January 2026 Policy and Law Updates Affecting Schools and Clinics

Beginning in 2026, many states are adjusting Medicaid reimbursement structures and utilization controls for autism-related services, including ABA. These changes stem from broader federal budget measures enacted in 2025 that reduced long-term Medicaid funding growth and increased state discretion over rate-setting and service limits.

Operational impact for clinics:

• Increased prior authorization scrutiny
• More frequent eligibility redeterminations for families
• Reimbursement rate reductions in some states
• Greater variability in coverage stability depending on payer mix

Private clinics relying heavily on Medicaid should expect more administrative overhead and should review staffing, documentation, and authorization workflows accordingly.

Several state insurance laws affecting autism services take effect January 1, 2026. These changes are not uniform across states.

Examples include:

• Removal of mandatory repeat autism re-diagnoses to maintain coverage in certain states
• Elimination of fixed visit caps in favor of utilization review models
• Alignment of autism coverage with mental health parity enforcement

Operational impact for clinics:

• Reduced re-evaluation burdens in some markets
• Continued payer-specific interpretation of “medical necessity”
• Ongoing need to verify plan-level rules rather than relying on state summaries

*Schools should note that these changes affect clinical coverage, not educational obligations.*

As of January 1, 2026, CMS has made ABA-related CPT codes permanently eligible for Medicare telehealth billing. While Medicare rarely funds pediatric ABA, this change signals broader acceptance of remote behavioral services within federal payment systems.

Operational impact:

• Limited direct effect on most pediatric clinics
• Potential downstream influence on commercial payer policies
• Continued requirement to comply with state licensure and telehealth rules

This change does not alter IDEA, school-based services, or private school obligations.

As of January 2026, no statutory changes to IDEA have taken effect. Proposals discussed in federal budget planning, including consolidation of funding lines or block-grant concepts, remain proposals rather than enacted law.

Operational impact for schools:

• No change to IDEA eligibility, IEP requirements, or FAPE obligations
• Continued uncertainty for long-term federal funding levels
• Increased importance of state-level budgeting decisions

Federal autism research, training, and coordination funding authorized under the Autism CARES Act remains in effect through fiscal year 2029.

Operational impact:

• Stability for research, workforce training, and technical assistance programs
• No direct mandate changes for schools or clinics
• Continued reporting and compliance obligations for grant recipients

Across states, there is growing attention to how private schools and clinics communicate enrollment criteria, capacity limits, and dismissal policies. This trend is driven more by complaints and civil rights enforcement than by new statutes.

Operational impact:

• Greater importance of clear intake documentation
• Consistent application of enrollment standards
• Clear distinction between accommodations and services offered

Programs with ambiguous or informal policies face higher risk than those with clearly articulated boundaries.

The following remain unchanged:

• Diagnoses alone do not guarantee services or enrollment
• Compliance does not require programs to alter their fundamental model
• Private programs retain discretion within non-discrimination limits

Much confusion in early 2026 stems from policy discussions rather than enacted changes.

A common source of confusion is the legal distinction between education and clinical services. Schools are governed primarily by education law. Clinics are governed primarily by healthcare, insurance, and licensing law. Hybrid models must navigate both.

• Public Schools and District Programs: Public schools have affirmative obligations under IDEA and Section 504. They must identify eligible students, provide services, follow procedural safeguards, and ensure access to due process. Enrollment is generally compulsory based on residency.
• Private Schools and Education Programs: Private schools generally have more discretion over enrollment and dismissal. They are not required to provide FAPE or IEPs unless acting under a public contract. Many private schools are subject to ADA and Section 504 non-discrimination rules, but these do not create IDEA-level obligations.
• Clinics and Therapy Providers: Clinics are governed by state licensure, insurance mandates, Medicaid rules, and federal parity laws. They do not provide education under IDEA unless contracted by a public agency. They may provide services that complement education but operate under different compliance frameworks.