Alabama Medicaid Pauses New ABA Referral Rule Before July 1

What the June 15 Alert Required

MONTGOMERY, ALABAMA – On June 15, the Alabama Medicaid Agency told pediatricians they had 16 days to request a specialty designation or their autism-related diagnoses would no longer support referrals to ABA therapy. By June 18, the agency paused the July 1 deadline, but the underlying requirement remained the core change.

The provider alert, titled Applied Behavioral Analysis Therapy Diagnostic Requirements, explained the process. Physicians enrolled as Provider Type 31, Specialty 345, the agency’s pediatrician classification, needed to submit a written request on official letterhead to add ABA Specialty 175 to their Medicaid enrollment file. The request had to include the provider’s name, National Provider Identifier, Alabama Medicaid provider number, and service location address. Starting July 1, an autism-related diagnosis from a pediatrician without the designation would not be valid for ABA referrals, and referrals based on such a diagnosis would be denied, according to the alert reported by WSFA 12.

The alert offered no retroactive relief. The designation took effect only on the day the agency approved it and added it to the provider’s file. A pediatrician who filed late would leave referrals exposed in the meantime.

Compliance looked simple. “As I understand it right now, the requirement is that we put it on our official letterhead, include all our designations and location, and state that we are pediatricians requesting to add this designation to our profile,” Dr. Derrol Dawkins, founder of Metro Pediatrics in Birmingham, told CBS 42. His office had already responded before the pause was announced.

Nurse Practitioners Lose Medicaid Diagnostic Role

The same alert applied to nurse practitioners. Certified registered nurse practitioners, the agency said, are not authorized to diagnose autism-related conditions for ABA referrals for Medicaid beneficiaries. Pediatricians could restore their referral authority with a letter. Nurse practitioners had no path.

The exclusion hardened a restriction the agency signaled on May 18, when a separate alert limited ABA-qualifying diagnoses to licensed psychologists, licensed psychiatrists, and licensed pediatricians, a restriction more restrictive than the physician-or-non-physician-practitioner language in Chapter 37 of the provider billing manual, according to an analysis by the trade outlet Acuity News.

For families, the change adds to waitlists that already run in sequence. Kristi Krueger, a nurse practitioner interviewed by Huntsville station WAFF 48, described autism diagnosis waits of 3 months to a year depending on age and insurance, followed by a second wait for ABA capacity that “can be anywhere from months to years.” Nurse practitioner Teariah Wilder told the station some patients already receiving treatment may have to restart the diagnostic process.

“I’ve already had patients calling up here worried because they don’t want to leave us.” – Teariah Wilder, nurse practitioner, quoted by WAFF 48 (2026)

Pediatric subspecialty supply in Alabama is concentrated in metropolitan areas, Acuity News noted, and restricting diagnosis to 3 licensed provider types carries access consequences for rural families.

The Pause and What It Leaves Open

The pause came fast. Late on June 18, three days after the alert was published, the agency confirmed to CBS 42 that it had paused the July 1 deadline for pediatricians to respond. Melanie Cleveland, Medicaid’s communications director, said the agency will issue additional guidance and clarity on the requirement. In a follow-up provider alert, the agency suspended implementation tied to the July 1 deadline and said billing must still follow Medicaid’s rules, regulations, and billing manual.

The pause resolved little else. The follow-up alert sets no new effective date. It says nothing about whether letterhead requests already filed will be processed. It also does not say whether the nurse practitioner exclusion, stated flatly in the June 15 alert, is paused along with the pediatrician deadline.

The biggest issue right now, Dr. Albert Holloway, a general pediatrician with Payne & Holloway Pediatrics in Montgomery, told WSFA the day before the agency confirmed the pause, is that parents do not know what the change means. “I think the frustration is that a lot of parents are confused and not sure what they need to do,” he said. Holloway said services should remain available once referring physicians sign up with Medicaid but noted families can already wait one to two years for behavioral therapy.

Tightening Beyond Alabama

The June 15 alert was the agency’s fourth ABA action of 2026. On February 5, a standalone ABA fee schedule removed CPT codes 97151 through 97158, the adaptive behavior services code set, from the physician fee schedule. A February 24 alert required ABA providers to operate from physical facilities with visible business signage. The May 18 alert narrowed who can diagnose, all per Acuity News. None of the four touched the core treatment rates. Alabama pays $10.00 per 15-minute unit on CPT 97153, the code for adaptive behavior treatment by protocol, or $40 an hour. This rate has been unchanged since at least October 2023 and is the lowest among its Southeast neighbors in MediRate’s comparison cited by Acuity News.

Alabama is not the only state narrowing who can make the qualifying diagnosis. Florida’s refreshed Medicaid coverage policy added a Comprehensive Diagnostic Evaluation requirement. Arkansas requires agreement between at least 2 of 3 licensed clinician types- physician, psychologist, and speech-language pathologist- before an autism diagnosis stands under its Medicaid autism rule. In Virginia, a provider and family campaign is fighting budget language that, according to the campaign, would require a formal autism diagnosis before ABA authorization beginning July 1, 2026. At the federal level, audits by the HHS Office of Inspector General in 4 states have recommended more than $123 million in recoupments; 3 more audits are pending, and CMS in April directed all 50 state Medicaid programs to submit provider revalidation plans; Acuity News links to the state-level tightening.

Alabama gave pediatricians 16 days and paused the deadline after 3. What follows depends on guidance the agency has promised but not scheduled. Meanwhile, the follow-up alert directs provider questions to appliedbehavioranalysis@medicaid.alabama.gov. Whether letterhead requests already on file, like Dawkins’s, will be processed remains open.

AT A GLANCE

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