South Carolina Tightens Medicaid ABA Rules Effective July 1

A Telehealth Cut Leads

COLUMBIA, SOUTH CAROLINA – South Carolina Medicaid moved to a revised autism therapy manual on July 1, the effective date the department set in a May 15 bulletin. The change that reaches provider schedules first is a telehealth cut. Under the updated Autism Spectrum Disorder (ASD) Services Provider Manual, the Behavior Identification Assessment code, 97151, can no longer be provided via telehealth. The South Carolina Department of Health and Human Services (SCDHHS) announced the overhaul on May 15 and gave providers until June 1 to comment on the draft.

The revision is incremental. It layers new requirements onto the manual SCDHHS restructured in September 2025, and read together the two updates tighten the documentation and screening requirements around applied behavior analysis.

Manual Changes on July 1

The May 15 bulletin, MB# 26-015, lists six areas of change: telehealth guidance, medical necessity criteria, the list of non-covered services, provider qualifications and enrollment, plan-of-care and documentation requirements, and clarified service guidelines and procedure code standards. For ABA providers, the telehealth rules are the most immediate operational change.

SCDHHS split its telehealth policy along assessment-versus-treatment lines. Family Adaptive Behavior Treatment Guidance (97156) becomes permanently eligible for telehealth. Direct Adaptive Behavior Treatment with Protocol Modification (97155) is also permanently telehealth-eligible, but with prior authorization. Behavior Identification Assessment (97151), the diagnostic-observation code, must now be delivered in person. The department said it based the split on utilization data, clinical evidence, and provider feedback.

On enrollment, the manual follows the federal push on provider screening. SCDHHS said it added guidance to clarify and align the “high risk” enrollment categorization for ASD providers, part of what it described as the Centers for Medicare and Medicaid Services (CMS) strengthening Medicaid provider screening to prevent fraud, waste, and abuse.

The September 2025 Criteria Underneath

The manual, ahead of the July rewrite, already reset the criteria for how a child qualifies for ABA in South Carolina. Effective September 1, 2025, SCDHHS replaced the Comprehensive Psychological Evaluation with a Comprehensive Diagnostic Assessment (CDA), which must be administered directly by a licensed physician (MD or DO), a licensed psychologist (PhD or PsyD), or a licensed psychoeducational specialist. The CDA has to include a structured observation using one of three validated tools: the ADI-R, the ADOS, or the CARS.

SCDHHS framed the September changes as improving access, and paired the CDA with two alternative pathways. A Medical Care Home Autism Assessment lets a primary care physician establish medical necessity without a full CDA referral for certain members. Children between 18 and 36 months whom a validated screener flags as “at risk” can be found presumptively eligible for ABA while a CDA is pending.

Where the Rates Stand

SCDHHS said the ASD fee schedule will be updated to match the new manual, but it did not preview any rate changes. Under the schedule that took effect July 1, 2024, South Carolina Medicaid pays $14.88 per 15-minute unit for adaptive behavior treatment by protocol (CPT 97153), which a registered behavior technician (RBT) delivers under the supervision of a behavior analyst, and $21.25 per 15-minute unit for protocol modification (97155). The 97153 code is capped at 160 units a week, the equivalent of 40 hours of direct treatment, and 97155 is capped at 64 units a month.

South Carolina is adding documentation, screening, and telehealth limits now, and revising the fee schedule later. Providers have to adjust to the new manual before they know what it will pay.

Private Providers Enter Schools

The manual change lands the same season South Carolina opened a new delivery setting for ABA. Governor Henry McMaster signed H.3974, now Act No. 186, on May 18, 2026, after unanimous final votes in both chambers. The law requires districts to consider a parent’s request for medically necessary ABA from a private provider during the school day, reviewed under the ADA standard rather than the child’s IEP; a district can refuse only if the service would impose an undue burden or fundamentally alter school operations. It codifies case-by-case guidance the state education department first issued to districts in 2024.

The law and the manual meet at the payment line. Act 186 counts Medicaid among the third-party payers for in-school services, so a Medicaid-funded hour in a classroom still runs through this manual: the CDA gateway, the unit caps, and the $14.88-per-unit rate for RBT-delivered treatment. The act changes where ABA can be delivered, not what it pays.

The State Board of Education must finalize a model policy by January 6, 2027, and districts must adopt it or an approved equivalent by July 1, 2027. That timeline, more than the manual itself, will decide how quickly private ABA reaches South Carolina classrooms.

AT A GLANCE

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