Vermont Medicaid covers applied behavior analysis for members under 21. Its rule, HCAR 4.229, lists functional assessment, treatment plan development, direct treatment, program supervision and parent or caregiver training as covered services. The Department of Vermont Health Access (DVHA) runs the benefit directly. Vermont has no Medicaid health plans to contract with. The only managed care entity in Vermont Medicaid is PC Plus, a primary care case management program that DVHA itself administers. ABA prior authorization, enrollment and payment all go through DVHA and its fiscal agent, Gainwell.
For an agency, 2026 changed nearly everything. From January 1, DVHA banned billing 97153 and 97155 for the same time, removed telehealth from all but three codes, and dropped the team-conference codes. From July 1, a fee-for-service schedule replaced the tiered monthly case rate. From October 1, every authorization has needed a new standardized Comprehensive ABA Assessment. Vermont also licenses behavior analysts, and Medicaid pays only Vermont-licensed, Medicaid-enrolled BCBAs and BCaBAs.
HCAR 4.229 makes a member eligible for ABA if they are actively enrolled in Medicaid, under 21, carry a DSM diagnosis of autism spectrum disorder, early childhood developmental disorder or a successor diagnosis, have a prescription for ABA from a listed specialist, and are medically stable without 24-hour hospital-level monitoring. EPSDT stands behind it: HCAR 4.106 covers all medically necessary services for members under 21 "without regard to service limitations" elsewhere in the rules, with medical necessity decided case by case. The legislature has also applied the commercial mandate to Medicaid: 8 V.S.A. § 4082 "shall apply to Medicaid and any other public health care assistance program."[1][2][15][13][5][7]
Vermont has no Medicaid managed care plans to contract with. The General Provider Manual names one managed care entity, PC Plus, a primary care case management program that "DVHA administers." The ABA Supplement sends every ABA authorization and claim to DVHA and Gainwell. None of the DVHA ABA documents read (the Supplement, HCAR 4.229, the 2025 and 2026 FAQs, the coding presentation and GCR 26-058) gives an accountable care organization any role in authorizing or paying ABA. So the intake question is not "which plan" but "is Medicaid primary, or is there other insurance?"[1][2][15][13][5][7]
Assessment codes need no authorization. 97151, 97152 and 0362T are each limited to 4 hours every 6 months. Every other ABA code needs DVHA approval on the State of Vermont ABA Prior Authorization Request form, "updated and resubmitted at least every six months." Since October 1, 2026 the packet for a new member, and for each current member’s first authorization on or after 10/1/26, is: the PA form, the prescription for ABA, the current diagnostic assessment, DVHA’s standardized Comprehensive ABA Assessment form, and an ABA treatment plan. Later requests need the treatment plan, the PA form and the updated Comprehensive Assessment. The Comprehensive Assessment must be completed in full, with no references to outside documents. Sections E (developmental domains), G (current services) and H (treatment recommendations) must be updated every time. Either the prescriber or the diagnosing clinician signs it, attesting that the child would benefit from the recommended intensity. DVHA says that clinician "does not independently evaluate the child." Neither the ABA Supplement (08-04-2026) nor the August 2026 FAQ asks for graphs: the reauthorization evidence is the updated Comprehensive Assessment, the six-monthly PEAK, VB-MAPP or ESDM results and the treatment plan’s measurable goals and monthly progress notes. ABA is billed on CPT 97151–97158, 0362T and 0373T; the online fee schedule (queried October 18, 2026) returns no line for H0031, H0032 or H2019.[5][6][1][3][12]
One assessment tool is required at least every six months: PEAK, VB-MAPP or the Early Start Denver Model. Other tools can be added but not substituted. The treatment plan must have measurable goals, at least one family or caregiver goal, the list of staff and their credentials, and at least one progress note a month that reflects session duration. Prescriptions must be dated before services start. A new prescription is needed after any change in diagnosis, and for children who started before age 6, again within six months after the 6th birthday. On who may prescribe, HCAR 4.229 lists board-certified or board-eligible psychiatrists, pediatricians and neurologists, doctorate-level licensed psychologists, and developmental-behavioral or neurodevelopmental disabilities pediatricians. The Supplement’s shorter list leaves out general pediatricians, and DVHA has said that is an error it will correct to match the rule. DVHA decides medical necessity with its Medical Necessity Determination Tool, the Comprehensive Assessment score, InterQual and its own guidelines. Under HCAR 4.103 (effective January 1, 2026) it must decide a standard request within seven days and an expedited one within 72 hours, with up to 14 more days if justified.[5][6][1][3][12]
Since July 1, 2026, DVHA pays ABA fee-for-service. GCR 26-058 ended the "tiered case rate payment methodology for members with Medicaid as their primary insurance." Until then, Medicaid-only members were paid by a monthly tier keyed to hours (for 2026, from $219 for 2–5.99 hours up to $13,667 for 170 or more), and only members with other insurance were billed per unit. The current online fee schedule pays, per 15-minute unit: 97151 $65.80, 97152 $30.00, 97153 $15.00, 97154 $7.50, 97155 $49.35, 97156 and 97157 $21.39, 97158 $16.45, 0362T $52.00 and 0373T $26.00. It flags prior authorization on every code except 97151, 97152 and 0362T. DVHA told the legislature in February 2026 that it would run an ABA rate study under Act 14 before July 2026, and that "if access issues arise, rates are the appropriate remedy."[10][8][12][9][11][5]
Billing rules changed on January 1, 2026. 97153 and 97155 may not be billed for the same child at the same time; DVHA applies the AMA rule that the child’s face-to-face time is what is reported. Team-conference codes 99366 and 99368 were removed from the benefit. The HO, HN, 59, 76, 77 and group-size modifiers were retired. Modifier 95 is now used on the three telehealth codes. BCBAs (provider type T46, specialty S50) are paid the full rate on every ABA code. BCaBAs (T46/S51) may bill only 97152, 97153 and 97154, since 97151, 97155–97158, 0362T and 0373T require a qualified health professional. For 2:1 work (0362T, 0373T) the BCBA must be on site, the time counts as one member hour, and BCaBAs may not bill it. DVHA also found that ABA does not fall under the state’s supervised-billing rules.[10][8][12][9][11][5]
Vermont Medicaid pays only Vermont-licensed clinicians. HCAR 4.229.4 says BCBAs and BCaBAs "must be licensed in Vermont, working within the scope of their practice, and enrolled in Vermont Medicaid." The Supplement adds a background check for every BCBA, BCaBA and technician: a Vermont criminal record check (or an FBI check for anyone resident under five years) plus the child and adult abuse registries. Technicians need 40 hours of ABA training (at least 3 on ASD and 3 on ethics), first aid, CPR, universal precautions, HIPAA and mandated-reporter training before their first session. Unlicensed master’s-level clinicians still collecting supervised hours are treated as behavior technicians until they are licensed.[1][5][9][16][17][4][8]
Licensure itself comes from the Office of Professional Regulation under 26 V.S.A. chapter 95. A BCBA qualifies for licensure by endorsement on BACB certification. A BCBA licensed in another state who wants to treat a Vermont child only by telehealth may use the chapter 56 telehealth license (up to 20 Vermont clients over two years) or telehealth registration (up to 10 clients over 120 days). Those routes require a license from another U.S. jurisdiction, though. DVHA’s telehealth rule also requires the provider to be "enrolled in Vermont Medicaid," and Medicaid telehealth covers only 97155–97157. In practice, an out-of-state BCBA serving Medicaid members needs a Vermont license and a Vermont Medicaid enrollment.[1][5][9][16][17][4][8]
The General Billing and Forms Manual (October 2026) sets the timely filing limits. Medicaid-primary claims must be received within 180 days of the date of service. Claims where other insurance (not Medicare) is primary get 365 days. Waiting for a prior authorization "is not an acceptable reason for late filing." Telemedicine on a CMS-1500 is billed with POS 02, not modifier GT. The ABA coding update adds modifier 95 on 97155, 97156 and 97157. Vermont’s prompt-pay statute (18 V.S.A. § 9418) does not reach DVHA, which it excludes from the definition of a payer. We found no published DVHA clean-claim payment deadline for ABA. Electronic visit verification is not mentioned in the ABA Supplement or the billing manual.[14][8][19][5]
A denied or reduced authorization can be appealed internally within 60 calendar days. The appeal is decided within 30 days, or within 72 hours if it is expedited. To keep services during the appeal, the family must ask within 11 days. After the internal appeal, or if DVHA takes more than 30 days, the family can request a state fair hearing. For services to members 21 or older, a "not covered" denial can be met with an exception request.[14][8][19][5]
The questions that decide whether a family can start with Vermont Medicaid (Green Mountain Care / DVHA), and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21. HCAR 4.229.3 requires the member to "be under the age of 21"; DVHA describes the benefit as running "from birth until the age of 21 years."[1][5]
No fixed expiry. The diagnostic assessment must be completed before ABA starts, and DVHA "may request a reassessment" when more services are requested. The prescription must predate services and be renewed after any change in diagnosis and within six months after the 6th birthday for children who started earlier. The Comprehensive Assessment and a PEAK, VB-MAPP or ESDM assessment are redone at least every six months.[5][6]
The diagnostic assessment must be done "by a clinician experienced in the diagnosis and treatment of autism and working within their scope of practice." The prescription must come from a board-certified or board-eligible psychiatrist, pediatrician or neurologist, a doctorate-level licensed psychologist, or a developmental-behavioral or neurodevelopmental disabilities pediatrician (HCAR 4.229.3). Vermont law keeps diagnosis outside a behavior analyst’s scope (26 V.S.A. § 4928).[5][1][6][16]
No diagnostic instrument is named. What DVHA names is the ongoing assessment tool: PEAK, VB-MAPP or the Early Start Denver Model at least every six months (others may be added, not substituted), plus the developmental-domain scoring in Section E of the Comprehensive Assessment.[5][6]
Yes: a written prescription for ABA from a listed specialist, dated before services begin (HCAR 4.229.3(d); ABA Supplement). Vermont’s licensure law also lets a licensed behavior analyst practice only on a referral from a licensed health professional or school official (26 V.S.A. § 4928).[1][5][16]
Three codes. Since January 1, 2026, telehealth is authorized only for 97155, 97156 and 97157, with modifier 95. 0362T, 0373T, 97151, 97152, 97153, 97154 and 97158 must be delivered in person. A BCBA may supervise by telehealth only while the technician is physically with the child; direct treatment and protocol modification by the BCBA personally must be on site. The billing manual requires POS 02 on telemedicine claims.[8][5][9][14][4]
HCAR 4.103 (effective January 1, 2026): a standard decision "not more than seven days" from receipt, an expedited one "no later than 72 hours," each extendable by up to 14 days at the provider’s request or when DVHA justifies needing more information (maximum 21 and 17 days). Renewals are due at least every six months. From October 2026, DVHA staggers them to each child’s assessment and treatment-plan schedule.[3][5][6]
Medicaid pays last. Providers must "pursue and apply all third-party payment resources" first. When the primary plan denies ABA, the provider or family must exhaust every level of the primary plan’s reconsideration and appeal, then seek Department of Financial Regulation review if the service costs over $100. Only then does the request go to DVHA, with the original documentation and every denial. A denial for a non-covered service or exhausted benefit can go to DVHA without appealing. Claims with other insurance primary have 365 days for timely filing.[5][14][20]
Coverage decides whether Vermont Medicaid (Green Mountain Care / DVHA) 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.
DVHA sets no billable supervision ratio. HCAR 4.229.1 defines a BCaBA as "directly supervised by a BCBA" and a behavior technician as practicing "under close, ongoing supervision of a BCBA or BCaBA supervisor." Vermont’s licensure law requires a licensed assistant behavior analyst to have at least five hours a month of off-site case supervision (26 V.S.A. § 4929). Asked how to document supervision now that concurrent billing is barred, DVHA said that "best clinical practice and the national standard are to have 2 hours for every 10 hours of service," but that "standards and best clinical practice are different than billing."[1][16][9]
Prohibited since January 1, 2026. "97153 and 97155 are prohibited from being billed concurrently, meaning on the same day at the same time," and the rule applies to all billing including fee-for-service. Services "provided simultaneously by more than one ABA provider" are not covered unless medically necessary, prior authorized and in the approved plan. DVHA pays 2:1 (0362T/0373T) only on those terms.[8][9][5][6]
The fee schedule’s maximum-units column lists: 97151, 97152, 97156, 97157, 97158 and 0362T, 16; 97153 and 0373T, 32; 97154, 18; 97155, 24. The Supplement caps 97151, 97152 and 0362T at 4 hours every 6 months, and refers the other codes to the MUE. Total authorized units are set per six-month authorization.[12][5][6]
Every Vermont Medicaid service must be documented on the day of the encounter or within one week, with two patient identifiers, the rendering provider, and the provider’s signature, printed name and date (General Provider Manual). The ABA treatment plan must include progress notes, at least one a month, "containing detailed clinical information that reflects session duration." Claims must "reflect member time and not provider time."[13][5]
Community settings. ABA under an IEP belongs to the School-Based Services program, billed through the local education agency: "Community services are never provided in schools." HCAR 4.229.6 excludes IDEA school services paid by the Agency of Education, respite, and members in long-term out-of-home placement outside a community setting. Services must be in the least restrictive, most integrated setting.[6][1][5]
Only Vermont-licensed BCBAs and BCaBAs enroll (provider type T46, specialties S50 and S51). BCBAs are paid 100% of the rate on every ABA code; BCaBAs may bill only 97152, 97153 and 97154. DVHA ruled that ABA "doesn’t fall under supervised billing," because technician codes "inherently require supervision." The documents read do not say whose NPI goes in the rendering field for a technician’s 97153 line, so confirm that with your Gainwell provider representative.[1][8][12][5]
Every later request needs the ABA treatment plan, the State of Vermont ABA Prior Authorization Request form and the updated Comprehensive ABA Assessment. DVHA’s ABA Supplement and FAQ do not require graphs.
No. ABA is billed on CPT 97151–97158, 0362T and 0373T; the online fee schedule returns no H0031, H0032 or H2019 line.
Yes, for members from birth to 21 with autism spectrum disorder, an early childhood developmental disorder, or a successor diagnosis, and a prescription from a listed specialist (HCAR 4.229). DVHA authorizes and pays it directly.
No. Vermont has no Medicaid MCOs. Its only managed care entity is PC Plus, a primary care case management program DVHA runs. ABA prior authorization and payment go to DVHA and its fiscal agent, Gainwell, and no DVHA ABA document gives an ACO a role.
Fee-for-service since July 1, 2026, per 15-minute unit: 97151 $65.80, 97152 $30.00, 97153 $15.00, 97154 $7.50, 97155 $49.35, 97156 and 97157 $21.39, 97158 $16.45, 0362T $52.00, 0373T $26.00. The tiered monthly case rate for Medicaid-only members ended June 30, 2026.
No. 97151, 97152 and 0362T need no prior authorization, but each is limited to 4 hours every 6 months. Treatment codes need DVHA approval, renewed at least every six months.
Only with a Vermont credential and a Vermont Medicaid enrollment. HCAR 4.229 requires BCBAs and BCaBAs to be licensed in Vermont and enrolled. Vermont’s out-of-state telehealth license or registration allows telehealth only, and Medicaid pays telehealth only on 97155–97157, so a full Vermont license (available by endorsement on BCBA certification) is the practical route.
Only 97155, 97156 and 97157, with modifier 95, since January 1, 2026. Assessments and technician treatment must be in person. A BCBA can supervise remotely only while the technician is physically with the child.
No. Since January 1, 2026, DVHA prohibits billing 97153 and 97155 for the same child at the same time, under every payment method.
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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