For a Hawaii intake team, an Aetna card means three layers: Aetna’s national ABA policy, Hawaii’s autism mandate (Luke’s Law, HRS § 431:10A-133), and the plan’s funding type, which decides whether the mandate applies. Aetna runs no QUEST plan in Hawaii, and we found no Hawaii-specific Aetna ABA policy — the national documents plus the state law are the whole picture.
Aetna covers ABA for autism spectrum disorder under CPB 0554 (with CPB 0648 for ASD) and its ABA medical necessity guide, and considers ABA "experimental, investigational, or unproven" for Down syndrome without ASD and for all other non-ASD indications. The guide requires a DSM-5 ASD diagnosis by an appropriate provider, functional impairment on a standardized scale within the past 12 months, and a treatment plan with defined targets, baselines, generalization and titration. Progress is evaluated every six months. The behavioral health precertification list names all ten ABA codes.[1][2][3][4]
Hawaii’s autism mandate is Luke’s Law, Act 235 of 2015. It added the same autism section three times — to the insurance code as HRS § 431:10A-133, to chapter 432 for mutual benefit societies (HMSA’s chapter), and, through HRS § 432D-23, to HMO contracts — so every state-regulated carrier in Hawaii carries it. The text is narrow by current standards. Policies issued or renewed after January 1, 2016 must cover the diagnosis and treatment of autism for "individuals under fourteen years of age," and applied behavior analysis "shall be subject to a maximum benefit of $25,000 per year for services for children ages thirteen and under." Payments for anything other than ABA do not count toward that cap, and cost-sharing may be "no less favorable" than for substantially all medical services.[6][7]
The statute also sets rules intake should know: treatment requests "shall include a treatment plan," and the carrier may review the plan and medical necessity at its discretion; treatment must be "prescribed or ordered" by a licensed physician, psychiatrist, psychologist, licensed clinical social worker or registered nurse practitioner; coverage excludes custodial care, services by family or household members, experimental treatment and "services provided outside of the State"; network autism providers must clear state and federal criminal background checks; and a child diagnosed under an older DSM edition "may be required to undergo repeat evaluation" when a new edition is published. Exempt: self-funded employer plans (not state-regulated insurance) and disability, accident-only, Medicare, Medicare supplement, student, dental-only and vision-only policies and policies of six months or less. Whether a $25,000 annual ABA dollar limit can still be applied to a given plan alongside federal parity rules is a plan-level question; the statute text itself has not been amended since 2015.[6][7]
Hawaii licenses behavior analysts under HRS chapter 465D, run by the Department of Commerce and Consumer Affairs. A license requires having passed the BCBA examination and maintaining active BACB status as a BCBA or BCBA-D (HRS § 465D-8). Section 465D-7 exempts, among others, BCaBAs practicing "under the direction of a licensed behavior analyst," RBTs who directly implement ABA "under the direction of a licensed behavior analyst or a licensed psychologist," licensed psychologists and their supervisees, and graduate students and people accruing BACB experience hours under a licensed behavior analyst. Luke’s Law then limits covered autism treatment to providers "licensed by a state licensure board," so the supervising analyst on a commercial claim needs the Hawaii license, not just BACB certification.[9][8][13][6]
Aetna does not publish commercial ABA fee schedules for Hawaii; rates are set in your participating-provider agreement. Med-QUEST’s published FFS ABA rates (97153 at $17.66 per 15 minutes for 2025) are a public reference point, not a commercial floor.[14]
The questions that decide whether a family can start with Aetna in Hawaii, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis, but functional impairment must be shown on a standardized scale "in the past 12 months," and progress is re-evaluated every six months. Luke’s Law lets a carrier ask for a repeat evaluation when a new DSM edition is published.[3][6]
DSM-5 ASD "obtained by an appropriate provider (i.e. licensed psychologist/psychiatrist, physician or other health care professional qualified to diagnose mental health conditions within their scope of practice)." CPB 0648 lists professionals appropriate for ASD evaluation, from developmental pediatricians and neurologists to psychologists and SLPs.[3][2]
CPB 0648 names ADI-R, ADOS-2, CARS-2 and the Asperger Syndrome Diagnostic Scale for the diagnosis; the ABA guide requires a standardized functioning measure (Vineland-3, ABAS, VB-MAPP or ABLLS) within 12 months showing impairment at least one standard deviation below the mean, or significant risk of harm.[2][3]
Aetna’s national policies need no physician referral; they need precertification on all ABA codes. For fully insured Hawaii plans, Luke’s Law covers treatment "prescribed or ordered" by a licensed physician, psychiatrist, psychologist, LCSW or registered nurse practitioner, and each request must include a treatment plan.[4][3][6]
Aetna’s policies set no age cap. Luke’s Law requires coverage only for "individuals under fourteen years of age" on fully insured plans; beyond 13, coverage depends on the plan. Self-funded plans are outside the statute.[3][6]
Ask the plan: Benefits verification on the member ID — funding type, then the plan’s own ABA age terms.
Depends on funding. Group plans (fully insured through 45 CFR 147.136, self-funded directly) follow 29 CFR 2560.503-1: pre-service decisions "not later than 15 days," one 15-day extension, urgent within 72 hours. We found no Hawaii statute setting a shorter initial-decision deadline for fully insured plans; HRS § 432E-5 sets internal appeals at 72 hours expedited and 60 days.[10][11][12]
Ask the plan: Ask Aetna at benefits verification for its precertification turnaround and continuation lead time for this plan.
Order is set by the plans’ COB provisions; we found no Hawaii rule fixing it, so ask Aetna which plan is primary (and whether the birthday rule applies). If the child also has QUEST, Aetna pays first and Medicaid last — get Aetna precertification even so. TRICARE pays after this plan; CHAMPVA pays last.[14][15][16][17]
Ask the plan: Aetna benefits verification — record every other coverage the child has.
Coverage decides whether Aetna in Hawaii 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.
Services must be "provided directly or billed by licensed behavior analysts (in states with behavior analyst licensure laws), board-certified behavior analysts, or licensed psychologists" where ABA is in scope, unless state mandates, plan documents or contracts say otherwise; where others deliver services, "there must be supervision and direction" in line with practice standards. Aetna publishes no numeric ratio. In Hawaii, RBTs and BCaBAs may practice only under a licensed behavior analyst’s direction (HRS § 465D-7).[3][8]
No per-day or per-week unit cap. The guide gives typical intensities — comprehensive ABA 10–25 hours a week, focused ABA 1–20 hours a week — as typical, not limits. On fully insured Hawaii plans Luke’s Law caps ABA at $25,000 a year for children 13 and under.[3][6]
Outpatient ABA is setting-agnostic in Aetna’s guide, which expects coordination with the school district as applicable. Luke’s Law excludes "services provided outside of the State" and does not reduce IEP or IFSP obligations.[3][6]
Services must be "provided directly or billed by the appropriately licensed provider" — licensed behavior analysts in licensure states, BCBAs, or licensed psychologists in scope. Hawaii licenses behavior analysts (HRS ch. 465D), and Luke’s Law covers treatment only from a provider "licensed by a state licensure board."[3][9][6]
Yes — for ASD under Aetna’s national policy, with precertification on every ABA code. Fully insured Hawaii plans also carry Luke’s Law: coverage for children under 14, with ABA capped at $25,000 a year for ages 13 and under.
Luke’s Law (HRS § 431:10A-133) requires state-regulated plans to cover autism diagnosis and treatment for individuals under 14, with ABA subject to a $25,000 annual maximum for children 13 and under. Self-funded employer plans are exempt.
Commercial rates are negotiated in your provider agreement and not published.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 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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