Molina Healthcare of New York — the plan formerly branded Affinity, including the TotalCare ("TONY") plan code — reviews ABA itself. Its notice adding ABA to the managed-care benefit names four codes that need prior authorization before services are rendered (97151, 97152, 97153, 97155), and Molina has administered all behavioral health for its Mainstream, HARP and Child Health Plus members in-house since January 1, 2022, when Beacon Health Options stopped managing it. September 15, 2026 changed the review itself: Molina replaced MCG criteria with its own clinical policy, MCP 482, and moved ABA to a weekly approved-unit billing structure. One nuance worth knowing at intake: "Affinity" isn't purely legacy branding — Molina still markets a co-branded "Affinity by Molina Healthcare" Medicaid Managed Care product in the New York metropolitan area, so a family naming "Affinity" may be describing a current product rather than an outdated card.
Two Molina bulletins dated July 14, 2026 changed ABA for New York members from September 15, 2026. First, Molina Clinical Policy MCP 482 (Applied Behavioral Analysis for Autism Spectrum Disorder, approved June 10, 2026) became the review standard. Molina's FAQ says MCG criteria will no longer be used, "there are no fixed limits" on hours, and determinations rest on "detailed and individualized clinical documentation, functional assessments, and treatment plan detail." What MCP 482 asks for: a comprehensive diagnostic assessment using at least one validated tool (ADI-R, ADOS-2, CARS-2 or DISCO); adaptive and functional assessments such as the Vineland or ABAS to set a baseline; updated documentation of current symptoms if the standardized diagnostic assessment is more than 24 months old; documentation from the primary care physician of the initial developmental concerns; documented parent or caregiver participation; a treatment plan developed by a BCBA or BCBA-D with measurable goals; and reassessment at least every 6 months. Requests above 25 direct hours a week need extra documentation, a defined treatment period and a tapering plan. Telehealth is limited to caregiver training, coaching, supervision and other indirect components, inside a hybrid plan with in-person services.[3][4][2][5][9]
Two parts of MCP 482 sit awkwardly with the New York Medicaid benefit, which covers members under 21 with ASD and/or Rett syndrome and sets no minimum age. MCP 482 lists "ASD initiation age is 18 months or older" as a diagnostic component, and calls ABA not medically necessary for any indication except diagnosed ASD, "including, but not limited to, Rett syndrome and Down syndrome in the absence of ASD." Molina's own bulletin says New York "may have additional regulatory or contractual requirements that supplement this policy." For a child under 18 months or a Rett-only diagnosis, get Molina's answer in writing before assuming either way. Second, from the same date Molina reimburses ABA on a weekly approved-unit basis instead of a total across the authorization period: bill the units delivered each week, up to the approved weekly limit. Existing authorizations and those crossing September 15 need no action, and the covered ABA codes did not change.[3][4][2][5][9]
Molina's notice adding ABA to the Medicaid managed-care package (effective October 1, 2021) says "Prior authorization will be required for Applied Behavioral Analysis (ABA)" and lists 97151, 97152, 97153 and 97155 as codes that "will require prior authorization before the services are rendered," pointing to the Codification Matrix on Molina's website for the current list; questions go to Molina's Utilization Management department at 1-877-872-4716. Behavioral health moved in-house on January 1, 2022: Molina's December 2021 letter says Beacon Health Options would no longer manage behavioral health for Mainstream, HARP and Child Health Plus members and that utilization management, case management, appeals and claims all go to Molina. Separately, Molina ended its eviCore arrangement on September 1, 2021, but that notice covered imaging, radiation therapy and sleep services, not ABA. Instructions naming Beacon or eviCore for Molina New York ABA are stale.[1][6][7][8]
Molina's published materials still leave a few operational questions open: whether 97154, 97156, 97157 and 97158 need prior authorization (the 2021 notice names only four codes), authorization length, rates, and how Molina applies MCP 482's 18-month and Rett-syndrome language to New York members. On that last point the policy's own preamble points to the benefit: “If there is a discrepancy between this policy and a Member's plan of benefits, the benefits plan will govern,” and “coverage may be mandated by applicable legal requirements of a State” — and the New York Medicaid benefit covers ASD and/or Rett under 21 with no minimum age. How Molina applies that in a given review is still a per-case answer. Work from the state's clinical baseline (under 21, ASD/Rett, complete practitioner referral) plus the MCP 482 documentation package, submit through the current Molina portal, and confirm the rest with Molina in writing. Families transferred through the Affinity-to-Molina rebrand may also carry outdated card branding — verify plan identity on every inquiry.[8][1][2][9]
Molina Healthcare of New York 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.[15][16][11][2][12]
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).[15][16][11][2][12]
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).[15][16][11][2][12]
Code set: Molina’s national ABA clinical policy (MCP 482) lists CPT 97151–97158, 0362T and 0373T and, separately, HCPCS H0031 (“Mental health assessment, by nonphysician”) and H0032 (“Mental health service plan development by nonphysician”), with the caveat that codes are “for reference purposes only” and “listing of a service or device code in this policy does not guarantee coverage”. For a Medicaid member, the state baseline is narrower still: 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).[15][16][11][2][12]
The questions that decide whether a family can start with Molina Healthcare of New York, 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 adult pathway — the 21st birthday is a hard cliff. The state sets no minimum age, but Molina’s clinical policy MCP 482 (effective for New York September 15, 2026) lists “ASD initiation age is 18 months or older” among its diagnostic components, and Molina’s bulletin says New York rules may supplement the policy. For a child under 18 months, get Molina’s answer in writing before booking.[9][2][3]
Two clocks. The state referral is valid no more than two years, with no maximum age on the diagnostic evaluation itself. Molina adds one from September 15, 2026: under MCP 482, “If a standardized diagnostic assessment is more than 24 months old, updated documentation must describe current ASD symptoms and functional impact.” An older evaluation is not rejected, but it needs a current-symptoms update. MCP 482 also requires reassessment at least every 6 months once treatment starts.[9][2]
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 MCP 482 describes the diagnosis as made by “a multidisciplinary team with expertise in diagnosing ASD” and says evaluations are done by “a qualified provider or multidisciplinary team with ASD expertise (e.g., clinical psychologists, developmental pediatrician, pediatric neurologist, psychiatrist, or other licensed clinicians permitted under applicable state law to diagnose ASD)”; it also asks for documentation from the child’s primary care physician of the initial developmental concerns, screenings and referrals.[9][2]
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.” Molina adds named instruments from September 15, 2026: MCP 482 requires the diagnosis to use “at least ONE clinically validated tool (e.g. Autism Diagnostic Interview-Revised [ADI-R], Autism Diagnostic Observation Schedule [ADOS-2], Childhood Autism Rating Scale [CARS-2], or Diagnostic Interview for Social and Communication Disorders [DISCO])” and says screening instruments “do not independently establish” the diagnosis. It also asks for adaptive and functional assessments “(e.g., Vineland Adaptive Behavior Scales [VABS], Adaptive Behavior Assessment System [ABAS])” as a baseline, and a validated tool (e.g., ATEC, SSIS, VB-MAPP) behind the requested intensity.[9][2]
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. On top of the referral, Molina requires prior authorization before the services are rendered on 97151, 97152, 97153 and 97155, per its notice adding ABA to the managed-care package, and MCP 482 also asks for documentation from the primary care physician of the child’s initial developmental concerns, screenings and referrals. Behavioral health has been handled by Molina in-house since January 1, 2022 (Beacon Health Options before that), so route requests through Molina’s own portal or Availity.[9][1][2][6]
Limited to indirect components from September 15, 2026. MCP 482: “Telehealth is limited to caregiver training, coaching and supervision, or other indirect service components,” used “in conjunction with in-person ABA services as part of a clinically justified hybrid service model documented in the authorized ABA treatment plan,” and “not used solely for convenience, access, geographic distance, or provider preference.” The plan must also document that the member’s needs do not require in-person observation during the telehealth component. So technician-delivered 97153 by telehealth does not meet the policy. Molina publishes no ABA code list, modifier or place-of-service rule for New York; the state’s general telehealth manual (95/GT modifiers, POS 02, 10 or 11) is the billing baseline.[2][13]
“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.[17][18]
“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.[17]
Coverage decides whether Molina Healthcare of New York 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.” Molina sets no supervision ratio of its own. Its clinical policy MCP 482 (from September 15, 2026) requires a treatment plan developed by a BCBA or BCBA-D who “provides direct and consistent supervision” to BCaBAs, RBTs “or another appropriately certified behavior technician as allowed by state mandate,” and says technician-delivered services “do not reduce or replace required direct involvement of the supervising behavioral analyst.” In New York the supervising analyst must also hold the NYSED LBA license to bill.[9][2]
No per-day ceiling is published; the operative limit is the authorization’s weekly number. From September 15, 2026 Molina reimburses ABA “based on the approved number of units that may be delivered each week,” replacing a total across the authorization period: “Claims exceeding weekly limits will be denied and adjusted,” and billing above the approved frequency may be reviewed or reconciled after payment. Existing authorizations, and those crossing September 15, 2026, need no action. On hours, the MCP 482 FAQ says “There are no fixed limits”; requests above 25 direct hours a week need extra documentation, a defined treatment period, reassessment at least every 6 months and a tapering plan. Authorization length and rates are not published.[5][4][2]
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.[9][8]
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. Molina’s MCP 482 adds that the treatment plan must document “service modalities and settings (e.g. home, clinic, community)” and that interventions may not primarily address academic instruction or replace services required under an IEP; the state’s school bar remains the operative constraint.[9][2]
Not published. Molina’s New York bulletins cover PA codes, MCP 482 and weekly-unit billing rather than claim edits, and the state manual is silent on 97153 with 97155.[8][9]
Ask the plan: Molina NY provider services and the NY Medicaid bulletins index — confirm in writing before billing the overlap.
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. From September 15, 2026 each claim should carry the units delivered in that week, up to the approved weekly limit. Confirm the rendering/supervising NPI convention with Molina rather than an old provider packet.[9][1][5]
Ask the plan: Molina NY provider services — confirm the current portal/Availity route, the PA code list, and the rendering/supervising NPI convention.
Yes — it carries the NY Medicaid ABA benefit for members under 21 with ASD/Rett. Prior authorization is required before services on 97151, 97152, 97153 and 97155, and since September 15, 2026 Molina reviews requests against its own clinical policy, MCP 482, which replaced MCG criteria.
Two things. Molina Clinical Policy MCP 482 became the medical-necessity standard, with a documentation package: a diagnosis using at least one validated tool (ADI-R, ADOS-2, CARS-2 or DISCO), a Vineland or ABAS baseline, measurable goals and reassessment at least every 6 months. And billing moved to weekly approved units, so claims above the approved weekly number are denied or adjusted. Existing authorizations and those crossing September 15 were not affected.
Neither. Molina has administered all behavioral health for its Mainstream, HARP and Child Health Plus members in-house since January 1, 2022, when Beacon Health Options stopped managing it. Molina's 2021 move away from eviCore covered imaging, radiation therapy and sleep services, not ABA. Route requests through Molina's portal/Availity.
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.
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.
Molina’s national ABA policy lists H0031 and H0032 for reference, but says a listed code does not guarantee coverage, and the New York Medicaid ABA fee schedule carries only CPT 97151–97158. Bill ABA on the CPT codes and get Molina NY’s answer in writing before billing an H-code.
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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