Aetna Better Health of Kentucky is one of the five Kentucky Medicaid MCOs and the plan that runs SKY (Supporting Kentucky Youth) for children in foster care. Its ABA rules are spread across three documents: a December 2024 notice that adopted MCG criteria and an autism-diagnosis claim edit, a May 2025 notice that reinstated prior authorization for every ABA code, and the 2026 provider manual for claims and appeals.
Aetna Better Health of Kentucky "adopted Milliman Clinical Guidelines (MCG) as the primary criteria for medical necessity for all services except for substance use treatment services." Its December 17, 2024 network notice explains the consequence for ABA: under the MCG Behavioral Healthcare Guideline, ABA is appropriate for autism spectrum disorder, and "ABA is considered experimental, investigational, or unproven for all other non-ASD indications." From January 1, 2025, ABA claims must carry the ASD diagnosis; claims without it "will be denied," with the standard appeal process available. MCG is licensed criteria the plan does not publish.[1][4]
After House Bill 695, Aetna Better Health resumed behavioral health prior authorization "for all members – adults, adolescents, and children," including SKY members, for new and ongoing treatment. Its table lists ABA codes 97151 through 97158 with "Clinical Record, copy of assessment(s) confirming Autism diagnosis and Treatment Plan" required, for dates of service from June 25, 2025. The ABA Outpatient Treatment Request form asks for diagnosis, setting, weekly intensity, units by code, a functional impairment rating, clinical data, progress and discharge planning, and says requests "MUST be received within (2) buisness days of the requested start date" and "The maximum timeframe that may be requested is (6) months." The treatment plan must be attached. Out-of-network providers need authorization for everything except emergent or urgent care.[2][3]
The 2026 manual sets timely filing at "365 calendar days from the date of service" for professional claims, 365 days from the primary payer’s remittance for coordination-of-benefits claims, and 24 months from the first remittance for corrections. Claims need an active Kentucky Medicaid ID and an NPI and taxonomy matching the state provider file. Provider appeals of a denied claim go to KY Appeals & Grievances and "We must receive your appeal within one (1) year of the incident, remit date or date of notice"; Aetna answers in writing within 30 calendar days. An appeal on a member’s behalf (with written consent) follows the member process: file within 60 days of the adverse benefit determination.[4]
The questions that decide whether a family can start with Aetna Better Health of Kentucky, and what they have to bring. Each maps onto something intake should ask on the first call.
No age limit: the PA notice applies to "all members – adults, adolescents, and children," and the state regulation sets none.[2][7]
No referral is required by the plan’s ABA documents or the state regulation; what is required is prior authorization with the clinical record, autism assessment and treatment plan.[2][7]
Aetna Better Health’s manual says telehealth follows "Commonwealth regulations" and publishes no ABA telehealth rule, so the state rule applies. 907 KAR 3:170 makes its telehealth policies "supersede any in-person requirement established within KAR Title 907" (unless a law, licensing board, professional criteria or the billing code itself requires in-person), applies them to fee-for-service and to MCO coverage alike, and defines place of service as wherever the patient is, "including … the patient’s home or office, or a clinic, school, or workplace." A service is reimbursable by telehealth when it is appropriate and safe for the technology, not prohibited by the provider’s licensing board, and delivered by an enrolled provider; reimbursement is at least 100 percent of the in-person rate (an MCO may negotiate otherwise), telehealth must be denoted "by place of service or other means," and referral rules are the same as in person. Neither DMS nor any Kentucky MCO document read publishes an ABA-specific telehealth code list or modifier. The licensing board requires a Kentucky license for anyone delivering ABA by telehealth to a client located in Kentucky (201 KAR 43:100, Section 2).[4][8][16]
Kentucky’s MCO contract (§ 18.6) is stricter than the federal floor: a standard prior authorization is decided "no later than five (5) Days after receiving the necessary information" (contract "Day" means calendar day; "necessary information" is as defined in KRS 304.17A-607), extendable up to 14 days at the provider’s or enrollee’s request; expedited decisions within 24 hours of all necessary information; and "an untimely service authorization constitutes a Denial" that can be appealed. Federal law caps standard MCO decisions at 7 calendar days from the request for rating periods starting on or after January 1, 2026.[6][11]
Aetna Better Health is the payer of last resort; bill the primary and send its EOB, and COB claims must arrive within 365 days of the primary carrier’s remittance. A commercial bypass list lets some codes go straight to the plan without an EOB. Medicaid pays last. The MCO contract (§ 14.2) says Medicaid "shall be used as a source of payment for Covered Services only after all other sources of payment have been exhausted," and when another resource is known the plan "shall avoid payment by ‘cost avoiding’ (denying) the Claim and redirecting the provider to bill the other Third Party Resource as a primary payer" (42 CFR 433.139). So bill the commercial plan first and follow its ABA prior authorization.[4][6][12]
Not stated by the plan; MCG criteria are licensed and unpublished.[1]
In licensed criteria: Aetna Better Health of Kentucky behavioral health UM, 1-855-300-5528.
Not stated by the plan. Kentucky law excludes diagnosis from the practice of ABA (KRS 319C.010(8)).[1][15]
Ask the plan: Aetna Better Health of Kentucky behavioral health UM, 1-855-300-5528.
The plan asks for "assessment(s) confirming Autism diagnosis" but names no instrument; MCG is licensed.[2]
In licensed criteria: Aetna Better Health of Kentucky behavioral health UM, 1-855-300-5528.
Coverage decides whether Aetna Better Health of Kentucky pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Aetna Better Health’s manual and ABA notices publish no supervision rule of their own, so the state rule applies. 907 KAR 15:010, Section 3(3)(r)4 says ABA "shall be provided by" a licensed behavior analyst, a licensed assistant behavior analyst, or an approved behavioral health practitioner (or one under supervision) "with documented training in applied behavior analysis," and that "a registered behavior technician under the supervision of an appropriate practitioner" may provide "support services." No numeric supervision ratio is set. The documentation rules carry the supervision: notes by a practitioner working under supervision must be co-signed and dated by the supervising professional within 30 days, with a monthly supervisory note on the case. 907 KAR 15:005 defines the RBT by BACB training, competency assessment and exam, within six months of hire.[4][7][14]
No ABA unit cap is published; the OTR form asks for units by code and caps the authorization period at 6 months.[3][2]
The plan publishes no ABA-specific note rule; the state rule applies. Under 907 KAR 15:010, Section 6, service notes must be made within 48 hours of each visit, say whether the service was face-to-face or telehealth, state a start and end time, and be "recorded and signed by the rendering behavioral health practitioner" with the practitioner’s professional title; "initials, typed signatures, or stamped signatures shall not be accepted" (compliant electronic signatures are allowed under Section 9). Notes by a practitioner under supervision are co-signed by the supervisor within 30 days, and the plan of care is reviewed at least every six months.[4][7]
The manual requires an active Kentucky Medicaid ID and an NPI and taxonomy that match the Commonwealth’s provider file for the date of service, or the claim denies. It publishes no ABA-specific rendering rule; the state rule bills the practitioner who provided the service or under whose supervision it was rendered, or the group (907 KAR 15:010).[4][7]
The plan publishes no ABA concurrent-billing rule. The state’s rule: DMS allows 97155 to be billed concurrently with 97153 from December 2, 2025 "when the patient is present, and the qualified health professional is directing the technician." DMS’s letter is addressed to providers, not specifically to MCOs.[9][4]
Ask the plan: Aetna Better Health of Kentucky Network Relations, 1-855-300-5528: confirm it pays 97153 and 97155 for the same time under the DMS letter.
The plan publishes no ABA setting rule beyond the "Treatment setting" field on its OTR form; the state regulation sets no ABA setting restriction, and 907 KAR 3:170 counts the home, clinic or school as the telehealth place of service.[3][7][8]
Ask the plan: Aetna Better Health of Kentucky Network Relations, 1-855-300-5528: ask which place-of-service codes it pays for ABA.
Yes, for all ABA codes (97151–97158) for dates of service from June 25, 2025, for adults and children, including SKY members.
No. It uses MCG criteria, which support ABA for ASD only, and since January 1, 2025 it denies ABA claims that lack the ASD diagnosis.
The OTR form says requests must be received within 2 business days of the requested start date, and a request can cover at most 6 months.
365 calendar days from the date of service; corrected claims within 24 months of the first remittance.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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