NC Medicaid has posted a revised Policy 8F draft with post-comment changes marked in green, even as a July budget deal softens the reauthorization rule it contains.
Key Takeaways
- A second look at a contested rewrite. NC Medicaid has posted a revised draft of Clinical Coverage Policy 8F, the rulebook for research-based behavioral health treatment (ABA) for autism, opening a short additional comment period with new changes highlighted in green. The revisions follow an initial round of public feedback that ran through mid-June.
- A statutory clock. The window is ten days rather than the customary fifteen, a length the state reserves for policies compelled by an act of the General Assembly. That framing ties Policy 8F directly to House Bill 696, the Medicaid law Governor Josh Stein signed on April 30.
- The numbers driving it. State and federal Medicaid spending on ABA in North Carolina rose from 1.9 million dollars in 2020 to roughly 505 million in the fiscal year that ended in 2025, with the Department projecting a figure above 1 billion next year. Officials say utilization has outrun the growth in autism diagnoses.
- Why the draft may already be dated. A July budget deal eased the law’s monthly reauthorization requirement to once a quarter, and the Department has said a further-revised policy will post in the coming days. Readers should treat the current draft as a moving target: Acuity will monitor the comment period and update this piece as the picture settles.
North Carolina has reopened the rewrite of its autism coverage rules for a brief second round of public comment, a procedural step that says as much about the speed of the state’s Medicaid overhaul as about its substance. NC Medicaid has posted a revised draft of Clinical Coverage Policy 8F, the policy that governs research-based behavioral health treatment for autism spectrum disorder, the category that covers applied behavior analysis. The document marks its new material in green, so that anyone who submitted feedback during the first comment period can see precisely what the state changed in response. The additional window is short by design, and the shortness is itself a signal.
What the Revised Policy 8F Draft Changes for ABA Providers
The draft is dense, but it pulls in one direction. It tightens documentation, limits who may deliver care and from where, and hands the state more control over how much therapy a child receives. Services would not be covered when rendered by out-of-state providers located more than 40 miles beyond North Carolina’s borders. Behavior technicians would have to hold either Registered Behavior Technician certification from the Behavior Analyst Certification Board or the Applied Behavior Analysis Technician credential from the Qualified Applied Behavior Analysis Credentialing Board, obtained within 120 days of hire. At least 10 percent of the services a paraprofessional delivers would have to be observed and directed by a licensed qualified autism service provider, and for beneficiaries receiving more than 200 hours in a six-month span, the ratio of licensed to paraprofessional time would sit between 10 and 20 percent.
Other provisions push toward individualized planning. Treatment plans could not carry default recommended service hours or apply uniform minimum thresholds across children regardless of clinical need. The list of covered modalities is broadened beyond ABA to name approaches such as the Early Start Denver Model, the PLAY Project, Pivotal Response Training, JASPER, Enhanced Milieu Teaching, and the TEACCH program. Non-provisional diagnoses would have to rest on validated tools, among them the ADOS-2 and the second edition of the Childhood Autism Rating Scale. Authorization periods would run to 180 days for plans of 16 hours or fewer per week and 90 days for plans above that threshold.
Why North Carolina’s Policy 8F Comment Window Is Only Ten Days
The length of the comment period is doing real work. Under North Carolina’s own process for proposed Medicaid policies, the standard cycle is a 45-day initial comment period followed by a 15-day additional period when a policy is modified. Those windows collapse to 30 and 10 days in one specific circumstance: when the change is necessitated by an act of the General Assembly or a shift in federal law. The current draft carries a ten-day additional period, which places it squarely in that category. In other words, 8F is not being revised at the Department’s discretion. It is being conformed to statute.
The statute is House Bill 696, the Medicaid funding law that Governor Josh Stein signed on April 30 and that carries the most detailed set of ABA requirements the state has ever put into law. It arrived after a run of numbers that alarmed lawmakers. By the Department’s accounting, state and federal Medicaid spending on ABA in North Carolina climbed from 1.9 million dollars in 2020 to roughly 505 million in the fiscal year that ended in 2025, with a projection above 1 billion next year, a rise that the Department’s Secretary, Devdutta Sangvai, told legislators far outpaced the growth in autism diagnoses and could not be explained by expanded access alone. The state auditor has opened a review, and the attorney general, Jeff Jackson, said in April that his office is investigating. Acuity has covered the funding fight and the contours of the oversight framework in its earlier reporting on the HB 696 rate restoration.
Telehealth Limits, an Out-of-State BCBA Ban, and a Workforce Cliff
Two provisions worry providers more than any documentation change. The first is telehealth. House Bill 696 caps remote supervision at no more than 50 percent of the time a technician spends with a patient; the draft policy tightens that further, to 20 percent. The second is geography. The law bars behavior analysts who live outside North Carolina from enrolling as out-of-state Medicaid providers, and pairs it with the 40-mile border rule. The imbalance is hard to miss. State licensure records show 4,010 people certified as behavior analysts to practice in North Carolina, of whom only 1,917 actually live in the state, with just 355 based in the four bordering states of South Carolina, Tennessee, Georgia, and Virginia. With the changes set to take effect on August 1 and no transition period built in, providers warn that practices cannot recruit and train replacements fast enough to avoid gaps in care.
And here the ground is still shifting under the draft itself. House Bill 696 had called for reauthorizations every month for any child receiving more than 16 hours of therapy per week, a requirement providers argued was unworkable given that a single reauthorization can run to 50 pages and take weeks to assemble. A state budget approved in early July and signed by the Governor on July 7 softened that to once a quarter. The Department has said the policy has been revised to reflect the recent changes and will be posted in the coming days, which means the monthly-reauthorization language still visible in the current draft is already out of step with the law it is meant to implement.
That churn is exactly why some in the field counsel patience. Greg Nersessian, president of the Medicaid rate service MediRate, suggested it may be wise to wait until this second comment period closes, so that whatever emerges from it can be captured in one place rather than chased across successive drafts. It is sensible advice for a policy still in motion. We are publishing now because the direction is clear and the August 1 effective date is close, but the details are not yet fixed. Acuity will monitor the comment period and the promised revision, and will update this piece as the final policy takes shape.
