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Nebraska Tightens ABA Again: No School Billing, and Prior Authorization Now Starts at 20 Hours a Week compliance Nebraska Tightens ABA Again: No School Billing, and Prior Authorization Now Starts at 20 Hours a Week ======================================================================================================= Nebraska Provider Bulletin 26-06 bans independent ABA providers from billing Medicaid for school-based services and cuts the prior-auth-free weekly cap from 30 to 20 hours, effective July 1, 2026. What Nebraska practices must operationalize now. 8 min read July 10, 2026 StreamABA Team Share [ ](https://x.com/intent/tweet?url=https%3A%2F%2Fstreamaba.com%2Fblog%2F2026%2F07%2Fnebraska-aba-school-billing-ban-20-hour-cap&text=Nebraska+Tightens+ABA+Again%3A+No+School+Billing%2C+and+Prior+Authorization+Now+Starts+at+20+Hours+a+Week) [ ](https://www.linkedin.com/sharing/share-offsite/?url=https%3A%2F%2Fstreamaba.com%2Fblog%2F2026%2F07%2Fnebraska-aba-school-billing-ban-20-hour-cap) [ ](https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fstreamaba.com%2Fblog%2F2026%2F07%2Fnebraska-aba-school-billing-ban-20-hour-cap) compliance medicaid state-policy billing practice-management nebraska ![](/images/blog/2026/07/nebraska-aba-school-billing-ban-20-hour-cap.jpg) The Second Hit in Eleven Months ------------------------------- On June 1, Nebraska DHHS issued Provider Bulletin 26-06, signed by Director Drew Gonshorowski. It took effect July 1. Thirty days of notice, and two structural changes inside it. First: independent ABA providers may no longer bill Nebraska Medicaid directly for services delivered in a school. School-based ABA is now explicitly the school’s reimbursement responsibility under Nebraska Administrative Code Title 471, Chapter 25 and the Medicaid State Plan. Second: the bulletin announced updated ABA Medicaid Service Definitions, also effective July 1. Per those definitions and local reporting from WOWT and KSNB Local 4, the maximum weekly ABA hours a child can receive **without prior authorization dropped from 30 to 20**. RBTs must now receive at least one hour of in-person supervision per month, and the treating LBA or psychologist must deliver at least one hour of in-person treatment per month. Caregiver training requirements were reworked: teacher training now counts toward the requirement, and clients receiving fewer than 10 hours of ABA per month carry a reduced training obligation. This lands 11 months after Nebraska’s August 2025 rate cuts, which reduced ABA reimbursement by 28% to 79% depending on the code. Themis Gomes, who owns Behaven Kids in Omaha, put a number on the new threshold: **54% of the children the clinic serves need more than 20 hours of services a week**. Every one of those cases now runs through prior authorization. That percentage is the number to sit with. When more than half of a typical caseload sits above the PA-free line, prior authorization stops being exception handling and becomes the default state of business. What Changed on July 1 ---------------------- The full package, from the bulletin and the updated service definitions: **School billing ban.** ABA delivered in a school setting falls under school-based services reimbursement. The school bills; the independent provider cannot. Services the school delivers must still meet Medicaid’s ABA service definition requirements. Any claim you submit directly for a school-delivered session with a July 1 or later date of service is a recoupment waiting to happen. **PA-free threshold cut from 30 to 20 hours per week.** The 30-hour ceiling was itself new: Nebraska added it in the August 2025 package. It survived 11 months. **One hour of in-person RBT supervision per month.** The BACB already requires supervision of at least 5% of an RBT’s hours. Nebraska’s addition is the word *in-person*. If your supervision model leans on remote observation (common in a state where the drive between clients can run two hours), at least one monthly hour per RBT now has to happen in the room. **One hour of in-person treatment per month by the treating LBA or psychologist.** This is separate from technician supervision: direct treatment, delivered by the license-holder, in person, every month, for every client. **Caregiver training reworked.** Two changes cut in the provider’s favor: teacher training now counts toward the caregiver training requirement, and clients receiving under 10 hours of ABA per month need fewer training hours. If school staff participate in a child’s program, that time now does compliance work it didn’t do before. **DD waiver assessments opened up.** Individuals on a Division of Developmental Disabilities waiver may receive ABA assessments (97151 and 97152) regardless of age, and for waiver recipients the assessment may be used for non-ABA purposes. Twenty Hours Makes Prior Authorization the Default -------------------------------------------------- Under CASP’s practice guidelines, comprehensive ABA treatment, the model most young children with substantial skill deficits receive, runs 26 to 40 hours per week. Focused treatment runs 10 to 25. Under Nebraska’s old 30-hour threshold, focused-treatment clients and a slice of comprehensive clients cleared without prior authorization. Under the 20-hour threshold, essentially every comprehensive-treatment client requires a PA, along with the upper half of the focused range. Behaven Kids’ 54% figure is what that looks like in a real caseload, and clinics weighted toward early intensive treatment will sit higher. The operational consequence is a volume problem. A practice serving 60 clients where half exceed 20 hours goes from a handful of PAs a year to 30 active authorizations that each need clinical justification at submission, tracking while pending, unit burn-down monitoring while active, and renewal before expiration. Miss a renewal and the hours above 20 are unbillable until the new authorization lands. Deliver them anyway and you’ve donated the sessions; hold them and the child’s dosage drops for reasons that have nothing to do with clinical need. And there’s a second effect. A PA requirement is a review checkpoint, and Nebraska has now built one into the majority of its ABA caseload. The state didn’t cap hours at 20; children can still receive more. But every hour above 20 now passes through a reviewer who works for the payer. Expect the documentation supporting those hours to matter more than it did in June: assessment data, dosage rationale, progress against goals. Authorization requests that read as boilerplate will be the first ones trimmed. The School Billing Ban Is a Contract Problem, Not a Billing Problem ------------------------------------------------------------------- You can’t fix the school rule in your billing system. There is no modifier, no alternate code. If the service happens in a school, the school is the biller under Title 471, Chapter 25. Nebraska practices with school-delivered hours have three options, and all of them involve conversations outside the clinic: 1. **Become the school’s arm.** Districts can deliver school-based services through contracted personnel. That means negotiating an agreement where the district bills Medicaid and pays you: a new counterparty at a new rate, on the school’s timeline. 2. **Relocate the hours.** Move school-delivered sessions to clinic or home settings. That touches the treatment plan (setting is a clinical variable, not a scheduling detail), family logistics, staff drive time, and authorized units. 3. **Drop the hours.** The outcome nobody wants, and the one that happens by default when options one and two stall past the effective date. The trap is the transition period. The bulletin took effect July 1. A district negotiation takes months. Sessions delivered in schools between now and a signed agreement are the exposure window: served but unbillable, or billed and recoupable. $4.6 Million to $85.6 Million: Why Nebraska Keeps Coming Back ------------------------------------------------------------- Nebraska’s stated rationale is spending growth. DHHS reports ABA expenditures went from **$4.6 million in 2020 to $85.6 million in 2024**. The department’s framing: “No state or federal program can sustain that level of growth without putting future access to services at risk.” The August 2025 response was rates. 97153, the technician-delivered treatment code that makes up the bulk of ABA billing, fell from $36.11 to $18.70 per 15-minute unit, a 48% cut. Other codes fell between 28% and 79%. Nebraska’s largest private ABA provider, which drew $28.5 million from Medicaid in 2024, announced it was exiting the state’s Medicaid market weeks later, then reversed course within a week. The July 2026 response is utilization. Rate cuts lower the price per unit; the new package reduces the number of units that flow without review, shifts school-setting costs onto a different budget line, and adds supervision requirements that raise the cost of delivering each hour. That sequence – cut rates, then tighten utilization – is the part providers in other states should study. Indiana capped hours and imposed a lifetime cap in April. Vermont changed a billing rule and clinic revenue fell 17% in 60 days. Nebraska has now demonstrated the two-step version, and it did the second step with a provider bulletin and 30 days of notice. If your state publishes a weekly-hours threshold, that threshold is a dial, and Nebraska just showed every Medicaid director that it turns. What Nebraska Practices Should Do Now ------------------------------------- **1. Segment your caseload at the 20-hour line today.** Pull every client’s authorized and delivered weekly hours. Everyone above 20 needs an active prior authorization covering the excess. Find the clients whose services are running ahead of their paperwork. That gap is unbillable exposure accruing daily. **2. Stand up a PA pipeline.** At this volume you need, for every authorization: submission date, payer status, approved units, units consumed, and expiration date. Renewal work should start 30 to 45 days before expiry, triggered by the system rather than by memory. One missed renewal now interrupts treatment for any client above 20 hours. **3. Inventory school-delivered hours and open district conversations this month.** List every client with sessions in a school setting and the weekly hours involved. Decide per client: pursue a district contract, relocate the setting, or wind down. Stop submitting direct claims for school-delivered dates of service on or after July 1; that ship has sailed regardless of where negotiations stand. **4. Put supervision and LBA-treatment hours on rails.** Two new monthly, in-person, per-person requirements: one supervision hour per RBT, one treatment hour per client from the LBA or psychologist. Schedule them recurring, document them as what they are (supervision notes for one, session notes for the other), and track completion monthly. A requirement this granular is exactly what a state reviewer checks first. **5. Rework caregiver training plans while the rules favor you.** Teacher training now counts. For school-adjacent clients, training school staff can satisfy requirements and preserve program consistency across settings. Recalculate obligations for any client under 10 hours per month. **6. If you’re not in Nebraska: find your threshold number.** Check your state’s ABA service definition for an hours-per-week trigger, then calculate what percentage of your caseload sits above it – and what that percentage becomes if the trigger drops by a third. Nebraska providers got 30 days. The practices that absorb a change like this are the ones that knew their number before the bulletin published. The Threshold Is the Story -------------------------- Rate cuts make headlines because the damage is arithmetic. Threshold changes rewire operations, and they compound: every future utilization decision in Nebraska now happens inside a PA review the state controls, one client at a time, with no further rulemaking required. Nebraska providers spent the last year absorbing a 48% cut to their core code. The ones still standing now need an authorization operation sized for half their caseload, district contracts for their school hours, and airtight supervision logs. None of that generates a headline. All of it determines who is still serving Medicaid families in 2027. --- *StreamABA tracks authorizations from request through unit burn-down and expiration, flags exhaustion before it interrupts treatment, and keeps supervision documentation audit-ready. Questions about operationalizing a PA-heavy caseload? Reach out at **hello@streamaba.com**.* *Follow us on [LinkedIn](https://www.linkedin.com/company/stream-aba) and [X](https://x.com/streamaba) for more industry updates.* Sources ------- - [Nebraska DHHS Provider Bulletin 26-06 (June 1, 2026)](https://dhhs.ne.gov/Medicaid%20Provider%20Bulletins/Provider%20Bulletin%2026-06.pdf) - [Nebraska DHHS: Medicaid Behavioral Health Service Definitions](https://dhhs.ne.gov/Pages/Medicaid-Behavioral-Health-Definitions.aspx) - [WOWT: Nebraska ABA therapy regulations undergo more changes (July 10, 2026)](https://www.wowt.com/2026/07/10/nebraska-aba-therapy-regulations-undergo-more-changes/) - [KSNB Local 4: Nebraska ABA therapy regulations undergo more changes (July 10, 2026)](https://www.ksnblocal4.com/2026/07/10/nebraska-aba-therapy-regulations-undergo-more-changes/) - [Nebraska DHHS Health Plan Advisory 25-08: Applied Behavior Analysis Rates](https://dhhs.ne.gov/Guidance%20Docs/Health%20Plan%20Advisory%2025-08%20-%20Applied%20Behavior%20Analysis%20Rates.pdf) - [Behavioral Health Business: Nebraska Medicaid Rolls Out Steep Cuts to ABA Services (July 14, 2025)](https://bhbusiness.com/2025/07/14/nebraska-medicaid-rolls-out-steep-cuts-to-aba-services/) [ All posts ](https://streamaba.com/blog) ![]() Related posts ------------- [Browse all posts](https://streamaba.com/blog) - [ ![](/images/blog/2026/04/vermont-concurrent-billing-ban-aba-medicaid.jpg) billing ### Vermont Banned Concurrent ABA Billing. Revenue at Affected Clinics Dropped 17%. Your State Could Be Next. Vermont Medicaid banned concurrent billing of CPT codes 97153 and 97155 on January 1, 2026, citing an OIG audit that flagged $18.5 million in improper Wisconsin payments tied to the practice. Clinic revenue at affected providers dropped 16–17% within 60 days. CASP says the interpretation is wrong. Oregon allows it with documentation requirements. Most states have said nothing — and silence is now an audit risk. Apr 21, 2026 8 min read ](https://streamaba.com/blog/2026/04/vermont-concurrent-billing-ban-aba-medicaid) - [ ![](/images/blog/2026/02/idaho-aba-billing-code-switch.jpg) billing ### Idaho's ABA Billing Code Switch Is a Warning for Every Practice Idaho eliminated ABA from its managed care program and forced providers onto HCPCS codes with less than 30 days' notice. No crosswalk. No guidance on supervision billing. It's a warning shot for the entire industry. Feb 13, 2026 5 min read ](https://streamaba.com/blog/2026/02/idaho-aba-billing-code-switch) - [ ![](/images/blog/2026/04/georgia-caresource-aba-rate-cut.jpg) payers ### CareSource Georgia Just Cut ABA Rates 20%. Accept the Cut or Lose Your Contract. CareSource Georgia notified ABA providers they'll be reimbursed at 80% of the state Medicaid fee schedule starting early May — take the cut or lose the contract. With Georgia's entire CMO landscape reshuffling in July and no rate guidance from three incoming payers, Georgia practices face a financial one-two punch with no easy moves. Apr 13, 2026 8 min read ](https://streamaba.com/blog/2026/04/georgia-caresource-aba-rate-cut) Live demo · No sales call Ready to Streamline your practice? ------------------------------------ Get instant access to a live demo of the all-in-one ABA platform built by clinicians, for clinicians. No sales call. 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