Shifting Accountability from Effort to Achievement: The Potential Impact of the ABA Toolkit

The autism therapy industry will likely have to justify itself at every turn when it comes to hour-intensive treatment plans as states digest the Applied Behavior Analysis Toolkit released by the Centers for Medicare and Medicaid Services (CMS) in August.

The 173-page toolkit comes without the force of a rule or regulation. However, it articulates CMS’ understanding of best practices for providing applied behavior analysis (ABA), how it is overseen and how it should be paid for. It offers the first federally developed roadmap for how states balance their mandates to ensure access to personalized treatment, keep spending in check and fight fraud, waste and abuse in Medicaid.

But for autism therapy owners and providers, the toolkit signals that regularly using stock, high-hour treatment plans may be seen as a potential fraud signal. It also repeatedly emphasizes that every patient requires a personalized treatment plan that is to be updated regularly to account for treatment progress.

Because it does not come with an edict, the ABA toolkit will likely have a diffuse impact. Each state will approach it in its own way. Still, it may help bring some predictability to autism therapy providers, investors and advocates as they try to anticipate changes in Medicaid practices and other state regulations.

It also semi-formally solidifies ABA as the mainstream treatment for children with autism, especially in early intervention settings. Advocates of care deliver models that offer an alternative to center-based, clinician-moderated therapy and hold up the toolkit as a win because it highlights that no major government or private regulating body in healthcare has endorsed ABA as the primary treatment for those with autism. The toolkit also names several behavioral and developmental models as valid and worthy of consideration for inclusion in state Medicaid plans. And yet, nearly every page of the document details best practices and guidance for the regulation of ABA.

“There’s a little bit of a paradoxical nature here in kind of mentioning that it doesn’t endorse ABA as the primary [treatment] and that other modalities should be looked at. However, it references CASP guidelines, which are all pretty much ABA,” Reed Walker, CEO and founder of Luna Family Autism Care, told BHB. “I do think that it has been a good forcing function for a lot of payers to start reaching out to us.” 

Luna Family Autism Care offers BCBA-led, parent-mediated ABA services. BCBAs and other co-occurring caregivers use interventions themselves, rather than relying on behavior technicians. Hourly commitments for families typically range from five to 10 hours a week, a far cry from traditional ABA. The underlying research of the tool kit finds that the average therapy hours for Medicaid beneficiaries in 2025 was 17.33 hours in 2025, up 22% since 2021. 

Policymakers need external validation to diverge from the status quo — and authority on matters. The bigger the validator, the easier the shift. For many payers that conversation is still early, but it is happening and starting to gain steam as they look for alternatives to the runaway costs of ABA. Total spending jumped from $1.94 billion in 2021 to $10.1 billion in 2025 — a 421% increase in four years.

“The approval or the permission from CMS to explore those things is powerful,” Mike Suiters, CEO of Positive Development told BHB. “We’re definitely seeing that in the tenor of the conversations that we have with states and with plans — where it just adds an extra degree of credibility, of air cover on a decision like that.”

Still, those who want to see the autism therapy industry organized around a center of gravity other than ABA fear that the ABA Toolkit will do just that. Many in the industry have watched the rise of ABA as the core treatment for autism therapy with chagrin and the displacement of many other treatment types, even pediatric primary care.  

“There is a risk for state Medicaid agencies to take this document and further entrench ABA as the doorway into autism care, when in fact, autism is a very complex medical condition that requires a multidisciplinary approach,” Robin McLeod, the founding CEO of the National Society of Autism Professionals (NSAP) told BHB.

She and others fear that the ABA Toolkit will narrow the view of state officials when it comes to autism treatment and Medicaid coverage generally.

Getting personal 

At every level and in every setting of oversight and payment, the federal government centralizes the need for treatment to be individualized in a demonstratable way.

“Cut and paste won’t cut it anymore in [the eyes of states and payers],” Rick Loewenstein, founder and CEO of TeamGame Advisors, told Behavioral Health Business. “That’s a red flag for payers and that is the recommendation to the states — to be on the lookout for that.

“I thought they spent an inordinate amount of time talking about individualized treatment plan, and we’re also seeing that from payers now who are flagging anything that’s over 35 hours or 30 hours.”

The toolkit recommends that states establish consistent, state-level standards and processes for evaluating the quality of individualized treatment plans, and that those plans must be completed before care begins.

The anti-copy-paste sentiment is stated explicitly in the toolkit. It also warns about unexamined approvals for high-hour treatment plans.

“Services at higher intensity levels should not be authorized by default and should only be authorized based on the [individualized treatment plan’s] documentation of needs and goals that warrant extensive treatment,” the toolkit states. “These high-intensity weekly treatment schedules leave virtually no time for nontreatment activities like schooling and family time and can easily take on the characteristics of respite care and childcare.”

This requires providers to avoid shoehorning patients who are brought to them into standardized treatment programs that they have developed to prioritize the close individualization that toolkit calls for. It also signals that providers need to be prepared for enduring scrutiny of nearly every major clinical decision that BCBAs make when they develop and reassess plans. This also requires that those who run autism therapy organizations get comfortable with not having uniform treatment from a staffing and operational standpoint.

“If that individual child needs 27 hours, then you need to have a treatment plan that clearly articulates why 27 hours is the right level of care, why 28 hours is too much, why 26 hours is not enough,” Mariel Fernandez, vice president of government affairs at the Council of Autism Service Providers (CASP), told BHB. “It’s really hard to get that precise, and it’s really hard to be thinking about an individualized treatment plan with individualized dosage and intensity and fitting all of that into a center-based model, where you have the challenges and the nuance associated with staffing, ensuring that everybody’s getting what they need.”

Value-based care versus private equity 

The toolkit highlights alternative payment structures, beyond fee schedules, as a potential way to align care quality with cost-saving initiatives. However, it stops short of giving a ringing endorsement to value-based care and other models. Still, it presents value-based care as a way to check against the incentives any provider faces to drive as much volume and scale as possible under a fee-for-service paradigm.

“States with concerns about quality related to private equity should consider outcomes-based models and formal monitoring plans,” the toolkit states. “CMS has not taken a formal position on corporate ownership of ABA providers to date; however, regardless of ownership structure, ABA needs to be provided based on an [individualized treatment plan]-driven individualized treatment model and not a one-size-fits-all model designed for revenue maximization.”

The toolkit also articulates the view that there are only two common ownership models in the autism therapy industry: “Private equity backed chains” [sic] and “Independent/founder-owned providers.”

Today, most providers operated nearly exclusively on fee schedules moderated by a managed care organization. Only a handful of organizations have value-based care agreement. But those that do say they are viable. Others have long predicted that the industry will consider such models more as it continues to grow and mature.   

“I think there’s going to be motivation from the payers to come up with alternate payment methods, and I think downstream we’ll continue aiming at a value-based pay model,” Kate Sheldon Princi, CEO of 360 Behavioral Health, told BHB. She added that her company is largely paid on a fee-for-service basis.

A key conversation that will likely accelerate as payers and providers consider alternative payment models will be the type of outcomes the two parties will standardize as an assessment of good care. At the same time, providers and payers will have to balance the need to standardize certain processes, like outcome tracking, with the individualized nature that care must take on.

“The industry has largely been accountable for effort,” Dennis Dixon, the chief clinical officer for 360 Behavioral Health, told BHB. “My hope is that it responds to this by becoming more accountable to achieve what we all want to achieve for the clients that we’re serving.”

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