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Payer policy report, October 2026: 98 verified changes across 37 states

What changed this month for ABA, behavioral health, therapy and FQHC billing, built from our payer policy matrices. Every change below links to the state agency, CMS or payer document it came from.

October 13, 20264 min readASP-RCM Solutions

98verified payer and Medicaid changes [1]
37states with at least one change, plus 12 federal items [1]
21prior authorization changes [1]
10rate changes (7 increases, 3 cuts) [1]

What kind of changes payers made

Most of the month was rule changes rather than rate moves. Policy changes and prior authorization changes together account for 57 of the 98 verified items. Rate changes are a smaller share but carry the most direct cash impact, so they are listed in full below.

Verified changes by type, October 2026 refresh [1]
Policy changes36Prior authorization changes21Enrollment and admin changes17Coverage expansions14Rate increases7Rate cuts3

Which specialties were hit hardest

Behavioral health carried the most change this month, followed by ABA, therapy and FQHC. Counts include state and federal items in each matrix.

Verified changes by specialty matrix [1]
Behavioral health41ABA21PT, OT and speech20FQHC16

Which payers changed the rules

State Medicaid programs and their managed care plans issued the largest share of changes. Blue Cross Blue Shield plans were the most active commercial payers.

Verified changes by payer type [1]
State Medicaid33Blue Cross Blue Shield plans25Medicaid managed care12Other payers and programs12Federal (CMS and others)12UnitedHealthcare / Optum4

Every rate change this month

These are all 10 verified rate changes in the refresh, oldest date first. Dates are as listed by the payer or agency.

Rate changes, October 2026 refresh [1]
StateMatrixDateChangeSource
WyomingBehavioral healthJul 1, 2026Wyoming Medicaid bulletin (issued Sept 23, 2026): behavioral health service rates rebased effective July 1, 2026 using prior cost study data plus inflation adjustments, funded by legislative budget increases; verify code...[2]
New YorkPT, OT and speechSep 16, 2026NY Medicaid: 20% rate enhancement for PT, OT and speech codes (e.g. 97110, 97140, 97530, 92526, 97161-97163) billed by OPWDD Article 16 clinics for people eligible for OPWDD services (RE code 95); FFS from Jul 1, 2026, M...[3]
ArizonaABAOct 1, 2026AHCCCS final FFY27 fee-for-service rate notice (posted Sept 30, 2026), effective Oct 1, 2026: ABA codes 97156 and 97157 get set rates replacing By Report, and 97154 with TJ modifier (community school group ABA) rises to ...[4]
ArizonaFQHCOct 1, 2026AHCCCS final FFY27 rate notice (posted Sept 30, 2026): FQHC and RHC fee-for-service PPS/APM rates rise about 3.44% for dates of service from Oct 1, 2026, per each center's chosen state plan methodology.[4]
FloridaFQHCOct 1, 2026Florida Medicaid FQHC PPS encounter rates for the Oct 1, 2026 rate semester are posted, increased by the Medicare Economic Index of 2.700% (3.5% in Oct 2025); October 2026 RHC and provider-based RHC rate files posted alo...[5]
New YorkABAOct 1, 2026NY Medicaid FFS cuts the fee for ABA delivered by unlicensed individuals/technicians, CPT 97153, to $9.63 per unit for dates of service on or after Oct 1, 2026, under the FY 2026-27 Enacted Budget (Medicaid Update Aug 20...[6]
NevadaFQHCOct 1, 2026Nevada Medicaid loaded FFY 2027 Medicare Economic Index adjustments for Rural Health Clinic (PT 17, specialty 180) T1015 encounter rates, dates of service on or after Oct 1, 2026; no automatic reprocessing, and MCOs must...[7]
DelawareABAOct 16, 2026Highmark BCBS Delaware Commercial PPO pays CPT 97153 (RBT/technician ABA) at $15.73 per unit for office and non-office from Oct 16, 2026, after a review found 97153 pay exceeded market norms; eligibility, auth and covera...[8]
West VirginiaABAOct 16, 2026Highmark BCBS WV commercial PPO resets CPT 97153 (RBT protocol treatment) pay effective Oct 16, 2026 to $14.53 office and $13.78 non-office after a review found 97153 pay in several markets exceeded prevailing levels; au...[8]
New YorkBehavioral healthNov 1, 2026NY Medicaid Managed Care plans must pay the new clinic enhancements from Nov 1, 2026 (FFS from Jul 1): +20% on physical health E/M in OASAS clinics (P1-P3 modifiers), +20% on listed codes in MHOTRS clinics, and +20% MHOT...[3]

Prior authorization changes to plan for

The 12 prior authorization changes below are the most likely to cause denials if intake and scheduling teams miss them.

Prior authorization changes, October 2026 refresh [1]
StateMatrixDateChangeSource
NevadaPT, OT and speechSep 15, 2026Nevada Medicaid MSM Chapter 1700 Therapy (effective Aug 26, 2026, announced Sept 15): prior authorization for PT, OT and speech therapy is not required for children under age 4, correcting the prior wording of through ag...[9]
NevadaBehavioral healthSep 29, 2026Nevada Medicaid Web Announcement 4020: MCOs may require prior auth where FFS does not, but may not require prior or post authorization for in-network CCBHC services, the first mental health or SUD assessment in a 12-mont...[10]
NevadaFQHCSep 29, 2026Nevada Medicaid Web Announcement 4020: under contract Section 5.7.3(A), Medicaid MCOs may not require prior authorization or post-authorization for FQHC and RHC services from in-network providers.[10]
GeorgiaABAOct 1, 2026Peach State Health Plan (Georgia Medicaid CMO): effective Oct 1, 2026, CPT 97157 (multiple-family group adaptive behavior treatment guidance) is listed as PA Required.[11]
IllinoisABAOct 1, 2026Meridian (HealthChoice Illinois Medicaid MCO): effective Oct 1, 2026, CPT 97157 (multiple-family group adaptive behavior treatment guidance) moves to PA Required under Behavioral Health treatment services.[12]
GeorgiaBehavioral healthOct 1, 2026Peach State Health Plan (Georgia Medicaid CMO): effective Oct 1, 2026, substance use treatment codes H0010 and H0011 require prior authorization, and PA is removed for behavioral assessment code 96121.[11]
OhioBehavioral healthOct 1, 2026Ohio Medicaid MCO behavioral health utilization thresholds start Oct 1, 2026 (counts from Jul 1, 2026), e.g. SUD IOP H0015 after 30 units a year; ODM told plans to open utilization lookup and PA submission 7 days before ...[13]
OhioBehavioral healthOct 1, 2026Anthem Ohio Medicaid and MyCare: behavioral health prior auth Phase I (SUD) starts Oct 1, 2026, e.g. withdrawal management H0010-H0012 after 7 days per episode and SUD IOP H0015 after 30 days a year; Phase II (mental hea...[13]
WyomingABAOct 1, 2026BCBS of Wyoming: from Oct 1, 2026 all Wyoming providers must submit initial prior authorization and concurrent review requests through Availity; faxed requests from in-state providers are no longer accepted (pharmacy PAs...[14]
WyomingBehavioral healthOct 1, 2026BCBS of Wyoming: from Oct 1, 2026 all Wyoming providers must submit initial prior authorization and concurrent review requests (including behavioral health) through Availity; in-state faxes no longer accepted; discharge ...[14]
FederalBehavioral healthOct 1, 2026UnitedHealthcare/Optum BH National Gold Card: from Oct 1, 2026, TINs with 10+ eligible prior auths a year and a 92%+ approval rate over 2 years skip clinical prior auth for IOP (H0015, S9480), PHP (H0035, S0201) and psyc...[15]
FederalPT, OT and speechOct 1, 2026UnitedHealthcare Medicare Advantage: from Oct 1, 2026, prior auth is no longer required for speech-language treatment 92507 and 92508 (MA and D-SNP) and swallowing treatment 92526 (MA). No PT/OT 97xxx codes are on the re...[16]

When the changes land

31 of this month's items are dated October 1, 2026, the largest single date, and 17 more land on January 1, 2027. Plan system, contract and authorization updates before each date, not after the first denials.

Changes dated October 2026 or later, by month [1]
Oct 202637Nov 202611Dec 20263Jan 202718

How this report is built

Researchers reviewed state Medicaid bulletins, CMS notices and payer provider bulletins for every state. Each candidate change was then re-checked automatically: the source page was fetched again and the quoted passage had to appear on it before the change was published. 110 candidates were researched for this refresh; 10 were left out because their source could not be re-checked, and 2 were held as not being policy changes.

You may cite this report and the matrices with a link to this page.

Frequently asked questions

How often is the payer policy report published?

Monthly, after each refresh of the ABA, behavioral health, therapy and FQHC payer policy matrices. Each report covers the verified changes added in that refresh.

Can I cite or share this data?

Yes. Please link to this page or to the payer policy matrices when you use the figures. Each individual change also links to its original source document.

Why are some changes dated in the future?

Payers and agencies often announce changes weeks or months before they take effect. The date shown is the one listed in the matrix entry for that change.

Sources

  1. ASP-RCM payer policy matrices (ABA, behavioral health, therapy, FQHC), October 2026 refresh
  2. Wyoming, Behavioral health: Wyoming Medicaid bulletin (issued Sept 23, 2026): behavioral health service rates rebased
  3. New York, PT, OT and speech: NY Medicaid: 20% rate enhancement for PT, OT and speech codes (e.g. 97110, 97140, 97530, 9
  4. Arizona, ABA: AHCCCS final FFY27 fee-for-service rate notice (posted Sept 30, 2026), effective Oct 1, 20
  5. Florida, FQHC: Florida Medicaid FQHC PPS encounter rates for the Oct 1, 2026 rate semester are posted, in
  6. New York, ABA: NY Medicaid FFS cuts the fee for ABA delivered by unlicensed individuals/technicians, CPT
  7. Nevada, FQHC: Nevada Medicaid loaded FFY 2027 Medicare Economic Index adjustments for Rural Health Clini
  8. Delaware, ABA: Highmark BCBS Delaware Commercial PPO pays CPT 97153 (RBT/technician ABA) at $15.73 per un
  9. Nevada, PT, OT and speech: Nevada Medicaid MSM Chapter 1700 Therapy (effective Aug 26, 2026, announced Sept 15): prio
  10. Nevada, Behavioral health: Nevada Medicaid Web Announcement 4020: MCOs may require prior auth where FFS does not, but
  11. Georgia, ABA: Peach State Health Plan (Georgia Medicaid CMO): effective Oct 1, 2026, CPT 97157 (multiple
  12. Illinois, ABA: Meridian (HealthChoice Illinois Medicaid MCO): effective Oct 1, 2026, CPT 97157 (multiple-
  13. Ohio, Behavioral health: Ohio Medicaid MCO behavioral health utilization thresholds start Oct 1, 2026 (counts from
  14. Wyoming, ABA: BCBS of Wyoming: from Oct 1, 2026 all Wyoming providers must submit initial prior authoriz
  15. Federal, Behavioral health: UnitedHealthcare/Optum BH National Gold Card: from Oct 1, 2026, TINs with 10+ eligible pri
  16. Federal, PT, OT and speech: UnitedHealthcare Medicare Advantage: from Oct 1, 2026, prior auth is no longer required fo

Checked October 13, 2026. Rules change; confirm against the source before relying on them.

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