The rule was read from the State Records Center and Archives copy of 8.321.2 NMAC, with the Autism Intervention state plan amendment SPA NM 22-0022 approved January 25, 2023, effective October 1, 2022, and the fee schedule attached to HCA Letter of Direction 53, dated March 21, 2025 (8.321.2 NMAC; CMS SPA NM 22-0022; HCA Letter of Direction 53). No fee schedule after January 1, 2025 was located, and a 2022 manual supplement used for settings and tiers may be superseded by a later manual that was not found.
The fee schedule pays the same code at different rates depending on who delivers it. The schedule's own notes say managed care rates may differ from fee-for-service, and the Letter of Direction sets the fee-for-service rate as the floor for the managed care organizations.
The reimbursement criteria at a glance
- Is ABA covered by New Mexico Medicaid
- Who is eligible and who diagnoses
- Rates
- Place of service and telehealth
- Prior authorization
- Provider qualifications and enrollment
- The commercial mandate
- Practices with in-house diagnostics versus ABA-only practices
- How this connects to the rest of your compliance stack
- What this guide could not verify
- New Mexico reimbursement variables at a glance
- Frequently asked questions
- Where professional advice is essential
Is ABA covered by New Mexico Medicaid
Yes. The rule states: "MAD pays for medically necessary, empirically supported, applied behavior analysis (ABA) services for eligible recipients who have a well-documented medical diagnosis of autism spectrum disorder (ASD), and for eligible recipients who have well-documented risk for the development of ASD." It adds: "There is no age requirement to receive ABA services and ABA is a covered benefit for medicaid enrolled adults" (8.321.2.13 NMAC, history 12/10/2024). The state plan covers Autism Intervention services under the preventive services benefit, and SPA 22-0022 was submitted "to prohibit age and dollar limits on services related to autism spectrum disorder," approved January 25, 2023, effective October 1, 2022 (CMS, SPA NM 22-0022).
Who is eligible and who diagnoses
"Confirmation of the presence or risk of ASD must occur through an approved autism evaluation provider (AEP) through a comprehensive diagnostic evaluation." The at-risk criteria apply to children between 12 and 36 months of age with listed conditions. A recipient "may be referred for ABA services with a presumptive diagnosis of ASD by a licensed practitioner whose scope of practice allows them to render a diagnosis of ASD," and the diagnosis "must have been received within three years of referral to stage two or three services" (8.321.2.13 NMAC). An AEP "must be a licensed psychologist, or board-certified or board-eligible physician in developmental behavioral pediatrics, pediatric neurology, or child psychiatry" (HCA Letter of Direction 53, fee schedule glossary).
Rates
The fee schedule is "Effective 1/1/25" and "the MCOs shall not negotiate less than the Medicaid fee-for-services (FFS) rate identified in the attached fee schedule" (HCA Letter of Direction 53, March 21, 2025). Each unit is 15 minutes unless noted. Rates are listed by the credential of the person delivering the service.
| Code | Qualifying psychologist / BCBA-D | BCBA | BCaBA | Technician (BT) |
|---|---|---|---|---|
| 97151 | $130.94 | $112.65 | ||
| 97152 | $65.47 | $58.33 | ||
| 97153 | $38.02 / $37.99 | $32.31 | $23.35 | $19.85 |
| 97154 (group) | $21.88 | $18.59 | $13.43 | $11.43 |
| 97155 | $55.55 | $39.69 | ||
| 97156 | $35.79 | $25.78 | ||
| 97157 | $71.43 | $51.59 | ||
| 97158 (group) | $15.88 | $12.69 |
For 97153, the qualifying psychologist rate is $38.02 and the BCBA-D rate is $37.99. State-specific T1026 codes pay per hour: the comprehensive diagnostic evaluation at $206.33, clinical management and case supervision for a BCBA at $142.84, and a supervising BCaBA at $109.27. Category III code 0362T pays up to $130.94 and 0373T up to $119.05 for a psychologist or BCBA-D and $107.13 for a BCBA. Whether a BCaBA billing under a supervising analyst's modifier changes the rates for 97155 and 97156 was not verified.
Place of service and telehealth
The program supports ABA "in all the following natural environments": home, school, clinics, hospitals and outpatient services, childcare centers, community-based settings, and place of work. The rule excludes "activities that take place in school settings and have the potential to supplant educational services." Payment for a residential facility's recipient "is made to the MAD enrolled ABA provider, not the residential facility" (8.321.2.13 NMAC; Supplement 22-02). "MAD allows and encourages the utilization of telemedicine to deliver MAD ABA services." Code 0362T "cannot be rendered in the recipient's home; must be rendered in a customized center or clinic setting" (Medical Assistance Program Manual Supplement 22-02, January 27, 2022).
Prior authorization
"Prior authorization to continue ABA stage three services must be secured every six months," and at each authorization a utilization review contractor assesses whether changes are needed to the treatment plan. The request states "the requested treatment model (focused or comprehensive)" and the "maximum hours of service requested per week" (8.321.2.13 NMAC). For fee-for-service recipients the Third Party Assessor reviews, and a managed care organization or the assessor "must employ or contract with a BCBA, BCBA-D, or a BACB Qualifying Psychologist" to review stage three requests. For a recipient from 12 months to under eight years, the service authorization is three years, with prior authorization every six months within it. An adult in Tier Three has 30 to 40 hours per week for up to eight weeks without prior authorization (Supplement 22-02). The Letter of Direction is addressed to the Turquoise Care managed care organizations; their names and any child hour cap were not verified.
Provider qualifications and enrollment
A behavior analyst is "a board certified behavior analyst (BCBA or BCBA-D) by the behavior analyst certification board or a psychologist who is certified by the American board of professional psychology in behavior and cognitive psychology and who was tested in the ABA part of their certification." Providers enroll by provider type and specialty, with behavior analysts and technicians "through an ABA provider agency," and "all providers must successfully complete a criminal background registry check" (8.321.2.13 NMAC). A BCBA or BCBA-D enrolls as provider type 445, specialty 099. A BCaBA is provider type 430, specialty 151. An RBT or board certified autism technician is provider type 430, specialty 098, must be at least 18 with a high school diploma or equivalent, and an RBT completes at least four hours of training in Autism Spectrum Disorders (HCA attestation forms MAD 877, 873, 878, issued 10/16/2024). See the New Mexico Licensing page.
The commercial mandate
NMSA 59A-22-49 covers "treatment of autism spectrum disorder through speech therapy, occupational therapy, physical therapy and applied behavioral analysis" (NMSA 59A-22-49, history Laws 2009, ch. 74; 2019, ch. 119). The current age and dollar limits after the 2019 amendment were not read from the official text, so none is stated here.
Practices with in-house diagnostics versus ABA-only practices
New Mexico's rate table pays a qualifying psychologist more than a BCBA for the same code, and a psychologist can also be an approved autism evaluation provider. A practice with an in-house psychologist can capture the diagnostic evaluation (T1026) and the higher psychologist-level rates, while an ABA-only practice sends the diagnostic evaluation outside and bills at the BCBA rates.
How this connects to the rest of your compliance stack
See the New Mexico Licensing page for the credential posture and the New Mexico entity page for the structure analysis.
What this guide could not verify
- Any ABA fee schedule effective after January 1, 2025.
- The Turquoise Care managed care organization names and any child hour cap.
- Whether Supplement 22-02 has been superseded by a later behavioral health policy and billing manual.
- The age and dollar limits of the commercial mandate after the 2019 amendment.
New Mexico reimbursement variables at a glance
| Variable | New Mexico value |
|---|---|
| ABA covered by Medicaid? | Yes, 8.321.2.13 NMAC (effective December 10, 2024); SPA NM 22-0022 |
| Age limit | None |
| 97153 rate | BCBA $32.31; technician $19.85 per 15 minutes (January 1, 2025) |
| Stage 3 prior authorization | Every six months |
| Provider types | BCBA 445/099; BCaBA 430/151; RBT or BCAT 430/098 |
Frequently asked questions
Is there an age limit?
Can a managed care organization pay less than the fee schedule?
Is telemedicine allowed?
Where professional advice is essential, not optional
New Mexico pays by credential, so the credential mix of your staff changes revenue more than in most states. Model each code by the person delivering it and confirm whether a newer schedule than January 2025 exists.
The governing authorities to know are 8.321.2.13 NMAC, SPA NM 22-0022, and NMSA 59A-22-49.
This page describes rules read from the New Mexico Administrative Code, CMS state plan documents, and Health Care Authority publications. The Health Care Authority, the Office of Superintendent of Insurance, and each payor provide current requirements. Do not rely on this page or any secondary source in place of direct verification.