NC Just Answered the 47% Question: HB 696 Bans Out-of-State BCBAs and Rewrites ABA Medicaid Coverage | StreamABA [ ![StreamABA](https://streamaba.com/build/assets/logo-light-CHa2KuSW.svg) Beta ](/) [Blog](https://streamaba.com/blog) [Back to Home](/) [Blog](https://streamaba.com/blog) [Back to Home](/) [ Back to Blog ](https://streamaba.com/blog) compliance medicaid state-policy north-carolina aba-therapy ccp-8f legislation NC Just Answered the 47% Question: HB 696 Bans Out-of-State BCBAs and Rewrites ABA Medicaid Coverage ====================================================================================================== April 22, 2026 StreamABA Team Share [ ](https://x.com/intent/tweet?url=https%3A%2F%2Fstreamaba.com%2Fblog%2F2026%2F04%2Fnc-hb-696-aba-medicaid-overhaul&text=NC+Just+Answered+the+47%25+Question%3A+HB+696+Bans+Out-of-State+BCBAs+and+Rewrites+ABA+Medicaid+Coverage) [ ](https://www.linkedin.com/sharing/share-offsite/?url=https%3A%2F%2Fstreamaba.com%2Fblog%2F2026%2F04%2Fnc-hb-696-aba-medicaid-overhaul) [ ](https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fstreamaba.com%2Fblog%2F2026%2F04%2Fnc-hb-696-aba-medicaid-overhaul) On April 22, 2026, the NC General Assembly adopted the conference report for House Bill 696 (112–1 House, 48–1 Senate). Section 3C.18 bans out-of-state BCBA and QASP Supervisor Medicaid enrollment, rewrites Clinical Coverage Policy 8F with nine required changes, and imposes monthly reauthorization for any ABA plan above 16 weekly hours. The Bill That Answered the Hearing ---------------------------------- Six weeks ago, North Carolina’s Joint Legislative Oversight Committee on Medicaid held a hearing on ABA therapy costs. The headline statistic: **47% of supervising BCBAs licensed in North Carolina don’t live in the state**. ABA Medicaid spending had grown 423% in four years, to a projected $639 million. Senators asked whether to pause Medicaid ABA entirely. On **April 21, 2026**, House and Senate negotiators released the Conference Committee Substitute for **House Bill 696 — Medicaid & HHS Adjust./Other Critical Needs**. On **April 22, 2026**, both chambers adopted it: **House 112–1, Senate 48–1**. Both chambers have placed the bill on calendar for **April 28, 2026** for final procedural action before transmission to the Governor. Section 3C.18 of HB 696 is the legislative answer to the March hearing. It rewrites NC Medicaid’s ABA coverage policy from the ground up. This post walks through what’s in it, line by line, and what NC ABA providers need to do before the rules take effect. What HB 696 Actually Is ----------------------- HB 696 is a 33-page Medicaid and HHS adjustment bill. It appropriates $319 million from the Medicaid Contingency Reserve to cover the 2025-2026 rebase and implements policy changes required by H.R. 1 (the “One Big Beautiful Bill Act”). It touches eligibility verification, community engagement (work) requirements, prepaid health plan networks, prepayment claims review, durable medical equipment rates, hospital assessments, and social services. For ABA providers, one section is the story: **Section 3C.18 — Medicaid Coverage for ABA Therapy.** Section 3C.18: The Nine CCP-8F Changes -------------------------------------- Clinical Coverage Policy 8F (Research-Based Behavioral Health Treatment for Autism Spectrum Disorder) governs NC Medicaid ABA coverage. HB 696 directs the Division of Health Benefits to amend CCP-8F — and seek CMS approval where required — to implement the following: ### 1. Paraprofessional Telehealth Prohibited > “Services under CCP-8F that are provided by a paraprofessional may not be conducted via telehealth unless exceptions are developed in accordance with subsection (b) of this section.” Direct ABA service delivery by RBTs and non-registered technicians must be in person. Exceptions require DHB to document medical necessity or access-to-care justification and report to the legislature. ### 2. Patient Assessments Must Be In Person > “Patient assessments by Licensed Qualified Autism Service Providers (LQASPs) are required to be conducted in person. Patient assessments conducted via telehealth shall not be reimbursed, unless exceptions are developed…” Initial and reassessment visits by the supervising clinician cannot be done remotely. ### 3. LQASP Supervision Telehealth Capped at 50% LQASP observation and direction of a paraprofessional **may be** conducted via telehealth — but those telehealth services cannot exceed **50% of the services provided by the LQASP under CCP-8F for any individual Medicaid recipient**. In practice: at least half of a BCBA’s supervision for each client must be in person. ### 4. Minimum 10% Supervised Observation > “At least ten percent (10%) of all services under CCP-8F that are provided by a paraprofessional must involve the observation and direction of the paraprofessional by a LQASP.” This is a floor on supervision intensity. For every 100 hours of paraprofessional service to a beneficiary, at least 10 hours must be with the LQASP observing. ### 5. Individualized Service Plans + 16-Hour Threshold LQASPs must develop and enforce an individualized service plan for each Medicaid beneficiary. The plan must include minimum requirements for parent, guardian, or caretaker involvement and training. Critical provision: > “For any plan involving more than 16 hours of services per week, the plan must be approved by a PHP or the Department. These plans shall be updated and reapproved monthly.” If you deliver more than 16 hours per week to a beneficiary, the PHP or DHB must approve the plan — and re-approve it every month. And unlike the telehealth limits in items 1–3, the 16-hour threshold has no exception pathway under Section 3C.18(b). Monthly reauthorization is the rule, not the default. ### 6. Parent/Caregiver Training Telehealth Allowed The one carve-out: parent, guardian, and caregiver training services delivered by LQASPs may be provided via telehealth with no in-person requirement. ### 7. Paraprofessionals Exempt from Medicaid Credentialing Paraprofessionals (RBTs and non-registered technicians) are exempt from Medicaid credentialing. This is a flexibility provision — it means you don’t have to enroll every RBT as a Medicaid provider. ### 8. RBT or ABAT Certification Required After 120 Days Paraprofessionals providing CCP-8F services must hold either: - **Registered Behavior Technician (RBT)** certification from the Behavior Analyst Certification Board (BACB), or - **Applied Behavior Analysis Technician (ABAT)** certification from the Qualified Applied Behavior Analysis Credentialing Board (QABA) Newly hired paraprofessionals get a **120-day grace period** from hire date (or from the provider’s Medicaid enrollment date, whichever is later). During the grace period, the paraprofessional may bill, but each service must be supervised by an LQASP. ### 9. LQASP-to-Paraprofessional Service Ratio: 10–20% For any beneficiary who receives **more than 200 hours of paraprofessional services in a six-month period**, the LQASP-delivered share must be **at least 10% but no more than 20%** of paraprofessional hours. Exceeding 20% is allowed with documented medical necessity. The ratio is calculated every six months. The provider must submit documentation to DHB in a format DHB will specify. Important scope note on all nine items: DHB may develop exceptions to **subdivisions (1) through (3) only** — paraprofessional telehealth, LQASP assessment telehealth, and the 50% LQASP supervision cap — based on documented medical necessity or access-to-care concerns (including poor provider availability in rural and underserved areas). Any exception must be adopted in CCP-8F or other medical coverage policy and reported to four legislative bodies: the House Health Committee, Senate Health Committee, Joint Legislative Oversight Committee on Medicaid, and Joint Legislative Commission on Governmental Operations. Items 4 through 9 — including the 16-hour threshold, the 10% observation floor, and the 10–20% LQASP ratio — have no exception pathway. The Out-of-State BCBA Ban ------------------------- Separate from the CCP-8F rewrite, Section 3C.18(c) amends G.S. 108C-9 to add: > “(e) Board Certified Behavior Analysts and Qualified Autism Services Practitioner Supervisors shall not be permitted to enroll in the North Carolina Medicaid program as out-of-state providers.” This is the direct response to the 47% statistic from the March hearing. It does not revoke NC behavior analyst licensure — that’s a separate board. It closes Medicaid **enrollment** to BCBAs and QASP Supervisors designated as out-of-state providers. Scope note: Section 3C.18(e) limits subsection (c) to **applications for enrollment submitted on or after enactment**. The bill does not on its face terminate already-enrolled out-of-state providers. Practices with existing out-of-state BCBA enrollments should expect the terrain to tighten — CCP-8F rulemaking, recredentialing cycles, and the state auditor’s review all pull in the same direction — but the April 22 bill text limits the immediate hit to new applications. Enforcement: Recoupment and Suspension -------------------------------------- Section 3C.18(d) gives DHB rulemaking authority to take two escalating actions for noncompliance with Section 3C.18 or any rule adopted under it: - **First or second occurrence of noncompliance**: recoup payments for all relevant noncompliant services. - **Third occurrence of *material and systematic* noncompliance**: suspend the provider’s Medicaid billing eligibility for a **minimum of one year to a maximum of two years**. The “material and systematic” qualifier on the third-occurrence tier matters. One-off documentation gaps aren’t the target; patterned, ongoing failure is. The bill does not enumerate a termination step beyond the 1–2 year suspension, and it does not define “occurrence” — rulemaking will fill both in. The Non-ABA Provisions That Still Affect ABA Practices ------------------------------------------------------ Section 3C.18 is the ABA-specific section. Several other parts of HB 696 affect every Medicaid provider — including ABA: **Section 3C.6 — Monthly eligibility data checks.** DHHS moves from quarterly to monthly review of beneficiary eligibility circumstances. Lottery and gambling winnings are added as tracked income sources. Effective October 1, 2026. Practices that rely on stable month-over-month authorizations should plan for more frequent eligibility churn. **Section 3C.7 — No self-attestation.** County DSS offices and DHHS cannot accept self-attestation as the only evidence of eligibility, except where federal law requires it. Effective October 1, 2026. Intake workflows that rely on client-reported income or household composition need documentation backup. **Section 3C.13 — Prepayment claims review tightened.** Placement on prepayment review now rests on credible fraud allegations, aberrant billing, failure to respond to documentation requests, or other DHB-defined grounds. Three changes matter for providers already on review or at risk of placement: (1) the clean-claims threshold a provider must achieve for three consecutive months to exit review rises from **70% to 80%**; (2) the 24-month cap on how long a provider can remain on prepayment review is **eliminated**; (3) PHPs may place providers on prepayment review without DHHS approval, and the 20-day advance notice period is gone. A provider that fails to meet the 80% threshold for three consecutive months within six months of placement can face sanctions including termination of the Medicaid Administrative Participation Agreement. PHPs may also exclude providers from their networks subject to DHHS approval — and DHHS has 90 days to respond to an exclusion request or it’s deemed approved. **Section 3C.12 — Closed PHP networks.** PHPs can develop closed networks for service categories where an open network would “jeopardize quality of care, program integrity, or cost-effective use of Medicaid funds.” DHHS has 180 days to respond to a closure request or it’s deemed approved. **Section 3C.5 — Community engagement requirements.** Effective January 1, 2027, Medicaid applicants must prove three consecutive months of work-requirement compliance before application, and three of the last six months at redetermination. For ABA practices whose beneficiaries depend on parent eligibility categories, redetermination cycles will need closer tracking. **Section 3C.10 — State Auditor performance audit.** $500,000 appropriated for a performance audit of Medicaid administration and NCWorks. Effective July 1, 2026. Timeline -------- DateWhat ChangesOn enactmentCCP-8F rewrite (Section 3C.18 subdivisions 1–9) effective; out-of-state BCBA/QASP enrollment ban (Section 3C.18(c)) applies to enrollment applications submitted on or after this dateJuly 1, 2026State Auditor Medicaid performance audit fundedOctober 1, 2026Monthly eligibility checks; self-attestation restrictions; immigration referral requirements; DHB efficiency plan dueJanuary 1, 2027Community engagement requirements take effectJune 30, 2027Section 3C.1 end date for most Medicaid program modifications in this Part (DHHS no longer required to maintain them beyond this date, except where statutorily required or otherwise specified)July 1, 2027Federal-maximum copayments requiredThe bill itself directs DHB to amend CCP-8F and, if necessary, seek CMS approval. Policy-driven operational rollout will span 2026 into 2027. What NC ABA Practices Need to Do This Week ------------------------------------------ **Audit your supervision model.** Section 3C.18(c) applies to enrollment applications submitted on or after enactment — new out-of-state BCBA/QASP Supervisor enrollments are blocked. For existing out-of-state Medicaid enrollments, the bill does not automatically unseat them on day one, but the CCP-8F rewrite, credentialing cycles, and the state auditor’s review all move in the same direction. Start the in-state recruiting and recredentialing conversation now. **Inventory your caseload by weekly hours.** Every beneficiary receiving more than 16 hours per week triggers PHP/DHB plan approval and monthly reauthorization. Build the workflow: who owns the monthly renewal, where does the documentation live, what’s the escalation path when a renewal stalls. **Calculate your LQASP-to-paraprofessional ratio.** For any beneficiary who will cross 200 paraprofessional hours in a six-month window, run the numerator/denominator now. If you’re below 10%, add LQASP hours. If you’re above 20% and can’t document medical necessity, either reduce LQASP hours or tighten documentation. **Verify RBT/ABAT certification status for every paraprofessional.** Newly hired techs get 120 days. Anyone past the grace period without certification cannot bill. Pull the roster, check BACB and QABA directories, and date-stamp the compliance. **Model your clean claims rate against the 80% threshold.** Under the new Section 3C.13, the exit bar off prepayment review rises from 70% to 80% clean claims for three consecutive months, and the 24-month cap is gone. Any placement on prepayment review — whether driven by fraud allegations, aberrant billing data, or a PHP decision — now leaves a provider on review indefinitely until they hit the higher threshold. Denial analysis is no longer a back-office concern — it’s a survival metric. **Plan for in-person assessments and 50%+ in-person supervision.** If your model routes most supervision through telehealth, you now have a structural ceiling at 50%. Budget the travel time, the mileage, and the BCBA capacity. The Pattern ----------- HB 696 is the third major NC regulatory action in 40 days. On [March 11, the legislative oversight hearing](/blog/north-carolina-aba-provider-quality-hearing) surfaced the question. On [April 16, NC Medicaid activated accreditation monitoring](/blog/nc-medicaid-accreditation-enforcement-april-2026). On April 22, the legislature delivered the policy response. The state auditor’s review is still to come. So is the DHB program integrity and efficiency plan due October 1, 2026. The direction isn’t ambiguous. For NC providers: the practices that were already running on individualized treatment plans, in-person supervision, documented clinical ratios, and clean documentation will adapt to HB 696 with operational friction but not existential risk. The practices that lean on out-of-state supervision, heavy telehealth, uncertified techs past 120 days, or 40-hour defaults with no individualization are the ones this bill pressures hardest. For providers outside North Carolina: this is a template. The 16-hour threshold, the 10-20% LQASP ratio, the telehealth caps, the paraprofessional certification floor — every one of these is portable policy. When [Centene](/blog/centene-aba-crackdown-what-small-practices-need-to-know) and state Medicaid programs in other states ask the same question NC legislators just answered, HB 696 is the answer they’ll reach for. --- Questions about how your practice’s supervision ratios, clean claims rate, or documentation workflows line up with HB 696’s new requirements? Reach out at **hello@streamaba.com** — we’re happy to walk through it. Follow us on [LinkedIn](https://www.linkedin.com/company/stream-aba) and [X](https://x.com/streamaba) for more industry updates. ![]() ### Ready to streamline your practice? Request an invite to the all-in-one ABA platform built by clinicians, for clinicians. Work email Request an Invite Related Posts ------------- [### North Carolina Is Asking How to Tell Good ABA Providers from Bad Ones. The Answer Is Measurable. NC legislators are alarmed over a 423% increase in ABA Medicaid spending. The state auditor is launching a deep dive. A Charlotte provider testified about quality variation. And a senator asked if the state should pause Medicaid ABA entirely. Here's what the hearing revealed — and what distinguishes quality providers at the system level. Mar 13, 2026 ](https://streamaba.com/blog/2026/03/north-carolina-aba-provider-quality-hearing) [### North Carolina Medicaid Switches On Accreditation Enforcement Monday. Does It Apply to Your ABA Practice? On April 20, 2026, NC Medicaid begins monitoring national accreditation status for all organizations enrolled under the 251S00000X (Community/Behavioral Health Agency) taxonomy. Individual NPI providers are explicitly exempt. ABA agencies enrolled as 251S00000X face a one-year accreditation clock. Apr 17, 2026 ](https://streamaba.com/blog/2026/04/nc-medicaid-accreditation-enforcement-april-2026) [### Centene Is Coming for ABA Outliers. Here's What That Means for Your Practice. Centene's CEO just told investors that behavioral health — driven by ABA — accounts for half their excess Medicaid costs. They've built a 29-state task force, they're hiring BCBAs to review your authorizations, and they've already cut outlier providers. Here's what they're looking for and how to make sure you're not on the list. Feb 14, 2026 ](https://streamaba.com/blog/2026/02/centene-aba-crackdown-what-small-practices-need-to-know) [### ABA Accreditation Is Becoming Mandatory — Not Just Nice to Have Massachusetts is the first state to require accreditation for Medicaid-funded ABA providers. With $56M in federal fraud audits and a single unified accreditation body, the rest of the country is watching. Here's what practice owners need to know. Feb 12, 2026 ](https://streamaba.com/blog/2026/02/aba-accreditation-becoming-mandatory) [ ![StreamABA](https://streamaba.com/build/assets/logo-dark-DgLdtTeS.svg) Beta ](/) The all-in-one practice management platform built specifically for ABA therapy providers. Work email Request [ ](https://x.com/streamaba) [ ](https://www.linkedin.com/company/stream-aba) [ ](https://instagram.com/streamaba) [ 👍 ](https://www.facebook.com/people/Stream-ABA/61587347484176/) #### Product - [Intake](https://streamaba.com/features/intake) - [Clinical Data](https://streamaba.com#clinical) - [Scheduling](https://streamaba.com#scheduling) - [Billing & Claims](https://streamaba.com#billing) - [Family Portal](https://streamaba.com#family-portal) #### Company - [About](https://streamaba.com/our-story) - [Blog](https://streamaba.com/blog) - Careers #### Resources - [Revenue Calculator](https://streamaba.com/tools/aba-revenue-calculator) - Case Studies - [Help Center](https://streamaba.com/support) #### Contact - - [ Contact Support ](https://streamaba.com/support) © 2026 STREAM ABA LLC. All rights reserved. [Privacy Policy](https://streamaba.com/legal/privacy-policy) [Terms of Service](https://streamaba.com/legal/terms-of-service) [BAA Agreement](https://streamaba.com/legal/baa)