The Department of Health and Human Services secured a national behavioral health pledge in July from the country's largest health plans, provider groups and medical societies. Signatories committed to delivering timely, evidence-based care that integrates mental and physical health, with measurement and accountability for treatment outcomes.
Last month, the Centers for Medicare and Medicaid Services released a 173-page toolkit establishing guidelines for Applied Behavior Analysis, a one-to-one therapy for autism that focuses on enhancing children's skills and behavior. Federal officials are trying to rein in rapidly escalating costs while ensuring quality.
Medicaid and CHIP spending on ABA surged 421 percent between 2021 and 2025, far outpacing the 67 percent growth in children receiving these services. The annual cost reached $10.1 billion by 2025—a dramatic increase driven by a reimbursement model that incentivizes high-volume service delivery. Some ABA providers routinely default to 40 hours of therapy a week for every child, a practice the CMS toolkit explicitly states is not best practice.
The CMS guidelines require state Medicaid agencies to implement stronger quality controls, including confirmed diagnoses from qualified medical practitioners before ABA treatment begins. They also mandate individualized treatment plans and closer oversight of billing to prevent fraud.
Dr. Suzanne Goh, a pediatric neurologist and board-certified behavior analyst at Cortica, called the combined pledge and toolkit a promising step toward fraud protections and quality oversight in ABA. But she warned of a dangerous pitfall: states responding to rising costs by imposing blunt instruments like rigid hourly caps and onerous prior authorization processes that delay or deny necessary care.
Nebraska's Medicaid agency has already imposed a 30-hour-a-week cap on ABA services. Indiana placed a 4,000-hour lifetime cap. Nebraska also cut reimbursement rates drastically in 2025, with some ABA services seeing reductions as high as 79 percent.
Those lower rates directly translate to lower wages for behavior technicians who deliver direct ABA services. The work is physically and emotionally demanding, hours are unpredictable, and low pay contributes to nearly 100 percent annual turnover industry-wide. High turnover undermines the continuity of care crucial for autistic children and their families.
Goh also warned that some ABA providers may respond to new requirements by seeking ways to meet payer demands with minimal investment of resources, potentially compromising care quality.
She advocates for reforming autism care by mandating outcomes-based reimbursements and interdisciplinary teams rather than focusing solely on hourly ABA billing. She emphasizes that the skills supporting independence in adulthood begin developing in childhood. Her work also highlights the importance of Augmentative and Alternative Communication systems for the approximately 25 percent of autistic children who are nonverbal or minimally verbal.
Goh calls for systemic changes in employment, education, healthcare and public perception to better support autistic adults. The federal actions by HHS and CMS represent a step toward redefining how the country approaches autism care, but implementation will determine whether the reforms improve outcomes or simply shift cost pressures to the states and providers.
