Magellan’s Cara Albanese and CentralReach’s Yagnesh Vadgama told ABA providers what payers want now, from rate talks and denials to value-based contracts.
When Acuity Media Network asked registrants for its recent webinar about what they most wanted to understand about working with health plans, nearly half wrote back, and their answers sorted themselves into four piles with little effort.
The tallest was rates. The complaint, as Sara Gershfeld, BCBA, the Acuity Media Network representative who moderated the September 10 session, summarized it for the audience, was not simply that reimbursement is low. It was that providers without scale have almost nothing to push against when they try to change it.
The hour that followed, “Payor Relations for ABA Providers,” was co-hosted by CentralReach and paired two Board Certified Behavior Analysts who have spent much of the past decade on the payer side of autism care. Cara Albanese is the Director of Clinical Services, Autism, at Magellan Health, where she has handled utilization management reviews and autism strategy for 10 years. Yagnesh Vadgama spent 11 years in clinical practice and ten and a half in managed care, much of it at Magellan, before joining CentralReach in February as Vice President of Payor Strategy and Network Development. The conversation moved through the registrants’ themes more or less in the order they had raised them.
ABA Rate Negotiation: What Gives a Mid-Sized Provider Leverage With a Payer
Vadgama began by declining the premise that a mid-sized organization negotiates from weakness. Its size, he argued, is what lets it move quickly when a plan wants to try something new, whether an outcomes-based pilot or a push on access. The difficulty is that “health plans are not homogeneous.” One plan may care about little beyond whether members are seen promptly; another may be preoccupied with the cost of care. He recalled a plan telling him recently that ABA had become its second-largest expense.
For publicly traded payers, he suggested, the priorities are often sitting in the quarterly earnings materials. The advice is easy to test. On Centene’s second-quarter 2026 earnings call in July, Chief Executive Officer Sarah London reported a second straight quarter of year-over-year moderation in behavioral health costs, “particularly in ABA,” and credited provider education, state policy work, and fraud, waste, and abuse efforts.
A provider who has listened, Vadgama said, can answer in kind with its own figures: time to the first functional behavior assessment appointment, time from that assessment to the start of treatment, the share of authorized 97153 and 97155 hours actually delivered, and the parent training hours completed each month. Albanese added that smaller organizations often hold an advantage in clinical consistency, with tighter interobserver agreement across a team. The currency, though, has changed. Payers, she said, want “outcomes-based metrics,” not “volume-based metrics,” along with evidence of a better member experience and more predictable total costs.
ABA Outcomes Data Payers Can Compare, Not Homegrown Measures
Gershfeld named the anxiety the word tends to produce: providers hear “outcomes” and get nervous, because nearly everyone measures them differently. Albanese’s first answer was to begin with what is already in hand. “Use the data you’re already collecting and package it in a way that it is going to show those outcomes,” she said. The package has to travel, however. “We don’t want something that is uniquely homegrown and individualized to only your provider group,” she said, and validated assessments, imperfect as they are, remain the field’s most practical basis for comparison. One mistake she sees is switching instruments between authorization periods or across clients, which leaves a provider with outliers it cannot compare. Nor does a count of mastered targets move a payer much. Family functioning, school readiness, length of stay, and avoided higher levels of care do.
That position now has federal company. The State Medicaid and CHIP ABA Toolkit that CMS released on August 4 describes it as best practice for states to require at least one standardized outcome assessment instrument, and says states should not allow provider-created outcome measures. Vadgama put the underlying logic in the field’s own terms. A homegrown system is fine as far as it goes, he said. “But now you’re benchmarking yourself against who? Yourself.”
Medicaid ABA Rate Cuts Are Arriving, and No One Can Name the Floor
Gershfeld then turned to the cuts registrants had named, citing CareSource and Amerigroup. Both have reduced Medicaid ABA reimbursement in Georgia, where CareSource moved providers to 80 percent of the state fee schedule in May (and in July rescinded the reduction for some providers in areas short of therapists) and Amerigroup has since notified providers of a reduction of its own. Asked where payers locate the floor, Vadgama was frank. When he left managed care at the end of December, he said, he doubted plans would follow through on cuts, because advocacy had so often forced them to retreat. “2026 has been completely different,” he said. As for the floor itself: “I don’t know, frankly.”
The pressure is not confined to one state. New York reduced Medicaid ABA rates in two 12.5 percent steps, in October 2025 and April 2026. The CMS toolkit reports that Medicaid and CHIP payments for ABA rose from about $1.94 billion in 2021 to $10.1 billion in 2025, an increase of 421 percent, while the number of children with an autism diagnosis who received ABA grew 189 percent. Vadgama also cited Idaho as a sign that states are reconsidering how the service is delivered; the state moved Medicaid ABA out of managed care in December 2025 and reclassified it as behavioral intervention under a state-administered benefit.
Albanese offered a structural reminder that tends to get lost in provider frustration. In Medicaid, she said, “payers don’t have control over those rates,” which are set by the states. (Plans can still pay below a published schedule where their contracts allow it, which is what made the Georgia reductions possible.) That makes state hearings and legislative outreach part of the work, she said, along with demonstrating that ABA, when it is warranted, should not be swapped out for other services.
ABA Medical Necessity Denials, Short Authorizations, and OIG Audit Pressure
The second-largest group of questions concerned denials, including a pattern that a couple of enterprise organizations described of rising denials for children seeking treatment for the first time. Albanese acknowledged that a single provider may work against many sets of medical necessity criteria at once and said that practicing to the most restrictive set is usually the safest course, alongside CASP’s practice guidelines and the BACB ethics code. She urged providers to log the rationales in their denial letters rather than simply absorb them, and to bring the pattern to a contact at the plan. Short authorizations, three months where six is the usual concurrent period, generally mean the record is not supporting medical necessity, she said, or that a member’s condition calls for closer monitoring.
Vadgama widened the frame to the federal audits and the CMS toolkit. Payers, he said, now operate on the assumption that “if there’s smoke, there’s fire,” and the field as a whole is experiencing “guilt by association.” The audits give that phrase its texture. In Colorado, the HHS Office of Inspector General found that all 100 sampled enrollee-months included at least one improper or potentially improper claim line, and recommended a $42.6 million federal refund, following similar findings in Indiana, Wisconsin, and Maine. His diagnosis was fragmentation. Over ten and a half years overseeing utilization management, he said, he saw treatment requests with “zero overlap” from one to the next, and that absence of consensus on assessment and dosage feeds uncertainty all the way up to CMS.
How ABA Providers Reach the Decision Maker Inside a Health Plan
One registrant asked how to get past a call center “in some faraway land.” Vadgama, who has worked in ABA for 23 years, admitted that he is “still struggling with it.” Authority might rest with a Chief Financial Officer, a Chief Actuary, a Chief Medical Officer, or the ABA review team, depending on the plan. His answer was collective: if a quarter or half of a network adopts the same assessments, “there’s strength in numbers,” and the plan has reason to listen.
Albanese recommended starting with the utilization management team, which can route a provider to the right person, and then building the relationship from there. Customer service, she observed, is not going to transfer anyone to the Chief Financial Officer. Gershfeld added two tactics of her own: a direct LinkedIn message to someone at the plan, and, for Medicaid, an in-person visit to the state agency. She recalled touring the Texas Medicaid offices with a client simply to learn how the department worked.
How Close ABA Value-Based Care Contracts Really Are
On timing, the panelists sounded more optimistic than many providers might expect. Albanese said value-based arrangements will “start happening in the next 12 to 18 months,” after interest stalled during the audit findings, and that Medicaid plans are now part of those conversations. Providers should arrive with benchmarks and roughly 12 months of data, she said, rather than a request. Vadgama placed the window at nine to 18 months, driven in part by actuaries’ appetite for predictable costs, and attached a caution: “value means value for all parties, not just one side,” which means shared risk.
He also spoke from experience. At Magellan, he said, the first value-based arrangement involved a single provider and never scaled, partly because it leaned on the Vineland alone. Magellan has publicly described its ABA value-based work, including a 2022 collaboration with Kyo Autism Therapy, as first to market. At CentralReach, Vadgama said, the company is building an assessment battery around AI.Measures, the assessment company led by Dr. Thomas Frazier, which CentralReach acquired in 2025 when Frazier became its Chief Clinical Officer. He added that CentralReach does not share provider data with plans without the provider’s consent.
Gershfeld pointed to parallel work in the field, including the seven providers who benchmarked their own outcomes against CASP’s intensity standards and reported the results through Acuity, part of a wider push toward standardized outcomes measurement across the industry. Vadgama mentioned Project ALIGN, a separate provider consortium that EarliPoint Health launched in July around longitudinal developmental measurement. The open question, Gershfeld said, is less whether the field should converge on common measures than who is best placed to lead it there.
ABA Payer Strategy: What Panelists Told Providers to Do in the Next 30 Days
Asked for one step apiece, Vadgama urged providers to research the assessments now available “so that you can start to change your practice.” Albanese asked them to “do your own internal quality control,” so that clinical consistency holds across clinicians and offices, not only in the data sent to a plan.
The audience questions that closed the hour showed how unsettled the ground remains. Asked whether Medicaid plans limiting assessments to the VB-MAPP, the Vineland, and the ABLLS reflects a move toward value-based care, Albanese said the plans are “just trying to limit variability.” (The CMS toolkit’s own list of example outcome instruments includes the VB-MAPP and the ABLLS-R.) Vadgama said it falls to the field to advocate for a more comprehensive set. And when a registrant asked whether the industry recognizes the tension between ABA’s single-case tradition and the population data payers rely on, Vadgama’s reply was blunt: payers “don’t know about it,” he said, and “don’t care.” Gershfeld offered the practical translation. Whatever a provider brings to the table, a plan has to be able to compare it with what everyone else brings.
