Nebraska Medicaid covers ABA for members under 21 through EPSDT, under a pair of Medicaid Service Definitions (MSDs) effective February 7, 2025 — and delivers it entirely through Heritage Health managed care, so every authorization runs through one of three MCOs: Nebraska Total Care, Molina, or UnitedHealthcare Community Plan (with ABA managed by Optum). Two things make Nebraska unusual. First, an autism diagnosis is not strictly required — a developmental or intellectual disability qualifies when the ABA assessment establishes need. Second, in August 2025 DHHS cut ABA rates roughly 28–79% by code after program spend exploded from $4.6M to $85M+ in four years, making Nebraska one of the lowest-paying ABA states in the country. Both facts should shape how a practice runs intake here.
Admission requires a diagnosis of ASD or a developmental or intellectual disability — plus significant functional impairment in at least two listed domains — when the need for ABA is established by the ABA behavior identification assessment. That makes Nebraska one of the states where intake should not turn away a family without an autism diagnosis: ask about developmental and intellectual disability diagnoses too. The gate that does apply universally is the Initial Diagnostic Interview: an IDI by a licensed clinician, completed within the previous 12 months, must establish the need for the ABA assessment (with an IDI addendum if the clinical presentation has changed). One additional carve-out worth knowing: DD-waiver recipients may receive ABA assessments (97151/97152) regardless of age, and even for non-ABA purposes — effective 7/1/2026, per DHHS Provider Bulletin 26-06, which directly confirms this rule (previously sourced here only by inference).[7][8][6]
Effective August 1, 2025, DHHS cut ABA reimbursement dramatically — roughly 28–79% by code per CASP's estimate — after program spend grew from $4.6M in 2020 to more than $85M in 2024, a >2,000% increase DHHS cites on its own ABA Facts page. The current schedule per 15-minute unit: 97151 assessment $38.16, 97153 direct treatment $18.70, 97155 protocol modification $22.72, 97156 family training $26.06 (also 97152 $25.88, 97154 $7.49, 97158 $12.05). Rates are credential-flat — no BCBA-versus-technician tier for the same code — and telehealth (modifier 95, POS 02/10) is allowed for 97151, 97155, and 97156 only. The cuts triggered a legislative interim study, a State Auditor attestation report, and the near-exit of the state's largest provider — but they remain fully in force: the SFY27 fee schedule effective July 1, 2026 carries the same numbers. DHHS also directs the Heritage Health MCOs to track this fee schedule (HPA 25-08), so there is no MCO rate refuge. For practices, Nebraska Medicaid volume is a margin question to model deliberately, not an afterthought.[9][12][11][10]
Prior authorization runs through the member's MCO. The treatment MSD requires the ABA assessment and treatment plan to be submitted with the initial prior authorization request, and Provider Bulletin 25-02 clarifies that PA duration is "based on medical necessity and therefore is variable in duration" — no fixed statewide authorization period. Separately from whatever the MCO authorizes, the treatment plan itself must be reviewed and updated at least every 90 days.[7][5][6][11]
On weekly intensity, the rule is now settled: the current ABA treatment MSD (the July 2026 edition) caps direct service at "6 hours in a single day or a total of 20 hours per week," with "Additional daily or weekly treatment hours" available only on clinical justification submitted for prior authorization. There is no 30-hour alternative anywhere in it. DHHS Provider Bulletin 26-06 (dated June 1, 2026, signed by DHHS Director Drew Gonshorowski) is what put that edition in force: it announces that "The 2026 updates to the Applied Behavior Analysis (ABA) Medicaid Service Definitions" are "effective July 1, 2026," after a provider-feedback period. The older 30-hour figure came from Provider Bulletin 25-02 (January 31, 2025), which described the original definitions as allowing "Up to 30 hours per week"; the July 2026 definitions replaced that. DHHS's public "Applied Behavior Analysis Facts" page has not caught up and still reads "Hours of service up to 30 hours per week" (re-checked September 27, 2026). Plan requests against the MSD's 20-hour text, and expect hours beyond 6/day or 20/week to require clinical justification through PA.[7][5][6][11]
Since January 1, 2025, every BCBA serving Nebraska Medicaid must hold a Nebraska Licensed Behavior Analyst (LBA) license (BCaBAs a LaBA license); an LBA may supervise at most 24 technicians, must directly observe at least 10% of weekly direct-service hours, and must personally deliver at least 1 hour per month of in-person direct service. Caregiver participation is a tracked compliance item: 1 hour per month when services run 10 or fewer hours/month, otherwise a 2–4 hour monthly minimum, with teachers countable for at most 25% of caregiver-training hours — services won't be denied solely for non-participation, but it factors into continued-stay review. Continued-stay progress must be demonstrated with Vineland-3, VB-MAPP, or ABLLS (the preferred tools), and discharge triggers include no progress over two consecutive authorization periods or more than 6 months without demonstrated progress. Also excluded from coverage: two concurrent LBAs (unless justified), shadow/aide services in schools, ABA concurrent with ST/OT/PT sessions, naps and recreation time, and services delivered by a legally responsible person. School-based ABA bills through the Medicaid school-based services program (471 NAC 25), not independent providers — confirmed directly by DHHS Provider Bulletin 26-06.[7][5][6]
At the technician level, Nebraska is now a pure-BACB state. Under the treatment MSD, the only staff who may deliver 97153/97154 under a licensed clinician are RBTs with current BACB certification or Licensed assistant Behavior Analysts (LaBAs) — and PB 25-02 dropped the state's longstanding bachelor's-degree-plus-experience requirement for RBTs, leaving BACB certification plus individual Nebraska Medicaid enrollment (RBT is its own provider type, 85, on the fee schedule) as the whole state requirement. There is no state technician registry and no training hours beyond the BACB floor — which itself requires each RBT applicant to pass both a criminal background check and an abuse-registry check within 180 days of applying, attested by a certificant.[7][5][13][14][15][16][17][18][19][20]
Nebraska's enrollment screening is lighter on ABA than agencies often assume. Provider types are risk-tiered per 42 CFR 455: BCBA (type 83) screens at Moderate risk (federal database checks plus unannounced site visits), while BCaBA (84) and RBT (85) screen at Limited — no fingerprint-based criminal background check at enrollment unless a trigger (payment suspension for a credible fraud allegation, a $1,500+ overpayment, an exclusion within 10 years) escalates the provider to High risk. The registry checks that trip up multi-line agencies bind elsewhere: the annual Child/Adult Abuse and Neglect Central Registry, Sex Offender Registry, and NDEN checks attach to individual HCBS (waiver/PAS) and NEMT providers, not ABA provider types 83–85 — so for a standard ABA practice, abuse-registry screening reaches staff through the BACB's own 180-day check rather than a state mandate. Two caveats: DHHS states that enrolled providers "should also be screening their employees based on the services they provide," and an agency that also delivers waiver service lines inherits the HCBS checks for those staff.[7][5][13][14][15][16][17][18][19][20]
Supervision is where the staffing math binds. Since January 1, 2025, every Medicaid-serving BCBA must hold a Nebraska LBA license and every BCaBA a LaBA license under the Behavior Analyst Practice Act (Neb. Rev. Stat. §§ 38-4401 to 38-4414, with BACB certification as the licensure floor) — note the practice-act regulations (172 NAC 10) were still in draft on the DHHS licensure page, so confirm current application mechanics with the Licensure Unit. The MSD's floors: direct observation of each technician for no less than 10% of weekly direct-service hours, documented in progress notes (PB 25-02 and DHHS's Facts page describe the requirement as 10–20%, but the July 2026 MSD states a flat floor of "no less than 10%" — that is the binding number, and staffing above it is margin, not compliance), at least 1 hour per month of in-person observation of each technician or LaBA, and no more than 24 technicians per LBA. Plan-level extras: since January 1, 2025 all three Heritage Health MCOs run credentialing through a single CVO, Verisys; Nebraska Total Care adds a credentialing application (or CAQH authorization), malpractice face sheet, five-year work history, cultural-competency training evidence, and re-credentialing at least every 36 months; and Optum (UHC's ABA network) layers staff-level rules on groups — supervising BCBAs with BACB supervisory certification, RBT (or equivalent national) certification for technicians, and $1M/$3M professional liability coverage.[7][5][13][14][15][16][17][18][19][20]
Nebraska publishes no rule on whether an MCO authorization follows the child to a new agency; that is a question for the member's Heritage Health plan. What the state does set is the handoff from the agency the family leaves. The ABA service definition makes discharge planning "an ongoing process that occurs through the duration of service," and "A copy of the discharge plan must be given to the individual and to providers at the individual's next level of care, as applicable." The Medicaid requirements document for ABA adds a discharge summary, signed and dated by the supervising clinician, that must be "provided within the time frame specified in the program's policies and procedures which considers the prompt transfer of clinical records and information to ensure continuity of care," and must document the reasons for discharge and referral information.[7][13]
For fee-for-service claims, the Nebraska Medicaid Provider Manual (§ 5.1.1): "all claims must be submitted within six months from the date of service"; adjustments must arrive within 90 days of the original claim’s payment or denial date (§ 5.2.1). For members in a Heritage Health MCO, § 5.3 sends providers to that MCO’s own manual and billing guidance, so the MCO’s filing limit governs those claims.[1][2][23]
Federal rules bind Nebraska Medicaid’s own fee-for-service payments: the agency "must pay 90 percent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within 30 days of the date of receipt" and 99 percent within 90 days, with the date of receipt being the agency’s date stamp and the date of payment the date of the check or other payment (42 CFR 447.45(d)(2), (3), (5), (6)). The same rule makes 12 months from the date of service the outer limit any state may allow for filing (42 CFR 447.45(d)(1)). Managed care plans are held to the same 90/99 percent clean-claim standard through their state contracts (42 CFR 447.46).[1][2][23]
Nebraska's rule is conditional. The provider manual (republished October 9, 2026) says "All claims to Nebraska Medicaid for payment for items and services that are ordered, rendered, or referred must contain the National Provider Identifier (NPI) of the physician or other professional who ordered, rendered, provided, or referred each item or service," and "Providers must be enrolled in Medicaid for the service provided, ordered, referred to, or rendered to be covered."[23][7][25]
The ABA service definitions require no physician order or referral. The gate is the Initial Diagnostic Interview plus the ABA assessment and treatment plan. So there is no separate ABA referral to report. If a clinician did refer or order the service, report that clinician's NPI, and make sure they are enrolled with Nebraska Medicaid. Each Heritage Health plan runs its own claim edits: Nebraska Total Care's billing guide requires field 17 only for PT/OT/ST, DME and hearing-aid claims.[23][7][25]
Nebraska sets a monthly floor, which is rare among state Medicaid programs. The July 1, 2026 ABA service definition requires providers to "Ensure family participation. For individuals receiving 10 hours or less per month of ABA services, 1 hour per month is required. For individuals receiving more than 10 hours per month of ABA services, 2-4 hours per month at minimum is required. Inability to meet this requirement must be documented and will be considered on a case-by-case basis." Continued-stay criteria repeat it: "Caregivers are participating in treatment a minimum of 2-4 hours per month."[7]
Providers must also include family-involvement goals in the treatment plan, document the family's agreement to participate, assess and plan for barriers, and offer weekend and evening availability. Teachers can count as caregivers, but teacher training "may not account for more than 25% of required parent or caregiver training hours," and IEP meetings neither bill nor count. ABA "will not be denied solely on the basis of lack of parent or caregiver involvement," but involvement is weighed at reauthorization.[7]
The questions that decide whether a family can start with Nebraska Medicaid (Heritage Health), and what they have to bring. Each maps onto something intake should ask on the first call.
The service definitions put it in one line: "Age: 0-20" — the ABA treatment definition and the Behavior Identification Assessment definition carry the identical admission bound, which is the EPSDT under-21 benefit expressed as an age range. One carve-out runs straight past it: individuals receiving waiver services from the Division of Developmental Disabilities "may receive Applied Behavior Analysis Assessments (HCPCS codes 97151 and 97152), regardless of age," and for waiver recipients only the ABA assessment "may be recommended and used for non-ABA related purposes."[7][8]
Twelve months, measured on the Initial Diagnostic Interview rather than on the autism diagnosis. An "Initial Diagnostic Interview (IDI) must be completed, if one has not been completed within the previous 12 months of admission to the service," and it "must establish the need for an Applied Behavior Analysis Behavior Identification Assessment (ABA assessment) and outline the needed services and resources for the individual to make progress toward desired behavior changes." The refresh rule is narrower than a re-diagnosis: where the clinical presentation has changed significantly inside those twelve months, "a licensed clinician who is able to diagnose and treat major mental illness within their professional competencies, must review the IDI to determine if the diagnosis and treatment, recovery, and rehabilitation plan are still applicable," and any new information is documented as an IDI addendum reflecting current functional status. So an older autism report does not block a family — a stale IDI does.[7][8]
The IDI definition names the list, and it is a mental-health list rather than a developmental-pediatrics one. The IDI is performed by "A licensed practitioner who is able to diagnose and treat major mental illness within his/her scope of practice": Physician, Physician Assistant, APRN/NP, Psychologist, or LIMHP. It must carry a DSM (current version) diagnosis with recommendations for active treatment interventions, a comprehensive mental status exam, history and symptomatology consistent with DSM criteria, psychiatric treatment history, risk assessment, medical history and current medications. Nebraska's qualifying diagnosis is also wider than autism: ASD or a developmental or intellectual disability admits, when the ABA assessment establishes the need — so intake should not screen out a family for lacking an autism label.[21][7]
No ASD diagnostic instrument is required — neither ADOS-2 nor ADI-R appears anywhere in the Nebraska definitions. The instruments Nebraska names are functional, and they sit inside the ABA assessment and the treatment plan rather than behind the diagnosis. The ABA assessment must include "Skills-based assessments" and "Standardized/norm-referenced or criterion-referenced assessments," plus preference assessments to identify reinforcers and risk assessments where behaviors are challenging, and its report must explain "data collection methodology including use of validated rating scales and tools." The treatment plan must carry "baseline and ongoing measurement of skills, when applicable, using norm-referenced / standardized assessment tools, for example Vineland, VB-MAPP, ABLLS" — and continued stay names Vineland-3, VB-MAPP and ABLLS as the preferred tools for demonstrating progress.[8][7]
No physician referral and no order is a condition of the benefit. The gate is the IDI plus the ABA assessment: the IDI "must establish the need" for the ABA Behavior Identification Assessment, the assessment "must be completed prior to the initiation of ABA treatment interventions," and both plus the Individualized Treatment, Rehabilitation, and Recovery Plan are submitted with the initial prior-authorization request to the member's Heritage Health MCO. What the MSD does require in the other direction is outbound referral: the ABA provider "must consult with, or refer, the individual to other health care providers for suspected or diagnosed comorbid medical, psychiatric, and psychological needs as needed." Plan-level policies can and do add a recommendation requirement on top — check the MCO.[7][8]
Three codes, and the conditions are spelled out per code. 97155 with protocol modification "may be completed via audiovisual telehealth" only if "The individual is receiving 97153 services concurrently," the environment has been assessed as safe, caregivers have technology and a secure internet connection, the technology lets the supervisor see the session and give real-time feedback, the behavior "is not so severe as to need more than 1:1 support," technology-related distractions are planned for, and documentation justifies telehealth as "necessary and formative for the ABA treatment, and not solely for the convenience of the provider or the caregiver." 97156 carries the same list with active caregiver participation in place of the concurrent 97153. On the assessment side, 97151 may be delivered by audiovisual telehealth if caregivers are on-site and the child has "the basic prerequisite skills needed to attend the telehealth evaluation, such as the ability to sit independently at a computer or tablet for 8-10 minutes." Flatly excluded: "Other ABA treatment services (CPT 97153, 97154, 97158) cannot be provided via telehealth," and 97152 "cannot be completed via telehealth." The billing allowances themselves live on the Medicaid Mental Health and Substance Use fee schedule, where ABA telehealth rides modifier 95 with POS 02/10.[7][8][9]
Nebraska runs every ABA authorization through the member's Heritage Health MCO, and DHHS publishes no timeframe of its own. Its provider manual points to each MCO for "coverage and authorization processes." The federal managed-care floor therefore governs. Standard decisions are due "within state established time frames that may not exceed 7 calendar days after receiving the request for service" for rating periods starting on or after January 1, 2026; Heritage Health rates are certified by calendar year, so this applies to 2026. Expedited decisions are due "no later than 72 hours after receipt of the request for service." Either clock can be extended up to 14 more calendar days at the family's or provider's request, or when the plan justifies needing more information. The 2025–2026 quality review reports that DHHS's MCO contracts still said 14 days and recommends updating them to seven. The three plans' 2026 manuals are not aligned: Nebraska Total Care and UnitedHealthcare Community Plan publish 7 calendar days, Molina still publishes 14. No statewide reauthorization lead time is published. The treatment plan must still be reviewed at least every 90 days.[26][23][27][28]
Ask the plan: The member's MCO for its current turnaround and any reauthorization lead time: Nebraska Total Care 1-844-385-2192, Molina 1-844-782-2678, UnitedHealthcare Community Plan / Optum 1-866-331-2243.
Medicaid pays last, and Nebraska enforces it at the claim. "All third party resources available to a Medicaid client must be utilized for all or part of their medical costs before Medicaid. … Medicaid is the payor of last resort." Bill the child's commercial plan first. When it pays part or denies, send its EOB or valid denial with the Medicaid claim: "The dates of service on the third party documentation must match the dates of service on each claim." A Medicaid prior auth does not skip that step: "The provider must resolve all third party resources before Nebraska Medicaid can consider paying a claim regardless of whether Medicaid prior authorization has been given." File with Medicaid within 12 months of service even while the other plan is unresolved. "Waiver claims" are the only listed pay-first exception, and Nebraska publishes no pediatric-preventive pay-and-chase carve-out for ABA. You may not turn a family away because another payer might be liable. TRICARE pays before Medicaid, because its double-coverage rule excludes Medicaid. Whether the MCO also wants its own ABA prior auth when it is the secondary payer is not written in the state rules.[29][23][30]
Ask the plan: The member's MCO utilization-management line, to confirm whether it requires its own ABA prior authorization when a commercial plan is primary. None of the three plans' manuals says.
Coverage decides whether Nebraska Medicaid (Heritage Health) 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.
Nebraska sets a percentage, a monthly floor, a caseload cap and a corrective-action duty. "Direct supervision by observation of the technician must occur no less than 10% of direct service hours (97153/97154/97155) provided in a week. Supervision must be documented in progress notes. Failure to meet 10% of direct service hours must be documented, including the reason that the supervision did not take place and a corrective action plan." Note the base: the 10% is measured against 97153, 97154 and 97155 hours together, weekly — not against 97153 alone. Layered on top: "The supervisor must provide direct supervision by observation of the technician or LaBA in person for at least one hour per month," and "The treating LBA or psychologist must provide at least one hour of in-person, direct services to the individual receiving services at least monthly." An LBA "may not supervise more than 24 technicians." LaBA work runs under an LBA; RBT work under an LBA or a psychologist with ABA training; provisionally licensed psychologists under a licensed psychologist with ABA training.[7]
Per day and per week, not per code. "Direct ABA service hours provided to the individual may not exceed 6 hours in a single day or a total of 20 hours per week," with "Additional daily or weekly treatment hours … requested in certain clinical circumstances for which clinical justification must be submitted for prior authorization and be approved." Two more numbers are published as staffing ratios rather than ceilings: 97151, 97153 and 97155 run 1:1, 97154 runs one technician to 2-5 children, 97158 one licensed clinician to 2-5, and 97156 one clinician to one family. Read the weekly figure alongside its neighbors rather than alone, because three different documents carry three different weekly numbers for three different things: the treatment MSD's 20 hours per week is the Medicaid rule; Neb. Rev. Stat. § 44-7,106 caps behavioral health treatment including ABA at 25 hours per week for state-regulated commercial plans, a different program entirely; and DHHS's public "Applied Behavior Analysis Facts" summary page still describes the policy as allowing up to 30 hours per week. Quote the one that matches the member's coverage, and do not treat the other two as contradicting it. Underneath the program rule sit federal claim edits, which are a different thing from the authorization: section 6507 of the Affordable Care Act requires state Medicaid programs to apply CMS’s Medicaid NCCI methodologies, including medically unlikely edits (MUEs), to fee-for-service claims (a state may ask CMS to deactivate an individual edit; for managed care plans it is optional). CMS’s published Medicaid MUE table for practitioner services, dates of service October 1 – December 31, 2026, sets the per-provider, per-member, per-day values at 97151 32 units, 97152 16, 97153 32, 97154 18, 97155 24, 97156 16, 97157 16, 97158 16, 0362T 16 and 0373T 32. Nebraska’s own documents publish no per-code MUE table, so a fee-for-service day above those values is an MUE problem, and anything above the weekly hours is an authorization problem.[3][4][7][22][11]
Nebraska says what a progress note must contain, sets the deadline by reference, and never names a session-note signer. Progress notes "must be completed within the time frame specified in the program's policies and procedures" and must substantiate each service through narrative description, "Include an accurate start and end time for the service," tie the service to plan goals and priorities, document participation and revision of goals, and record the individual's response "in the individual's own words if possible, if age and developmentally appropriate." Signatures attach to the other documents: the treatment plan must "Be approved and signed by the licensed clinician or supervisor if provisionally licensed" and carry the individual's or guardian's signature (a parent or guardian where the individual is under 19); the ABA assessment report "must be signed by the licensed clinicians who participated in the development of the report, including the supervising practitioner, when applicable"; and the discharge summary must "contain the signature of the supervising clinician and date of signature." Supervision itself must be documented in progress notes.[13][8][7]
Community, home, office or clinic — and school is not yours to bill. The treatment MSD lists the allowable settings as "Community, Home, Office or Clinic," then carves the school out entirely: "ABA services are covered as part of the Medicaid school-based services program, and are the responsibility of the school as outlined in Nebraska Administrative Code Title 471, Chapter 25 and the Medicaid State Plan. Independent providers may not bill Medicaid directly for services provided at a school." The assessment MSD keeps School on its settings list under the same carve-out. Where ABA does run in an educational setting, "A school plan is required for all educational settings, to include both public and private schools" (not daycare or after-school), it must be included in the student's IEP, it must focus on reducing behaviors that impede academic engagement rather than on general skill acquisition, and it must be time-limited with a transition plan shifting instructional control to school staff. Excluded outright: "Services delivered in the school setting as a shadow, or an aide, or to provide general support to the child or youth," and training for school personnel. Group homes are not addressed.[7][8]
Nebraska controls this through code-level provider eligibility rather than a modifier set. Licensed clinicians who may bill 97151 — and who render 97155, 97156 and 97158 — are a psychiatrist, physician, psychologist or provisionally licensed psychologist, each with training in ABA, or a Licensed Behavior Analyst. Technicians who may bill 97152, 97153 and 97154 under a licensed clinician's supervision are a Licensed assistant Behavior Analyst or a Registered Behavior Technician. Since January 1, 2025 every BCBA must be licensed as an LBA and every BCaBA as a LaBA, so the state license rather than the BACB certificate is what makes the claim payable, and RBT is enrolled as its own Medicaid provider type (85) on the fee schedule. Which NPI carries the claim line is not stated.[7][8]
Ask the plan: The member's Heritage Health MCO for the rendering-provider field on ABA claims — the service definitions specify who may render each code, not which NPI goes in which claim field.
Not stated in billing terms, though the definitions read as if it happens. The telehealth rule allows 97155 by audiovisual telehealth only where "The individual is receiving 97153 services concurrently," and the supervision percentage is measured against "direct service hours (97153/97154/97155)" as a single weekly pool — both of which presume the analyst and the technician on the clock at the same time. But neither MSD says in terms that both codes may be billed for the same clock time. What Nebraska does prohibit by name is a different concurrency: "Services delivered concurrently (at the same time) as another treatment modality (i.e. ST, OT, PT)," and "Services delivered by 2 LBAs unless non-duplicative and clinically appropriate."[7]
Ask the plan: The member's Heritage Health MCO — Nebraska Total Care, Molina, or UnitedHealthcare Community Plan (Optum). Ask specifically whether 97155 pays alongside 97153 for the same clock time.
Yes — for members under 21 through EPSDT, administered entirely by the three Heritage Health MCOs under the state's ABA Medicaid Service Definitions (effective February 2025). Prior authorization runs through the member's MCO.
No — admission criteria accept ASD or a developmental or intellectual disability, when the ABA assessment establishes treatment need and there's significant functional impairment in at least two domains. An Initial Diagnostic Interview within the previous 12 months must establish the need.
Per 15-minute unit, effective August 1, 2025: 97151 $38.16, 97153 $18.70, 97155 $22.72, 97156 $26.06 — a roughly 28–79% cut by code from prior rates, still in force in the SFY27 fee schedule. Rates are credential-flat, and MCOs are directed to track the state schedule.
Up to 6 hours a day and 20 hours a week of direct ABA. The ABA treatment service definition in force since July 1, 2026 says direct service hours "may not exceed 6 hours in a single day or a total of 20 hours per week," and more can be requested with clinical justification through prior authorization. DHHS's public "Applied Behavior Analysis Facts" page still says "up to 30 hours per week" — that summary predates the July 2026 update and is out of date; the service definition is the rule.
The state does not say whether the MCO authorization transfers, so ask the member's Heritage Health plan. The agency the family leaves must give the family and the next provider a copy of the discharge plan, and complete a signed discharge summary on a timeline that allows prompt transfer of clinical records.
Six months from the date of service for fee-for-service claims. Heritage Health MCO claims follow the MCO’s own limit (Nebraska Total Care, for example, allows 180 days).
Only when the service was actually ordered or referred: claims must carry the NPI of whoever "ordered, rendered, provided, or referred" the service, and that clinician must be enrolled with Medicaid. The ABA service definitions require no order, so a referring provider is not a standing ABA claim requirement. Check your MCO's claim edits.
A minimum: 1 hour a month when the child receives 10 or fewer ABA hours a month, and 2–4 hours a month above that (ABA service definition, July 1, 2026). Shortfalls must be documented and are judged case by case.
No. The ABA service definition excludes "Services delivered concurrently (at the same time) as another treatment modality (i.e. ST, OT, PT)." Schedule ABA around the other therapies, and document how ABA fits around them: the treatment plan must justify hours against the child's availability "given other commitments (i.e. school, other therapies, family engagements)."
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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