The Trump administration wants state Medicaid programs to implement guardrails for autism therapy providers amid concerns about skyrocketing costs and questionable practices in the field.
The Centers for Medicare and Medicaid Services issued a 173-page toolkit early this month spelling out a series of recommendations for states as they consider policy changes related to coverage of applied behavior analysis services.
The document advises states to limit use of telehealth and reconsider how many hours of therapy are warranted each week and how much consecutive therapy can be billed without giving children a break, among other suggestions.
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CMS issued the toolkit in response to soaring Medicaid and Children’s Health Insurance Program spending on ABA services. Between 2021 and 2025, data shows that ABA expenditures increased 421% across the programs even as the number of children with autism receiving services grew by just 67%.
Meanwhile, a series of government audits found nearly $200 million in improper Medicaid payments for ABA services across four states — Indiana, Colorado, Wisconsin and Maine. Investigators cited evidence that therapy was provided by staff lacking appropriate credentials, services were given to children without required evaluations or referrals and providers billed for ABA while children were napping, eating lunch and doing other nontherapeutic activities.
Together, the findings are fueling concerns that some providers are prioritizing profit over care.
“We are helping states shut down fraud schemes that exploit children with autism and misuse funds from American taxpayers,” Secretary of Health and Human Services Robert F. Kennedy, Jr., said. “This toolkit gives states practical tools that may be used to identify bad actors, protect families and hold providers accountable.”
The toolkit notes that the intensity of ABA for children with autism can vary from five to 40 hours per week depending on individual need. However, it cautions that higher levels of treatment do not correlate with better outcomes.
“Forty hours of ABA per week is not a best practice because it places states and managed care plans at risk of negative audit findings or other financial review penalties because children must be allowed time for activities of daily living such as toileting, napping, and eating, among others,” the document states. “Best practice is that states set a policy that prohibits more than a specified number of consecutive units to be delivered without a break.”
Aubyn Stahmer, executive director of the MIND Institute at the University of California, Davis, recently served on a National Academies of Sciences, Engineering, and Medicine committee evaluating ABA benefits provided by Tricare, the military’s health care program. That committee determined that while lower intensity programs of 10 to 12 hours per week can produce positive outcomes, a higher intensity of services — often 15 to 20 hours per week — and duration does produce significantly stronger positive outcomes.
“The concern from payers is that agencies will request 30 to 40 hours a week of services routinely rather than individualizing to the child’s needs,” Stahmer said. “It is unlikely that most kids need this many (hours) of intervention. However, determining the right amount is really a judgement.”
Stahmer said that many well-intentioned features of the guidance could pose practical issues. In particular, barring providers from billing during lunch breaks could make it hard to provide continuity of care. Similarly, requiring a comprehensive diagnostic assessment could delay needed services for children facing long waits for diagnoses.
The recommendations hold significant weight, Stahmer said, with private insurers likely to adopt many changes Medicaid recommends.
Individualized treatment plans should be reevaluated and updated based on outcomes, the toolkit said. In addition, CMS noted that ABA is not the only treatment option and other approaches like occupational therapy can be beneficial.
States should also take steps to identify providers who are billing for the maximum number of hours for 80% or more of their clients, excessively using telehealth and exhibiting other red flags. In addition, the toolkit indicates that states should monitor provider ownership changes given the large number owned by private equity-backed chains.
CMS said that the toolkit does not establish new federal requirements or reduce obligations to children with autism under what’s known as Early and Periodic Screening, Diagnosis and Treatment program, or EPSDT, a menu of services that all states must provide to Medicaid beneficiaries under age 21.
David Sitcovsky, vice president of advocacy at Autism Speaks, acknowledged that steps are needed to address wrongdoing in the field, but said that shouldn’t mean limiting needed care.
“Fraud and improper billing in autism services hurt the children and families who depend on them, and we want bad actors held accountable and care held to a high standard,” he said. “We would urge caution, however, in how growth in these services is interpreted. Some of it reflects genuine progress: in recent years, states have addressed longstanding barriers involving professional licensing, reimbursement rates and provider enrollment that had kept families from finding ABA providers who accept Medicaid. More children receiving care that was once out of reach is not in itself a red flag; it is a sign that access is improving.”
Likewise, Lori Unumb, CEO of the Council of Autism Service Providers, said that treatment decisions should be made between parents and providers.
“Parents, researchers, clinicians, and policymakers agree that ABA can make a positive difference in the lives of children with autism, and this evidence-based therapy is deserving of continued Medicaid coverage,” she said. “We look forward to working with CMS and the states to refine, clarify, and build out this guidance so that children get the care they need and stakeholders are assured of accountability and compliance with the law.”
