Vermont Medicaid’s 2026 ABA overhaul curbs concurrent billing and assistant-analyst codes, splitting autism pay between a 14-tier case rate and frozen FFS rates.
Key Takeaways
- Frozen base rates. Vermont Medicaid’s fee-for-service ABA rates have not moved since 2019, with technician-delivered treatment (97153) at $15.00 per 15-minute unit and analyst-delivered treatment (97155) at $49.35. Those figures apply mainly when Medicaid is the secondary payer, while a separate case rate covers children whose only coverage is Medicaid.
- A January 2026 billing overhaul. Effective January 1, 2026, the Department of Vermont Health Access barred concurrent billing of 97153 and 97155, restricted assistant analysts to technician codes, and limited telehealth to three codes. State officials framed the package as correct-coding compliance rather than a rate cut.
- A federal cautionary tale. Vermont pointed to a federal finding that Wisconsin paid more than $18.5 million in improper Medicaid ABA payments tied to concurrent 97153 and 97155 billing. The department argued the policy shields the state from similar liability amid intensifying federal scrutiny.
- A rate study on the horizon. Under Act 14, the department committed to completing an ABA rate study before July 2026 to evaluate payment adequacy. It has said that if access problems emerge, adjusting rates, not reversing the billing rules, is the appropriate remedy.
On January 1, 2026, Vermont Medicaid put in place the most significant rewrite of its applied behavior analysis (ABA) billing rules in years, recasting how the state pays for autism treatment delivered to children on Medicaid. The Department of Vermont Health Access (DVHA), which administers the program, barred providers from billing for a behavior analyst and a technician at the same time for the same child, restricted the codes that assistant analysts may use, confined telehealth to three specific codes, and dropped two conference codes from the benefit entirely. The changes took effect without a public comment period because DVHA treated them as billing-compliance corrections rather than substantive rule changes, a framing providers have contested.
The changes land on top of a payment structure that already sets Vermont apart from most states. Rather than paying a single fee for each unit of service, Vermont runs two parallel tracks: a bundled monthly case rate for children whose only coverage is Medicaid, and a traditional fee-for-service schedule for children who carry other insurance alongside Medicaid. Understanding Vermont’s reimbursement means understanding which track a child falls into, because the dollars look very different depending on the answer.
How Vermont Medicaid Pays for ABA: The Case Rate and Fee-for-Service Tracks
Vermont’s ABA benefit traces to Act 158 of 2012, which required Medicaid and private plans to cover medically necessary, evidence-based treatment of autism spectrum disorder, including ABA supervised by board-certified behavior analysts, for children from birth to age 21. The Medicaid benefit took effect July 1, 2015. A decade later the program serves a small population: DVHA told state lawmakers in February 2026 that roughly 320 unique members received ABA in 2025, delivered by about twenty enrolled providers.
For children whose sole coverage is Medicaid and who carry an autism or early-childhood developmental diagnosis, DVHA pays a monthly case rate built on fourteen tiers tied to the volume of service hours. The schedule effective January 1, 2026 begins at $219 a month for roughly two to six hours (Tier 1) and climbs to $13,667 a month for 170 or more hours (Tier 14). The tier is set by counting member hours rather than provider hours, so an hour in which two or three technicians work with one child still counts as a single hour. Providers submit a monthly tier request form, and DVHA reconciles the year against submitted “shadow” claims, settling the difference to one hundred percent.
The monthly bundle is comprehensive: it folds in assessment codes (97151, 97152, and 0362T), direct treatment (97153, 97154, 97158, and 0373T), program supervision and modification (97155), and parent training (97156 and 97157), with assessment codes such as 97151 and 97152 each capped at four hours every six months. Providers still file zero-paid claims for data purposes even though payment no longer rides on them, and DVHA runs a mid-year check and a formal reconciliation each July, drawing on the state’s claims system to true up every member’s reported tier against the hours actually delivered.
The second track, fee-for-service, applies when Medicaid is the secondary payer behind private insurance. Those per-code rates have not moved since 2019. Technician-delivered treatment under 97153 pays $15.00 per 15-minute unit, and analyst-delivered treatment under 97155 pays $49.35.
CPT 97153 (technician-delivered adaptive behavior treatment), base rate per 15-minute unit. Source: MediRate.
CPT 97155 (analyst-delivered adaptive behavior treatment), base rate per 15-minute unit. Vermont’s figure reflects its fee-for-service rate. Source: MediRate.
The analyst comparison comes with an important caveat. Vermont’s $49.35 for 97155 towers over New Hampshire ($16.43) and New York ($19.26), but that reflects the track, not unusually generous pay: it is the fee-for-service rate that applies mainly to secondary-payer cases, while Vermont children whose only coverage is Medicaid receive ABA through the bundled case rate, where analyst time is folded into the monthly tier. Connecticut does not bill the analyst code, and Rhode Island and Maine do not bill the comparison codes, so none of the three appears in the analyst chart. These are the very codes at the center of coding-restriction fights in other states.
Vermont’s January 2026 ABA Billing Changes and the Concurrent-Billing Crackdown
The January 2026 overhaul reshaped both tracks. Board-certified behavior analysts (enrolled as provider type T46, specialty S50) now bill the full ABA code set at one hundred percent, while board-certified assistant behavior analysts (specialty S51) are limited to the technician codes 97152, 97153, and 97154 and barred from the analyst codes, including 97155. DVHA also confined the telehealth modifier to three codes (97155, 97156, and 97157), specifying that 97155 may be delivered by telehealth only when a technician is in the room with the child, and that an analyst personally modifying a protocol must be on site. Repeat-procedure and group-size modifiers were restricted, and two conference codes were dropped from the benefit.
DVHA has cast the telehealth limits as clinical rather than fiscal. In its February 2026 briefing to lawmakers, the department said it had reviewed national research and consulted licensed analysts, concluding that while telehealth works for some children with established skills, in-person care is more appropriate for many, and that the change largely returns pandemic-era flexibilities to in-person delivery. Officials noted the telehealth restriction would directly affect only a minority of the state’s roughly twenty enrolled providers.
The most consequential change was the prohibition on concurrent billing. DVHA determined that billing 97153 and 97155 for the same child at the same time does not meet national correct-coding standards, citing 2023 American Medical Association guidance that two clinicians cannot bill for the same face-to-face period with one child. The department tied the move to federal enforcement risk, pointing to a federal finding that Wisconsin had paid more than $18.5 million in improper Medicaid ABA payments tied to concurrent 97153 and 97155 billing. The reasoning echoes the cost-control reforms reshaping Medicaid ABA elsewhere.
Providers and families felt the effects quickly. Reporting by VTDigger and the Valley News documented clinics discharging children and warning that the loss of concurrent payment threatened their ability to operate. By DVHA’s own projection, ending concurrent billing would cut the hours providers can count toward tier payments by about 12 percent on average. The department has maintained that the rules protect Vermont from the kind of multimillion-dollar recoupment exposure that has followed audits in neighboring states, and it has emphasized that, unlike some states, it will not conduct retrospective reviews to claw back payments except in cases of fraud or material misrepresentation.
What Vermont’s Frozen ABA Rates Mean for Providers and the Act 14 Rate Study
Even setting the billing rules aside, Vermont’s fee-for-service rates have stood still while costs have risen. The 97153 and 97155 figures have not changed since 2019, a stretch in which wages and operating costs climbed sharply. Regionally the picture is mixed: New Hampshire pays the most for technician treatment in the comparison group at $17.79 per unit, while New York, which cut its 97153 rate effective April 2026, dropped to $14.45.
The state has signaled that rate adequacy is a separate question it intends to study. Under Act 14, DVHA committed to completing an ABA rate study before July 2026 to evaluate whether Medicaid payments are sufficient, and it has said that if access problems emerge, adjusting rates, not reversing the billing rules, is the appropriate response. As of early June 2026, that study had not been published. Its findings will land in a national environment of tightening oversight and a broader push toward objective quality measurement in autism care, a shift also visible in a contested Massachusetts recoupment audit next door.
The fee-for-service track carries its own gatekeeping. Because Vermont Medicaid is the payor of last resort, providers must exhaust a private insurer’s appeals (and, for items over $100, seek review by the state’s financial-regulation office) before billing Medicaid, and secondary-payer services require prior authorization, which DVHA acts on within three business days of receiving complete information. The department also reminds providers that misbilling carries weight beyond recoupment: knowingly billing for services not rendered is a felony under Vermont law.
Vermont’s participation requirements remain stringent regardless of track. Analysts and assistant analysts must be licensed in Vermont and enrolled as Medicaid providers; technicians must complete at least forty hours of training, including autism-specific and ethics components, and maintain current CPR and first aid certification. All staff need background and abuse-registry checks. Providers must reassess members at least every six months using one of three approved tools (PEAK, VB-MAPP, or ESDM) and document medical necessity throughout. For operators weighing whether Vermont Medicaid pencils out, the answer increasingly turns less on the headline rate than on which track their members occupy, a calculation that also shapes where the largest ABA platforms choose to grow.
