-auth decision time**: Nothing to decide at the fee-for-service layer: the eMedNY ABA manual requires no prior authorization, so the referral is the whole gate (FFS’s own new PA clocks — standard requests “adjudicated within seven days from the date received, provided all necessary documentation is included,” expedited within 72 hours, effective January 1, 2027 — only bite on services that carry a PA). For the majority of children, who sit in a Medicaid Managed Care plan, the state model contract sets the clock: a prior authorization request is decided “within three (3) business days of receipt of necessary information, but no more than fourteen (14) days after receipt of the Service Authorization request,” expedited requests within 72 hours, and a request for “more of an authorized service than what is currently authorized” (a concurrent review — reauths and unit increases) “within one (1) business day of receipt of necessary information”; either clock may be extended up to 14 days. Federal law caps the outer limit at 7 calendar days for plan rating periods starting on or after January 1, 2026 (42 CFR 438.210(d)). The state sets no reauth submission lead time; plans publish their own. [1][18][19][20]
- **Other insurance (who pays first)**: Medicaid pays last. “The Medicaid Program is designed to provide payment for medical care and services only after all other resources available for payments have been exhausted; Medicaid is the payer of last resort,” and “Providers must bill all applicable insurance sources before submitting claims to Medicaid. Payment from those sources must be received before submitting a Medicaid claim.” So check MEVS for a third-party coverage code at intake, bill the commercial plan first, then bill eMedNY for the balance — a claim pushed past Medicaid’s 90-day filing limit by the other payer’s processing must reach Medicaid within 30 days of that payer’s determination, with the Explanation of Medical Benefits on paper claims. Two practical twists: a child with other insurance may be excluded from managed care (“Enrollees who have other third party insurance so that managed care enrollment is not cost-effective”), which lands them in FFS, where ABA has no PA at all; and if the child is in a plan, the plan must “alert the provider and ask them to bill the TPHI that should be primary to the Plan.” A provider may not refuse service because a third party is liable. The manuals state no pay-and-chase exception for ABA. [21][22][19]

## Delivery and billing rules

Coverage decides whether New York Medicaid (NYS DOH / eMedNY) 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**: Effective October 1, 2025 the supervision rules have hard numbers. “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” — explicitly not telephonic, email or text — with the LBA observing the technician delivering services in at least one. One of the two contacts may be a small-group meeting. 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 separately require direct supervision, cannot exceed six per LBA, and their 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.” Because an LBA may not delegate any task inside the ABA scope of practice, supervision capacity is a hard cap on census. [1][3]
- **Session-note signature**: The person who prepared the note signs it, and the supervising LBA countersigns a CBAA’s: the supervisor “should assess each patient’s/client’s progress at least every 6 months or as needed, and review and sign treatment notes and reports prepared by the CBAA supervisee.” Documentation of supervision itself “should be recorded in the patient file of the NYS Medicaid member.” Clinical documentation “should include, but may not be limited to” the treatment plan with assessment and goals, specific goals with associated data, total hours of service per week and who provided them (including caregiver training), and the location(s) of services. Retention: “a minimum of six years and, for minors, until the patient turns 22 years of age.” [1]
- **Place of service**: “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.” Then the line that shapes every New York intake: “Note: NYS Medicaid does not reimburse for ABA services in a school setting.” The treatment plan must record “location(s) of services (such as office, residence, community),” so setting is documented, not assumed. Managed-care plans have followed the state here rather than deviating — Fidelis stopped covering school-setting ABA on 9/1/2023 and MVP administratively denies any ABA code billed with POS = School from 7/1/2025. [1]
- **Bill as provider**: The LBA is the billing provider, always. “An LBA must be enrolled with the NYS Medicaid FFS program to receive reimbursement for ABA services provided to a NYS Medicaid FFS or MMC member,” and “CBAAs cannot bill the NYS Medicaid program directly” — they enroll as OPRA providers and their work is billed by the supervising LBA. The role mapping 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 non-enrolled unlicensed aides and LBA limited-permit holders, the supervising LBA’s NPI fills Billing, Supervising and Rendering alike. An Article 28 facility bills instead on the Ordered Ambulatory Fee Schedule, with its LBAs/CBAAs enrolled as OPRA providers and affiliated with the facility. [1]
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: eMedNY provider services (800) 343-9000 and the Medicaid NCCI edit files applied to the ABA fee schedule; for a managed-care member, the plan’s claim-edit policy. [1]

## What intake should collect for New York Medicaid (NYS DOH / eMedNY)

- **FFS or which MMC plan:** The single fact that decides whether there's a PA at all — get the card, not the family's guess.
- **Complete referral packet:** From a licensed, Medicaid-enrolled physician/psychologist/NP/PA: dx + initial dx date, co-morbidities, severity, statement of need, DSM-5 checklist. Referral ≤2 years old.
- **Age and diagnosis:** Under 21 with ASD and/or Rett only — 21st-birthday proximity is a coverage cliff to flag early.
- **Service setting:** Home, clinic, or community — school-based delivery is not reimbursable.
- **Supervising LBA capacity:** The 5%/2-contact/6-supervisee rules make LBA bandwidth a scheduling constraint from day one.

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

## Verification of benefits (VOB) data

How New York Medicaid (NYS DOH / eMedNY) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00163
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** none
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No
- **Where the 271 carries MCO enrollment:** MMC enrollment is flagged by EB01='U' (Loop 2110C EB segment) — "the patient's benefits are administered by another payer indicated in EB05" — but the MCO's actual NAME is carried in Loop 2120C, NM1 segment (NM101='Y2' Subscriber Benefit Related Entity Name, NM108='PI' identification-code qualifier), not in a coded field within 2110C itself. A companion REF segment in Loop 2110C (REF01='18' Plan Number or '6P' Group Number) may carry the plan/policy number tied to that same 2120C entity.
- **Eligibility span granularity:** Query granularity is by date-of-service, constrained to the CURRENT calendar month only — no future-month requests, no date-range requests ("if a range is submitted, eligibility determination will be based upon the 'from' date"). Underlying coverage determinations are month-based per the MEVS/DVS Provider Manual ("PLAN DATE IS...the first day of the month eligibility information was requested"). The 271's EB06 Time Period Qualifier carries codes 26/27/29/34 for benefit-amount date ranges, but this companion guide doesn't define those codes in prose.

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Not required — no PA/prior-approval requirement anywhere in the ABA Policy Manual (Oct 1, 2025); the gate is a practitioner referral valid ≤2 years, not a per-claim authorization. | No hour/unit cap published in the ABA Policy Manual | private practice, clinic, hospital, residence/home, community setting, NOT reimbursable in a school setting (explicit exclusion) | — | — |
| 97152 | Yes | Not required — no PA/prior-approval requirement anywhere in the ABA Policy Manual (Oct 1, 2025); the gate is a practitioner referral valid ≤2 years, not a per-claim authorization. | No hour/unit cap published in the ABA Policy Manual | private practice, clinic, hospital, residence/home, community setting, NOT reimbursable in a school setting (explicit exclusion) | — | — |
| 97153 | Yes | Not required — no PA/prior-approval requirement anywhere in the ABA Policy Manual (Oct 1, 2025); the gate is a practitioner referral valid ≤2 years, not a per-claim authorization. | No hour/unit cap published in the ABA Policy Manual | private practice, clinic, hospital, residence/home, community setting, NOT reimbursable in a school setting (explicit exclusion) | — | — |
| 97154 | Yes | Not required — no PA/prior-approval requirement anywhere in the ABA Policy Manual (Oct 1, 2025); the gate is a practitioner referral valid ≤2 years, not a per-claim authorization. | No hour/unit cap published; group SESSIONS capped at 8 individuals per per session (group-size cap only) | private practice, clinic, hospital, residence/home, community setting, NOT reimbursable in a school setting (explicit exclusion) | — | — |
| 97155 | Yes | Not required — no PA/prior-approval requirement anywhere in the ABA Policy Manual (Oct 1, 2025); the gate is a practitioner referral valid ≤2 years, not a per-claim authorization. | No hour/unit cap published in the ABA Policy Manual | private practice, clinic, hospital, residence/home, community setting, NOT reimbursable in a school setting (explicit exclusion) | — | — |
| 97156 | Yes | Not required — no PA/prior-approval requirement anywhere in the ABA Policy Manual (Oct 1, 2025); the gate is a practitioner referral valid ≤2 years, not a per-claim authorization. | No hour/unit cap published in the ABA Policy Manual | private practice, clinic, hospital, residence/home, community setting, NOT reimbursable in a school setting (explicit exclusion) | — | — |
| 97157 | Yes | Not required — no PA/prior-approval requirement anywhere in the ABA Policy Manual (Oct 1, 2025); the gate is a practitioner referral valid ≤2 years, not a per-claim authorization. | No hour/unit cap published in the ABA Policy Manual | private practice, clinic, hospital, residence/home, community setting, NOT reimbursable in a school setting (explicit exclusion) | — | — |
| 97158 | Yes | Not required — no PA/prior-approval requirement anywhere in the ABA Policy Manual (Oct 1, 2025); the gate is a practitioner referral valid ≤2 years, not a per-claim authorization. | No hour/unit cap published; group SESSIONS capped at 8 individuals per per session (group-size cap only) | private practice, clinic, hospital, residence/home, community setting, NOT reimbursable in a school setting (explicit exclusion) | — | — |
| 99366 | Not confirmed (see code notes) | — | — | — | — | — |
| 0362T | Not confirmed (see code notes) | — | — | — | — | — |
| 0373T | Not confirmed (see code notes) | — | — | — | — | — |

Code notes:

- **97151:** Assessment code — billed in 15-min units at $19.26/unit (see rates).
- **97152:** Confirmed covered on the current fee schedule at $19.26/unit — no distinct historical effective date is published (unverified when this code was first billable).
- **97153:** Technician-delivered direct treatment — the volume code. Rate is being phased down: $19.26 → $16.85/unit (eff. 10/1/2025) → $14.45/unit (eff. 4/1/2026, current). See rates for the full history.
- **97154:** Group adaptive behavior treatment — capped at 8 individuals per session; billed at $3.31/unit per member (not the $19.26 individual rate). Also subject to the 97156/97157 'concert of care' rule is NOT stated for 97154 specifically — that rule applies only to 97156 & 97157 per the manual.
- **97155:** QHP protocol-modification code — billed at $19.26/unit.
- **97156:** Family guidance code — billed at $19.26/unit. Per the ABA Policy Manual: "CPT code 97156 & 97157 can only be billed when the service is delivered in concert with care of the patient as part of the child's treatment plan" (applies jointly to both codes).
- **97157:** Multiple-family group guidance — billed at $3.31/unit per member (group rate). Subject to the same 'delivered in concert with care of the patient' restriction as 97156, per the manual.
- **97158:** Group adaptive behavior treatment with protocol modification — capped at 8 individuals per session (same cap as 97154); billed at $3.31/unit per member. Fee-schedule footnote: "effective for dates of service on or after 11/1/2022."
- **99366:** 99366 does not appear in NY Medicaid FFS's ABA fee schedule or policy manual — the state's actual billable ABA code set (per both primary documents) is 97151-97158 only. Verify via eMedNY Provider Enrollment/DRG unit before assuming this code is billable.
- **0362T:** 0362T does not appear in NY Medicaid FFS's ABA fee schedule or policy manual — the state's actual billable ABA code set (per both primary documents) is 97151-97158 only. Verify via eMedNY Provider Enrollment/DRG unit before assuming this code is billable.
- **0373T:** 0373T does not appear in NY Medicaid FFS's ABA fee schedule or policy manual — the state's actual billable ABA code set (per both primary documents) is 97151-97158 only. Verify via eMedNY Provider Enrollment/DRG unit before assuming this code is billable.

### Medicaid rates

Source: eMedNY ABA Fee Schedule (.xls, effective 4/1/2026), cross-confirmed for the 97153 phase-down history against the NYS Medicaid Update Aug 2025 (Vol 41 No 8) — the FFS fee schedule is a single flat statewide rate per code with no credential tiers, no modifiers, no geographic variation. MMC plans negotiate their own rates (see each MCO guide's rates block). Effective 2026-04-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $19.26 per 15-min unit | 15min | — |
| 97152 | $19.26 per 15-min unit (no distinct historical effective date published) | 15min | — |
| 97153 | $14.45 per 15-min unit (current, eff. 4/1/2026) — phased down from $19.26 → $16.85 (eff. 10/1/2025) → $14.45 (eff. 4/1/2026) | 15min | — |
| 97154 | $3.31 per unit per member (group code) | 15min | — |
| 97155 | $19.26 per 15-min unit | 15min | — |
| 97156 | $19.26 per 15-min unit | 15min | — |
| 97157 | $3.31 per unit per member (group code) | 15min | — |
| 97158 | $3.31 per unit per member (group code); effective for DOS on/after 11/1/2022 per fee-schedule footnote | 15min | — |

### Contacts

- **Provider services phone:** 1-800-343-9000
- **Phone menu path:** eMedNY Call Center — separate queues for non-pharmacy billing/claims/provider enrollment vs. eligibility/POS/DVS/pharmacy claims (see hours).
- **Hours:** Non-pharmacy billing, claims, provider enrollment: Mon-Fri 7:30 a.m.-6:00 p.m. ET (excl. holidays). Eligibility, POS, DVS, pharmacy claims: Mon-Fri 7:00 a.m.-10:00 p.m. ET (excl. holidays), 8:30 a.m.-5:30 p.m. ET holidays/weekends.
- **Portal:** [ePACES](https://epaces.emedny.org)

Questions to ask on a verification call:

- Are CPT codes 0362T, 0373T, or 99366 billable under NY Medicaid FFS — they are absent from the published fee schedule and policy manual?
- Is ABA service delivery itself (not just LBA supervision) billable via telehealth under FFS Medicaid, and if so what code/modifier applies?
- What is the correct payer ID for Change Healthcare/Availity EDI routing, since no statewide FFS entry was found in either clearinghouse's public list?
- Is there a numeric carrier-code-to-MCO crosswalk for parsing which MCO a Medicaid member is enrolled in from the 271 response, or does it always return the MCO name as free text?
- What granularity does eligibility span cover on a 271 check — is it strictly the current calendar month, and how are the EB06 time-period-qualifier codes (26/27/29/34) defined?
- Which STC/service-type-code bucket does eMedNY return ABA benefit information under?
- Is there any defined cap period for 97151/97152/97153/97155/97156/97157, given no hour cap is published?

### VOB data sources

- https://www.emedny.org/hipaa/5010/transactions/eMedNY_Transaction_Information_CAQH-CORE_CG_X12_version_5010.pdf (accessed 2026-07-23)
- https://www.emedny.org/ProviderManuals/5010/MEVS/MEVS_DVS_Provider_Manual_(5010).pdf (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/06/pVeify-Payer-List-June-26.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.emedny.org/ProviderManuals/ABA/PDFS/ABA_Policy.pdf (accessed 2026-07-23)
- https://web.archive.org/web/20251031063334if_/https://www.health.ny.gov/health_care/medicaid/program/update/2025/no08_2025-08.htm (accessed 2026-07-23)
- https://www.emedny.org/ProviderManuals/ABA/PDFS/ABA_Fee_Schedule.xls (accessed 2026-07-23)
- https://acuity.news/regulation/new-york-medicaid-aba-reimbursement-rate-reduction-2026/ (accessed 2026-07-23)
- https://www.emedny.org/contacts/emedny.aspx (accessed 2026-07-23)
- https://www.emedny.org/ (accessed 2026-07-23)

## Common questions

### Does New York Medicaid require prior authorization for ABA?

At the fee-for-service layer, no — the current FFS policy manual contains no PA requirement; the gate is a practitioner referral valid up to 2 years. But most children are in Medicaid Managed Care, and every major MMC plan does require prior authorization under its own process.

### Who qualifies for ABA under NY Medicaid?

Members under 21 with ASD as defined by DSM-5 and/or Rett syndrome, referred by a NYS-licensed, Medicaid-enrolled physician, psychologist, psychiatric NP, pediatric NP, or PA. Adults 21+ and non-ASD/Rett diagnoses are not covered.

### What does NY Medicaid pay for ABA?

A single statewide rate per code: $19.26 per 15-minute unit for 97151/97155/97156, and $14.45 for technician-delivered 97153 as of April 1, 2026 — after a phased 25% cut from $19.26. MMC plans negotiate their own rates.

### Can a BCBA bill NY Medicaid for ABA?

Not on the BCBA credential alone — New York requires NYSED licensure as a Licensed Behavior Analyst (LBA) to enroll and bill. CBAAs enroll as non-billing providers under a supervising LBA.

## Primary sources

1. [eMedNY ABA Provider Policy Manual (updated Oct 1, 2025)](https://www.emedny.org/ProviderManuals/ABA/PDFS/ABA_Policy.pdf)
2. [NYS Medicaid ABA Fee Schedule (effective April 1, 2026)](https://www.emedny.org/ProviderManuals/ABA/PDFS/ABA_Fee_Schedule.xls)
3. [NYS Medicaid Update, August 2025 (Vol 41 No 8)](https://health.ny.gov/health_care/medicaid/program/update/2025/no08_2025-08.htm)
4. [eMedNY — Managed Care Information plan directory (v2026-2, 4/1/2026)](https://www.emedny.org/providermanuals/allproviders/pdfs/information_for_all_providers_managed_care_information.pdf)
5. [Acuity News — NY Medicaid ABA rates 2026 (secondary; cross-checked against primary sources)](https://acuity.news/regulation/new-york-medicaid-aba-reimbursement-rate-reduction-2026/)
6. [NYSED Office of the Professions — LBA License Requirements (Section 8804, Subpart 79-17)](https://www.op.nysed.gov/professions/licensed-behavior-analysts/licensecertification-requirements)
7. [NYSED Office of the Professions — CBAA FAQs](https://www.op.nysed.gov/professions/certified-behavior-analyst-assistants/faqs)
8. [BACB RBT Handbook (June 2026 update)](https://www.bacb.com/rbt-handbook)
9. [eMedNY Provider Enrollment — federal application fee](https://www.emedny.org/info/providerenrollment/ffs.aspx)
10. [NYS Justice Center — Pre-Employment Checks](https://www.justicecenter.ny.gov/pre-employment-checks)
11. [OMIG — Medicaid Exclusions](https://omig.ny.gov/medicaid-fraud/medicaid-exclusions)
12. [Optum NY Medicaid ABA Provider Orientation (2025)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/nyaba/NYabaPres.pdf)
13. [Healthfirst — ABA supervision requirements](https://hfproviders.org/resource-posts/applied-behavior-analysis-supervision-requirements)
14. [Cerebral Palsy Associations of NYS — NY SFY 2027 Final Budget Highlights (secondary budget summary, unconfirmed against primary bill text)](https://cpstate.org/new-york-state-fiscal-year-2027-final-budget-highlights/)
15. [MHANYS — Report on the 2026-27 Budget Related to Behavioral Health (secondary budget summary, unconfirmed against primary bill text)](https://mhanys.org/mh_update/report-on-the-2026-27-budget-related-to-behavioral-health/)
16. [NYS DOH Medicaid Managed Care Enrollment Report, July 2026](https://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/2026/docs/en07_26.pdf)
17. [NYSED — LBA/CBAA assessment and treatment plans](https://www.op.nysed.gov/professions/licensed-behavior-analysts/professional-practice/assessment-and-treatment-plans)
18. [NYS Medicaid Update, May 2026 (Vol 42 No 6) — Prior Approval Changes Effective January 1, 2027](https://www.health.ny.gov/health_care/medicaid/program/update/2026/no06_2026-05.htm)
19. [NYS Medicaid Managed Care Model Contract (March 1, 2019), Appendix F §3](https://www.health.ny.gov/health_care/managed_care/docs/medicaid_managed_care_fhp_hiv-snp_model_contract.pdf)
20. [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)
21. [eMedNY Information for All Providers — General Policy (Version 2022-2)](https://www.emedny.org/ProviderManuals/AllProviders/PDFS/Information_for_All_Providers-General_Policy.pdf)
22. [eMedNY Information for All Providers — General Billing (Version 2025-1)](https://www.emedny.org/ProviderManuals/AllProviders/PDFS/Information_for_All_Providers-General_Billing.pdf)

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.