NC Medicaid health plans must now close RB-BHT networks, as 90-day reauthorization and a November 29 behavior technician deadline land together.
Key Takeaways
- Spending set the schedule. NCDHHS told lawmakers in March that research-based behavioral health treatment spending reached $544.4 million in State Fiscal Year 2025 against $121.7 million in SFY 2022, and now projects $1.14 billion by SFY 2027.
- The July budget closed ABA networks and rewrote the clock. Section 9E.22 of Session Law 2026-41 requires every health plan to maintain a closed RB-BHT network as of July 7, and moved reauthorization above 16 hours per week from monthly to quarterly.
- North Carolina authorizations fail on first pass more often than the national rate. Silna, a prior authorization vendor, reports 35 percent of its North Carolina ABA requests were not fully approved on first submission between June 1 and August 31, against 27 percent across its nationwide book.
- November 29 is the hard date. Uncertified behavior technicians entered a 120-day grace period on August 1, and the August 31 bulletin says claims for their services will not be reimbursed once it closes.
The bulletin NC Medicaid posted on Monday, August 31 carried the same headline as the one it posted on August 5, which carried the same headline as the one it posted on July 21. Each replaced its predecessor in full. The newest version went up four weeks into a compliance window whose deadlines had already started running, and it rewrote the sentence governing the requirement North Carolina applied behavior analysis providers have the least room to misread.
The July 21 and August 5 versions told providers that a paraprofessional without a qualifying certification required direct oversight by a Licensed Qualified Autism Service Provider any time they were delivering a service. The August 31 bulletin drops the word. Uncertified paraprofessionals must now receive LQASP supervision during the grace period described in Section 3C.18.(a)(8) of Session Law 2026-1, with ongoing supervision following the accrediting body’s guidance and Clinical Coverage Policy 8F. In exchange, the new bulletin adds a sentence the earlier two did not contain: claims billed for services delivered by non-certified paraprofessionals will not be reimbursed once that paraprofessional’s 120-day grace period expires.
For clinics that spent August building schedules around continuous one-to-one observation, the revision is a real loosening. For anyone who assumed the deadline would slip, it is the opposite. And for all the attention the three bulletins have drawn, the most consequential change to the North Carolina ABA market this summer is not in any of them.
North Carolina Closed Its Medicaid ABA Provider Networks in the July Budget
Section 9E.22 of the 2026 Appropriations Act, ratified July 2 and signed July 7 by Governor Josh Stein, amends G.S. 108D-22 to add a new subsection titled Mandatory Closed Networks. It provides that each prepaid health plan shall develop and maintain a closed network, and may exclude providers from that closed network, for peer support services and research-based behavioral health treatment services. The provision took effect on the day it became law.
Until then, North Carolina statute guaranteed RB-BHT providers an open network: a plan could exclude a provider only for failing to meet objective quality standards or for refusing to accept network rates. NCDHHS had asked the General Assembly to remove that guarantee. Action 10 of the Department’s policy paper last fall proposed exactly this change, calling the open network one factor behind the influx of new ABA providers at a time when health plans were raising concerns about care quality, and citing one North Carolina plan’s argument that closing the network would improve service management, sustainability, and fraud, waste, and abuse deterrence. The same paper cautioned that closing networks alone would not solve the benefit’s problems.
None of the three bulletins mentions it, and neither does the amended clinical coverage policy. A provider reading everything NC Medicaid published this summer about RB-BHT would not learn that a plan may now decline to contract with them for reasons unrelated to quality or rates. For an industry where platforms are actively coming to market and one of the assets currently in a sale process is a Charlotte-based provider serving North Carolina and Virginia, network access is not a technicality. It is the asset. Whether the plans build those closed networks aggressively or leave them nominally open is now a business decision rather than a statutory obligation, and it will not be visible in a bulletin. It will be visible in who gets a contract renewal, and the network adequacy enforcement now reaching behavioral health is the only external check on how far it goes.
What the NC Medicaid RB-BHT Reauthorization Rule Requires Above 16 Hours a Week
The same budget section rewrote the reauthorization clock, and this is the piece most often described backward. CCP 8F, amended effective August 1, authorizes up to 90 calendar days for treatment plans involving more than 16 hours of services per week and up to 180 days for plans at or below that line. All RB-BHT services count toward the 16-hour calculation. Existing authorizations are not being shortened, and the new duration applies at the next review.
Measured against the six-month cycles providers were working under in June, that is a tightening. Measured against the statute as ratified, it is relief. House Bill 696 became Session Law 2026-1 on April 30, and as Acuity reported in May, its Section 3C.18(a)(5)b required plans above 16 hours per week to be updated and reapproved monthly. Providers told North Carolina Health News that a single reauthorization packet can run 50 pages and take weeks to assemble. Section 9E.22 struck the word monthly and replaced it with a two-tier schedule: every six months at or below 16 hours per week, every three months above it.
The same edit did something else that has gone unremarked. Under the April statute, only plans above 16 hours per week required approval by a prepaid health plan or the Department. The July language now reads that all plans must be approved. Every treatment plan in the benefit, at any intensity, now runs through utilization management. Providers who read the change as pure relief may not have noticed that the population subject to plan approval expanded at the same moment the cycle for the heaviest cases contracted.
Quarterly is also still more frequent than the Department asked for. In the policy paper NCDHHS circulated for public comment last fall, drawing 165 written responses, the recommended action was reauthorization within three months of initial authorization and no less than every six months after that, with health plans free to require more where provider performance or a member’s progress warranted it. The General Assembly wrote a flat quarterly rule instead.
Underneath the clock sits the documentation, where most of the added work has landed. Treatment plans may no longer carry default recommended hours or minimum thresholds applied across a caseload. Plans above 16 hours per week must include a weekly schedule covering every service the child receives, Medicaid-covered or not, including school services, respite, and occupational, physical, and speech-language therapy. A titration plan is required at the start of treatment, staffing must be identified by name, and short-range goals may never exceed 12 months. Two specific and measurable caregiver goals are required, each with baseline data, mastery criteria, and timelines.
One requirement now sits awkwardly against the new cycle. The policy specifies a minimum of six caregiver training sessions per 180-calendar-day authorization period, but plans above 16 hours a week authorize in 90-day increments. CCP 8F does not say how the floor prorates.
Telehealth narrowed in the same amendment. It is gone for paraprofessional services under CPT codes 97152 through 97154. For 97155, telehealth is capped at 50 percent of total units per beneficiary per 180-day period, with clinical justification required beyond that, and telehealth delivery of the 97151 assessment now requires justification in the plan. Supervision acquired a floor and a ceiling: at least 10 percent of all paraprofessional-delivered services must involve LQASP observation and direction, and for any beneficiary receiving more than 200 hours of paraprofessional services in a 180-day period, the LQASP-to-paraprofessional ratio must fall between 10 and 20 percent unless the provider documents why it should not. It is a different instrument than the 20-hour weekly ceilings in Virginia and Nebraska, operating on documentation rather than on hours.
The RB-BHT Behavior Technician Certification Deadline Falls on November 29
Behavior technicians already employed on August 1 without a Registered Behavior Technician credential from the Behavior Analyst Certification Board or an Applied Behavior Analysis Technician credential from the Qualified Applied Behavior Analysis Credentialing Board began a 120-day grace period that day. New hires get 120 days from their date of hire, or from the date their employer first enrolls as a Medicaid provider, whichever is later. A technician who has not certified by the end of that window must stop rendering services.
The requirement itself is not controversial. NCDHHS noted that at least 29 states already require Behavior Analyst Certification Board credentialing for technicians while North Carolina asked only for equivalent competency-based training, and it proposed phasing the change in over time to avoid disruption. Lawmakers gave it 120 days. Read strictly, Section 3C.18(a)(8) extends the grace period to newly hired paraprofessionals; the bulletins extended the same 120 days to existing staff beginning August 1, a more generous reading than the text requires.
Sagar Jajoo, Co-Founder and Chief Operating Officer of Silna, a platform that automates prior authorization submissions for specialty providers, said the compression rather than the substance is what providers are struggling with. “Not to say that these changes aren’t changes that should be made, but the time frame and the grace periods should be sufficient in understanding how providers have to operationalize this,” he said. Certification means completing competency requirements, scheduling and passing an exam, and absorbing whatever processing delay follows, all while caseloads continue.
The deadline arrives on a workforce that was already contracting. Since August 2, Licensed Qualified Autism Service Providers and Certified Qualified Professionals, including Board Certified Behavior Analysts and Board Certified Assistant Behavior Analysts, may not enroll in NC Medicaid as out-of-state providers. North Carolina Health News, analyzing data from the North Carolina Behavior Analyst Licensure Board, reported in July that of 4,010 people certified by the state board as behavior analysts, 1,917 live in North Carolina. Whether reduced capacity is already producing smaller hour requests is not yet visible in authorization data, and Jajoo would not say that it is. “Providers generally adjust treatment plan hours accordingly to account for both what is medically necessary for the patient and what they actually have capacity for,” he said, describing a pattern he expects to intensify rather than one he has measured. That is a prediction, and the argument over what ABA dosage the evidence supports runs underneath it.
The state’s own numbers describe intensity climbing, not just headcount. In the March 10 presentation to the Joint Legislative Oversight Committee on Medicaid, Secretary Dev Sangvai and Interim Deputy Secretary for NC Medicaid Melanie Bush reported that beneficiaries receiving the service grew from 3,844 in SFY 2022 to 13,447 in SFY 2025, a 249 percent increase, while units of service rose 305 percent and spending rose 347 percent. Estimated mean RB-BHT hours per beneficiary per month moved from 47.5 in SFY 2022 to 54.1 in SFY 2024, with the median rising from 41.3 to 48.0. Children aged one through six accounted for $383.5 million of SFY 2025 spending, or 70.4 percent of the total.
North Carolina ABA Authorization Escalation Rates, and What They Do Not Show
Silna says 35 percent of the ABA prior authorization requests it submitted in North Carolina were not fully approved on the first pass, against 27 percent across its nationwide book. The figures cover June 1 through August 31 and rest on roughly 1,500 North Carolina authorizations out of about 9,000 the company processed nationally in that window. Silna calls these escalations and defines the category broadly: a straight denial requiring appeal, a partial approval for fewer units than requested, or a request for further information such as a missing Vineland report or a school schedule absent from the treatment plan.
The eight-point spread is the useful part, and it comes with limits. The numbers describe Silna’s own client base rather than the North Carolina market, the national rate is the company’s book across states rather than an industry benchmark, and Silna sells the service that addresses the problem the figures describe. Jajoo disclosed the last point unprompted, saying the company has grown its North Carolina business over the past month as providers sought help absorbing the change. North Carolina accounted for roughly a sixth of the ABA authorization volume Silna handled during the period.
The window matters as much as the gap. Two of the three months Silna measured closed before the August 1 policy took effect, which means the spread over its national rate largely describes North Carolina as it operated under the old documentation rules. Jajoo said the escalation rate had been climbing for two to three quarters, a trend a single three-month snapshot cannot show. The first authorization cycles running entirely under the amended policy will not close until November, alongside the certification deadline.
What the figure does illustrate is where the cost falls. Jajoo described the submission as the beginning of the work rather than the end of it, and the organizations least equipped for that follow-up are the smallest ones. Large multi-site operators maintain credentialing and contracting teams; a single-site practice may have one administrator handling authorizations, credentialing, payer enrollment, and now a recertification project. That asymmetry is consistent with a pattern Acuity has reported elsewhere, in which fixed compliance costs land hardest where there is no scale. It also compounds the closed-network change, since the providers with the least administrative capacity are the ones least able to argue for a contract.
The telehealth restrictions distribute unevenly by geography for the same structural reason: clinics serving the Research Triangle absorb them more easily than clinics serving rural counties where telehealth was the delivery method that worked. NCDHHS anticipated this. Among the four priorities the Department listed in March for implementing the changes was ensuring that rural regions are not harmed by changes to telehealth. Section 3C.18(b) of the April statute authorizes the Division of Health Benefits to develop exceptions to the telehealth limits based on documented medical necessity or access to care requirements, including poor provider availability in rural and underserved areas, and requires DHB to report any proposed exception to four legislative bodies. No such exception has been published.
Whether the four Tailored Plans, the Standard Plans, and NC Medicaid Direct will read the medical necessity standard the same way is still open. Silna said it has contacted seven plans: all four Behavioral Health and I/DD Tailored Plans (Alliance Health, Partners Health Management, Trillium Health Resources, and Vaya Health) and three of the four Standard Plans (UnitedHealthcare Community Plan, AmeriHealth Caritas North Carolina, and Carolina Complete Health, which absorbed WellCare of North Carolina in an April 1 merger). Healthy Blue, the fourth Standard Plan, is not on the list, nor is Healthy Blue Care Together, which operates the Children and Families Specialty Plan for children in foster care. Jajoo said each indicated it is applying the state’s guidance. Four weeks is not enough adjudication history to test that. Standardizing utilization management across delivery systems was itself one of the eleven actions NCDHHS proposed, which implies it was not standardized before, and the plans are already layering their own operational detail: Partners Health Management’s August 6 provider alert told providers that where an existing autism diagnosis was not established using one of the validated tools named in the policy, utilization management will recommend updated diagnostic testing to be submitted with the next authorization review. That is a concrete route by which a child already in treatment could see services interrupted, and it appears nowhere in the state bulletin.
The bulletin does spell out what will draw scrutiny. NC Medicaid says it will investigate treatment planning that appears non-individualized or lacks variability in intensity across a practice, a practice-wide absence of discharges or titration, excessive or exclusive telehealth use, services delivered by providers not located near the beneficiary, lapsed credentials, and caseload or supervision patterns inconsistent with expected clinical operations, using random onsite visits and desk reviews. The list reads as a direct descendant of the federal audit findings now working through state ABA programs, which the Department cited to lawmakers in March as raising questions about individualization, intensity, and duration.
Asked what is getting more attention than it deserves, Jajoo argued that North Carolina is being judged against the wrong comparison. “North Carolina, I think to its credit, has done a good job in at least being transparent, even though it hasn’t been much time,” he said, contrasting it with states where the rules tighten without a published bulletin to point at. He cited Texas managed care plans requesting assessments, including audiological screenings, that were not previously routine, and Georgia payers denying over school schedules, attendee names, and unlabeled graph axes, at a moment when Amerigroup is separately cutting Georgia Medicaid ABA rates. “It is unclear what the rules are. It is unclear what the goalpost is,” he said of that broader pattern.
It is an argument that runs against the interest of a company selling authorization software, which is part of why it is worth weighing, and on the reauthorization rules it holds. North Carolina published those, revised them twice in public, and softened the harshest provision before it took effect. The closed-network mandate is the exception that complicates the claim, because it changed who may participate in the benefit at all and arrived through an appropriations act rather than a bulletin. The open questions are operational: whether the state and its plans can adjudicate quarterly at volume when six-month cycles already ran late, how many technicians reach certification by November 29, whether the caregiver training floor survives contact with a 90-day period it was not written for, and which providers are still in a network next year. Florida is working through a version of the same problem with a task force whose meetings are public. North Carolina is doing it across a bulletin, a clinical coverage policy, and a 634-page budget, and only the first two come with a notification.
