NC Medicaid ABA Policy Update 2026: Key Changes for ABA Providers

Veronica Cruz
Jul 15
6 min read

Updated: Jul 29

If you bill ABA services for NC Medicaid beneficiaries, Policy 8F has just moved again. The state released a revised draft during a 10-day additional public comment period, with several changes worth understanding now, before they hit your billing team's workflow. None of this is final yet.

Here's what actually changed, what didn't, and what's just a paperwork fix dressed up to look bigger than it is.

What Changed in the Revised NC Medicaid ABA Policy

The most important updates for ABA providers include:

The proposed restriction on out-of-state rendering providers was removed from the revised draft.
Telehealth may account for up to 50% of eligible CPT 97155 services for a beneficiary.
CARS2-ST and CARS2-HF were added as accepted autism diagnostic tools.
Treatment plans involving more than 16 hours per week may require reauthorization every 90 days rather than monthly.
Treatment plans now carry more detailed requirements for staffing, caregiver involvement, service schedules, titration, crisis planning, and medical necessity.
Documentation requirements are becoming more specific, particularly for session notes, caregiver training, supervision, and concurrent billing.

Download the official revised PDF

Change 1: Existing Out-of-State Providers Can Continue Serving NC Medicaid Members

One of the biggest concerns in the original draft is gone.

The earlier proposal would have stopped Medicaid reimbursement for services from clinicians located more than 40 miles outside North Carolina. That rule is gone from the revised policy.

For practices already serving NC Medicaid members from neighboring states like Virginia or South Carolina, this is welcome news. Existing care arrangements won't get interrupted just because the provider is based outside the state.

Don't confuse this with enrollment rules. Session Law 2026-1 still bars new out-of-state BCBAs and QASP Supervisors from enrolling as NC Medicaid providers. Providers can review the NC Medicaid provider enrollment requirements before applying or updating their enrollment status.

What this means for providers: Current cross-state arrangements can continue, but there's still no new pathway for out-of-state providers to enroll.

Where to find it in the policy

Section 4.2.2 (Medicaid Additional Criteria Not Covered) - This is the main section. The old language restricting out-of-state providers beyond 40 miles is replaced with "None Apply."

Related Clinical Coverage Policies (top of document) - The cross-reference to CCP 2A-3 (Out-of-State Services) still appears. The general NC Medicaid OOS policy still governs how out-of-state services work at the program level. CCP-8F just no longer stacks its own restriction on top of that.

Section 8.0 (Policy Implementation and History) - The change log entry for Section 4.2.2 confirms the OOS restriction was added in the previous revision and is now being reversed.

Change 2: Telehealth Supervision Aligns With State Law

The revised draft updates the telehealth supervision limit for CPT 97155 to 50%.

It looks like North Carolina expanded telehealth flexibility. It didn't. The policy is just catching up to Session Law 2026-1, which already set that limit.

The earlier draft listed a 20% cap, which didn't match the law. The revision fixes that inconsistency.

For ABA providers, the expectation stays the same: telehealth supervision can't exceed 50% of a beneficiary's LQASP-delivered 97155 services, unless future guidance says otherwise.

What this means for billing teams: Check that your authorization tracking and telehealth reports reflect the 50% threshold, not the earlier 20% figure.

Where to find it in the policy

Attachment A, Section C (Telehealth Billable Services with GT Modifier) - The core change. The 97155 line now reads 50% instead of the previous 20%. Clinical justification is still required in the Treatment Plan if telehealth exceeds that threshold.

Attachment A, Section C (CPT Code Table) - The table for 97155 shows "Yes" under the telehealth column. The asterisk routes to the 50% cap.

Section 1.0 (Description, item c.1) - Confirms telehealth is accepted for observation and direction (which is what 97155 covers), referencing subsection 3.1.1.

Section 3.1.1 (Telehealth Services) - General telehealth requirements. All telehealth services must follow CCP 1-H.

Section 5.3.3.4 (Treatment Intensity, item e) - Requires clinical justification for telehealth use in the Treatment Plan. This connects to the Attachment A requirement for justification above 50%.

Section 5.3.4 (Treatment Plan Reviews and Updates) - References Session Law 2026-1 directly. Same law that set the 50% threshold.

Change 3: CARS-2 Is Now Officially Recognized

The revised policy now lists the diagnostic tools that can support a comprehensive autism diagnosis: ADOS-2, BOSA, TAP, CARS2-ST, and CARS2-HF.

The previous draft just said, "a scientifically validated diagnostic tool," leaving room for interpretation during medical reviews.

Naming CARS-2 directly gives providers and reviewers clearer guidance and should cut down on unnecessary questions during prior authorization. That's especially helpful since CARS-2 is more accessible and takes fewer resources to administer than ADOS-2, while still being well-established.

Where to find it in the policy

Section 3.2.4 (Non-Provisional Diagnosis) - Names the four approved diagnostic tools: ADOS-2, BOSA, Tele-ASD-Peds (TAP), and CARS-2 (CARS2-ST and CARS2-HF). Also specifies who can make a non-provisional diagnosis.

Section 3.2.4 (Licensed School Psychologist language) - Same section. School psychologist evaluations that include the required testing can count toward CCP diagnostic criteria if there's no clinical reason to repeat testing.

Section 3.2.1 (Specific Criteria Covered by Medicaid) - Requires diagnosis using "a scientifically validated diagnostic tool, or tools." Adds that RB-BHT services cannot be initiated based solely on screening tools, educational determinations, or informal clinical impressions.

Section 3.2.3 (Provisional Diagnosis) - Provisional diagnoses don't require the named tools from 3.2.4, but the beneficiary must complete a full diagnosis within six months.

Section 1.1 (Definitions, Provisional Diagnosis) - Updated to say "observation of symptoms in combination with caregiver concern" instead of the previous "parent report" language.

Section 5.3.1 (Assessment and Treatment Plan) - Lists treatment planning assessment tools (VB-MAPP, ABLLS-R, ESDM Curriculum Checklist). Separate from diagnostic tools, but all assessment results must inform Treatment Plan development. Providers can substitute alternative tools with clinical justification.

Section 5.5.1 (Contents of a Service Note) - New enforcement language. Providers must verify and maintain diagnostic documentation before initiating services. Services without adequate documentation may face denial, recoupment, or termination.

Change 4: Longer Authorization Periods, But Clinical Reviews Still Matter

Treatment plans over 16 hours of ABA per week now get a 90-day authorization period instead of a monthly renewal. That should ease the administrative load on billing and authorization teams.

But monthly clinical responsibilities haven't disappeared. Higher-intensity treatment plans still need regular review and updates to show continued medical necessity, with progress data and documentation kept current throughout the authorization period.

What this means for practices: Fewer authorization requests, but documentation still needs to stay current. That's still the best way to avoid delays or denials during utilization review.

Where to find it in the policy

Section 5.1 (Prior Approval, Initial Authorization) - The core change.

Two tiers: plans at 16 hours or fewer get up to 180 calendar days. Plans over 16 hours get up to 90 calendar days.

Section 5.1 (Reauthorization) - Timelines match the initial tiers. Reauthorization must be submitted before the current authorization expires.

Section 5.3.4 (Treatment Plan Reviews and Updates) - Monthly clinical review requirement, separate from the authorization cycle. Plans over 16 hours must be reviewed and modified at least monthly per Session Law 2026-1. Two timelines running in parallel: 90-day auth period, monthly clinical reviews.

Section 5.3.3.5 (Service Schedule) - Plans over 16 hours per week must include a full-service schedule covering all Medicaid and non-Medicaid services the beneficiary receives.

Section 5.3.3 (Treatment Plan, items b and c) - Plans cannot include default recommended service hours. Providers cannot require a minimum number of hours to access treatment unless clinically necessary. The 16-hour line is a billing/authorization divider, not a clinical recommendation floor.

Section 5.2.2 (Specific Prior Approval Requirements) - Authorization goes through the PIHP health plan for beneficiaries 3 and older, or the PIHP/State vendor for under 3.

Attachment A, Section C (Prior Approval/Authorization) - 97151 and 97152 don't require a service order or Treatment Plan for prior approval. Service orders are required before services begin under 97153, 97155, 97156, and 97157.

Attachment A, Section C (Service Hour Ratios) - The LQASP-to-paraprofessional ratio (10%-20%) is measured over each six-month authorization period, which could span multiple 90-day auth cycles for plans over 16 hours/week.

Does the Policy Update Change North Carolina Medicaid ABA Rates

The revised Policy 8F primarily addresses coverage, authorization, provider roles, telehealth, documentation, treatment planning, and billing rules. It is not itself a complete ABA reimbursement-rate announcement.

North Carolina previously increased rates for Research-Based Intensive Behavioral Health Treatment as part of broader behavioral health reimbursement changes. The state also uses rate floors for certain managed-care services, although contracted payment can depend on the applicable plan and provider agreement.

Providers should confirm current rates through the official NC Medicaid fee schedule and covered-code portal before relying on a third-party reimbursement table.

A correct CPT rate does not guarantee payment. The claim can still deny when: