This is an exclusive BHB+ story

When it comes to payer trends in behavioral health, value-based care is generally top of mind for most. And value-based care is certainly a critical movement set to impact the behavioral health industry in 2025 and beyond.

But several under-the-radar trends in behavioral health reimbursement could also significantly reshape the industry’s financial landscape.

For example, we’ve begun to see payers evaluate cost-cutting strategies for applied behavior analysis (ABA) services, particularly in the Medicaid space. This could impact patient care and the burgeoning autism treatment business.

While autism providers could face some challenges in reimbursement, substance use disorder (SUD) providers may have more options for treatment as contingency management programs come to center stage.

In this Update, I wanted to examine the lesser-written trends we’ve covered that are shaping the reimbursement landscape in behavioral health.

In this week’s exclusive, members-only BHB+ Update, I explore:

— How some payers plan to curb autism services spending

— Why contingency management could be on the rise

— Why more therapists are no longer taking insurance

Payers may limit ABA hours

Autism rates are on the rise in the U.S., with roughly 1 in 36 children have been diagnosed with the condition nationwide, according to the CDC.

While treatment for autism can vary, often children are prescribed a mixture of applied behavior analysis, as well as speech and occupational therapy. ABA is often the gold standard for autism care. But, intensive and long-term ABA can mean 25 to 40 hours of therapy a week for between 1 and 3 years.

As a result, some payers are seeing costs rise in relation to autism therapy.

Recently, we’ve seen Indiana’s Medicaid program propose a new plan to cap the coverage of ABA hours for children. Specifically, the plan would limit ABA coverage to 30 hours a week for a duration of three years. The proposal said that ABA cost the Medicaid program $398 million in 2024.

But this isn’t the only instance where payers are looking to curb ABA costs. At the end of December, a report by ProPublica said that Optum was executing a multi-pronged plan to curb spending on ABA provided to patients covered by Medicaid.

The report stated that Optum saw a 20% increase in the number of members seeking ABA services, with spending on ABA increasing $75 million yearly. While Optum said the ProPublica article “grossly misrepresents our efforts to ensure the people we serve are getting the most effective, evidence-based care for their needs,” it is clear payers are starting to look at the bottom line with autism services.

Anecdotally, Behavioral Health Business has also heard about some payers and the organizations that work with them trying to move to more of a case-rate framework around autism therapy, too. And there are ongoing efforts to better train parents, enabling them to be more hands on with therapy.

That latter is a trend we’ve seen in other parts of health care, including in the Medicaid home- and community-based services (HCBS) space via consumer-directed models.

I’m going to keep an eye out for any other payer moves to limit the spending on autism services, especially ABA.

More payers will cover contingency management plans

Contingency management programs have been a hot topic in substance use disorder treatment for a long time. Still, getting this type of program covered by payers has been difficult.

Contingency management programs use incentives, often financial, to reward positive behavior. For example, if a person with an SUD gets a clean drug screen, they may be rewarded with a gift card.

Research supports the efficacy of contingency management plans for substance use disorders. And that includes some conditions, such as methamphetamine use disorder and other stimulant addictions, that are often difficult to treat. Contingency management, in fact, has been proven to be one of the most effective methods of treatment for stimulant use disorders.

While implementing these types of programs seems like a no-brainer, there have been some concerns raised over them in recent years — mainly around concerns over fraud and impropriety.

Yet a few years back, the Office of the Inspector General (OIG) released a report demonstrating that contingency management services are working.

Over the last few years, some movement has been made in getting these types of programs covered. In 2022, California became the first state to cover contingency management through Medicaid following federal clearance for a special waiver.

But contingency management plans are now in the national spotlight. The Substance Abuse and Mental Health Services Administration announced at the beginning of the year that it will now allow SAMHSA grant recipients to provide a motivational incentive value of up to $750 per patient per year as part of a contingency management plan. Historically, patients could only receive $75 a year.

I think this is a step in the right direction, especially as there are so few options for treating stimulant disorders. Even so, it’s important to note that the bulk of the movement on contingency management programs is in the public sector. It will be interesting to see if private payers begin to adopt policies around contingency management in the future.

More therapists will start going cash pay

Frustrated by stagnant reimbursement rates in behavioral health, we’re starting to see an uptick in therapists nixing payer contracts altogether and going cash pay.

The numbers tell a troubling story. Thirty-four percent of psychologists are not currently in network with any insurance, according to the American Psychological Association.

Additionally, only 53% of therapists said it was “worth it” to accept insurance, according to Beacon Media and Marketing’s 2025 State of Mental Health Insurance and Marketing Report.

I don’t blame the therapists and psychologists for going out of network. A study from RTI International reported that behavioral health clinicians are reimbursed at rates 22% lower than medical and surgical clinicians. Of course, I think it’s a shame for patients struggling to access care. This move could potentially propel the move to a two-tier mental health system.

But this trend isn’t just a negative for patients. It could also hurt payers by impacting their network adequacy requirements. Additionally, the wave of providers moving away from in-network contracts, could also mean more ghost networks on the horizon.

One way that payers may try to combat this trend is by teaming up with behavioral health services like Grow Therapy, Alma and Headway that facilitate partnerships with insurance networks to offer in-network sessions with major payers.

While these could be one solution to boosting network adequacy, I can’t help but think patients are missing out if more therapists continue to move away from accepting insurance.