MetroPlusHealth, the NYC Health + Hospitals plan, carries the NY Medicaid ABA carve-in with two plan-specific wrinkles worth designing intake around. First, the mechanics: ABA authorization requests and clinical information go to MetroPlus by fax or email, and its 2026 BH/HCBS PA Request Guide now also lists the provider portal. Second, the diagnosis paperwork: MetroPlus Medicaid requires an autism or Rett diagnosis by a NYS-qualified provider, the comprehensive autism evaluation that preceded it, and a PCP Medicaid referral updated every two years. Its December 2022 ABA notice also says LBAs “do not meet the practitioner level to authenticate and validate an autism disorder diagnosis” and that the diagnosis must be validated every year — but that rule sits under the notice’s Qualified Health Plan heading (federal risk-adjustment validation for marketplace members), not its Medicaid section.
For Medicaid members MetroPlus runs the state’s paperwork, in its own words (June 2026 provider manual): “Must have an autism or Rett’s diagnosis, made by a NYS qualified health care provider (including psychiatrists, developmental/behavioral pediatricians, and clinical psychologists)”; “Must provide a diagnostic comprehensive autism evaluation that preceded the diagnosis, performed by a NYS licensed clinician,” conducted per the NYS DOH clinical practice guideline; and “Obtain a Medicaid referral from PCP (updated every two years).” The annual rule people quote from MetroPlus’s December 2022 ABA notice is a different line of business: under the heading “Qualified Health Plan,” the notice explains that federal risk-adjustment data validation treats autism as a lifelong permanent condition that “must be validated and authenticated each benefit year” by “a physician, nurse practitioner, licensed clinical social worker, Ph.D. or Psy.D. psychologist,” that “Licensed Behavioral Analysts do not meet the practitioner level to authenticate and validate an autism disorder diagnosis,” and that ABA providers should coordinate with the treatment team so the diagnosis is “authenticated and validated annually.” Build that yearly task into intake for MetroPlus marketplace (QHP) members; for Medicaid members the 2-year referral is the clock.[1][10][5]
Per the plan's 2023 benefit notice, authorization requests and supporting clinical information go to MetroPlus CSS by email or fax. The 2026 BH/HCBS Provider PA Request Guide (v1.3, posted September 2026) adds the provider portal: ABA requests go by fax to 212-908-5182, by email to MetroPlusABA@Metroplus.org, or through providers.metroplus.org. If you use email or fax, keep a submission template and confirm receipt. Assessment-PA specifics, authorization periods, hour caps, and rates aren't published in the materials we could verify; confirm current requirements with CSS or via the metroplus.org provider portal per case. The footprint is NYC-only, and the clinical baseline is the state's: under 21, ASD/Rett, practitioner referral.[1][3][12]
What a reauthorization must show. MetroPlus publishes no reauthorization packet or progress-data rule of its own in the documents we checked, so the state’s floor is the reference: the eMedNY ABA manual requires the treatment plan to be updated “at least every 6 months or as needed” with “updated goals and data,” each goal carrying “baseline data reported in objective terms” and “current data expressed by the same data collection method as the baseline data so that progress can be measured.” The state does not require graphs; ask the plan whether it wants graphed data before the first concurrent review.[1][3][12]
MetroPlusHealth sets its own filing limit in its provider agreement and manual; New York law sets the floor. Ins. Law § 3224-a, which covers New York insurers, Article 43 corporations and Article 44 HMOs, requires claims to be submitted within 120 days of the date of service unless the contract is more favorable to the provider — and for Medicaid managed care contracts lets the parties agree on a different period "but in no event less than ninety days." Undisputed claims must be paid within 30 days of receipt when submitted electronically and 45 days on paper, with interest at the greater of the corporate-tax rate or 12% per annum when paid late.[13][14][4][5][6][3]
Electronic Visit Verification does not reach ABA: the Department of Health’s EVV list for fee-for-service and managed care Medicaid covers personal care and home health care codes (CDPAP, home care, HCBS habilitation and respite) and no ABA code (97151–97158).[13][14][4][5][6][3]
For Medicaid managed care specifically, the state’s model contract adds a payment rule: the plan “shall make payments to Participating Providers and to Non-Participating Providers, as applicable, for items and services covered under this Agreement on a timely basis, consistent with the claims payment procedures described in SIL § 3224-a,” and must comply with 42 CFR 447.45(d)(5) and (6).[13][14][4][5][6][3]
Code set: MetroPlus publishes no ABA code list of its own in the documents we checked (its June 2026 provider manual and its 2023 ABA notice), so the state’s applies: New York Medicaid’s ABA fee schedule (effective October 1, 2026) and the eMedNY manual’s billing table carry only CPT 97151–97158 — no 0362T or 0373T and no HCPCS H-code (H0031, H0032, H2019, H2014). Bill ABA on the CPT codes; confirm the plan’s fee schedule before billing anything else.[13][14][4][5][6][3]
The questions that decide whether a family can start with MetroPlusHealth (NY Medicaid), and what they have to bring. Each maps onto something intake should ask on the first call.
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. MetroPlus publishes no age rule of its own; its footprint, not its age rule, is the plan-specific limit — New York City only.[3][1]
Follows the state for Medicaid. MetroPlus’s June 2026 provider manual lists “Obtain a Medicaid referral from PCP (updated every two years)” alongside a diagnosis by a NYS-qualified provider and “a diagnostic comprehensive autism evaluation that preceded the diagnosis” — the same 2-year referral clock as the eMedNY manual (“Referrals for ABA services are valid for no more than two years”). The annual rule in MetroPlus’s December 2022 ABA notice — that the diagnosis be “authenticated and validated annually” — sits under its “Qualified Health Plan” heading and rests on federal risk-adjustment validation of lifelong conditions “each benefit year,” so it governs MetroPlus marketplace members, not Medicaid.[5][10][3]
Follows the New York Medicaid rule. MetroPlus’s manual requires “an autism or Rett’s diagnosis, made by a NYS qualified health care provider (including psychiatrists, developmental/behavioral pediatricians, and clinical psychologists)” and “a diagnostic comprehensive autism evaluation that preceded the diagnosis, performed by a NYS licensed clinician,” plus the PCP Medicaid referral. For MetroPlus Qualified Health Plan members its 2022 ABA notice adds the annual validation, which must come from “a physician, nurse practitioner, licensed clinical social worker, Ph.D. or Psy.D. psychologist” — “Licensed Behavioral Analysts do not meet the practitioner level to authenticate and validate an autism disorder diagnosis.”[5][10][3]
No instrument is named. MetroPlus requires “a diagnostic comprehensive autism evaluation that preceded the diagnosis, performed by a NYS licensed clinician,” conducted as outlined in the NYS DOH clinical practice guideline, but does not specify which instruments must sit inside it; the state baseline requires only the DSM-5 Diagnostic Checklist with the referral and the standardized assessment used, identified as appropriate.[1][3]
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. MetroPlus’s own mechanics are old-school: authorization requests and supporting clinical information go to MetroPlus CSS by email or fax rather than through a portal workflow, so build a submission template and a delivery-confirmation habit. Assessment-PA specifics and authorization periods are not published.[3][1]
Ask the plan: MetroPlus CSS, or the metroplus.org provider portal, for assessment-PA specifics and authorization periods.
The NYS Medicaid Telehealth Policy Manual (Version 2026-V2, July 2026) applies to services delivered “under contracted Medicaid Managed Care (MMC) Plans,” lists “Providers licensed or certified by the New York State Education Department (NYSED) to provide Applied Behavioral Analysis (ABA) therapy” among telehealth providers, and requires that “Providers must meet all elements of the procedure code via telehealth.” Its managed-care section says plans “are required to cover, at a minimum, services that are covered by NYS Medicaid FFS and included in the MMC benefit package… and must provide telehealth coverage as described in this guidance,” must “ensure claims allow the use of the telehealth modifiers in this guidance” and “may establish additional claiming requirements.” Billing baseline: modifier 95 or GT for audio-video; place of service 02 (not the home), 10 (the member’s home) or 11 where the in-person visit would be POS 11; payment parity with in-person until April 1, 2028. A code defined as face-to-face with the patient (97152, 97153) qualifies only if every element can be met by video. The state ABA manual separately allows LBA supervision of technicians by synchronous audio-video, but the two monthly supervision contacts must be real time and never by phone, email or text. MetroPlus publishes no ABA telehealth rule of its own: its June 2026 provider manual points providers to the Department of Health’s post-emergency telehealth guidance for billing and criteria, and its 2023 ABA notice says nothing about remote delivery. So the state rule above is the MetroPlus rule. Neither the state manuals nor the plan say whether the authorization itself must flag telehealth — state the delivery mode in the treatment plan and ask at authorization.[7][3][5][1]
MetroPlusHealth’s June 2026 manual tightened every Medicaid clock: a standard prior authorization is decided “within three (3) business days of the receipt of all necessary information, but no later than seven (7) days after the request is received”; a fast-track (urgent) request “within seventy-two (72) hours from the date that the request is received”; a continuing-care (concurrent) request within one business day of all necessary information, again no later than 7 days (72 hours if fast-track). Extensions shrank too: timeframes “may be extended seven (7) calendar days” at the member’s or provider’s request or when the plan needs information (the March 2025 manual allowed 14). ABA requests go to metroplusaba@metroplus.org or fax 212-908-5182. No ABA reauth lead time is published for Medicaid.[5][2]
MetroPlusHealth’s June 2026 manual publishes no coordination-of-benefits procedure of its own (its only primary-insurer language covers no-fault and workers’ compensation denials), so the state rule governs. 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”; under the state contract, when other coverage is known the plan must “alert the provider and ask them to bill the TPHI that should be primary to the Plan.” In practice: bill the commercial plan first, then MetroPlus with the primary’s EOB. Whether MetroPlus still requires its own ABA authorization when it is secondary is not published — ask Provider Services (800-303-9629).[15][4][5]
Coverage decides whether MetroPlusHealth (NY Medicaid) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
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.” MetroPlus publishes no supervision ratio of its own; its plan-specific credential rule runs in the other direction, holding that LBAs do not meet the practitioner level to authenticate or validate the autism diagnosis.[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.” MetroPlus publishes no additional session-note signature rule; the annual diagnosis validation in its 2022 ABA notice applies to its Qualified Health Plan members, not Medicaid.[3][1]
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 MetroPlus-specific setting rule was located; the footprint is the plan-specific constraint — New York City only.[3]
Ask the plan: MetroPlus CSS for any plan-specific setting restriction.
Not published. The 2023 benefit notice is a process document, not a reimbursement policy, and the state manual is silent on 97153 with 97155.[1][3]
Ask the plan: MetroPlus CSS or provider services via the metroplus.org provider authorization page.
Not published — MetroPlus states no authorization periods, unit ceilings or hour caps in the materials that could be verified. Treat the authorized units as the ceiling and get the authorization period in writing with each approval, and track email or fax submissions yourself. Per-day claim edits: the federal Medicaid NCCI medically unlikely edits (October–December 2026: 97153 – 32 units a day, 97155 – 24, 97151 – 32, 97152/97156/97157/97158 – 16, 97154 – 18) are mandatory for fee-for-service claims, but CMS calls applying them to managed-care claims “desirable but optional,” and MetroPlus does not say whether it applies them — treat the authorized units as the ceiling and ask the plan about any per-day edit.[8][9][1][2]
Ask the plan: MetroPlus CSS or the metroplus.org provider authorization page — confirm authorization period, unit limits and rates per case.
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. MetroPlus states no managed-care claim convention of its own in the materials that could be verified, and the state manual directs MMC providers to their plan for billing guidance.[3][1]
Ask the plan: MetroPlus CSS or provider services — confirm the rendering/supervising NPI convention before billing CBAA- or technician-delivered units.
Yes — it carries the NY Medicaid ABA carve-in for NYC members under 21 with ASD/Rett, with authorization requests and clinical information submitted by fax (212-908-5182), email (MetroPlusABA@Metroplus.org) or the provider portal, per its 2026 BH/HCBS PA Request Guide.
For Medicaid members, on the state schedule: a PCP Medicaid referral updated every two years, backed by the comprehensive autism evaluation behind the diagnosis. The annual validation MetroPlus describes, by a physician, NP, LCSW or psychologist and never the LBA, is for its Qualified Health Plan (marketplace) members.
No — it's the NYC Health + Hospitals plan, with a New York City-only footprint.
Six at a time. New York Medicaid, which applies the rule to fee-for-service and managed care alike, says an LBA "can supervise no more than six CBAAs/unlicensed individuals at a time," must supervise each for at least 5% of their monthly service hours, and must hold at least two face-to-face real-time contacts a month, observing service delivery in one. In New York the supervisor must be a NYSED-licensed behavior analyst; BCBA certification alone is not a license.
Your contract sets it, but New York Ins. Law § 3224-a bars a Medicaid managed care contract from setting less than 90 days from the date of service (120 days is the default without a contract term). Clean electronic claims must be paid within 30 days, paper within 45.
Not on anything MetroPlus publishes. It posts no ABA code list of its own, and the New York Medicaid ABA fee schedule it builds on lists only CPT 97151–97158, with no H-codes and no 0362T/0373T. Bill ABA on the CPT codes.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 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.
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