Aetna ABA coverage in Michigan: the intake guide.

No expiry on the diagnosis itself, but a 12-month clock on function: medical necessity requires "demonstration of functional impairment on a standardized scale of functioning in the past 12 months" at least one standard deviation below the mean or a significant risk of harm; progress is re-evaluated every six months. On fully insured Michigan plans the mandate also lets the carrier request a repeat ADOS no more than once every three years.^[3][5]

A DSM-5 ASD diagnosis (ICD-10 F84.0, F84.3–F84.9) "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)." For fully insured Michigan plans the mandate defines the diagnosis as assessments, including the ADOS, performed by a licensed physician or licensed psychologist.^[3][5]

CPB 0648 names the diagnostic instruments: ADI-R, ADOS-2, CARS-2 and the Asperger Syndrome Diagnostic Scale. The ABA guide then requires a standardized measure of functioning within the past 12 months (examples: Vineland-3, ABAS, VB-MAPP, ABLLS) showing impairment at least one standard deviation below the mean or a significant risk of harm.^[2][3]

Aetna’s national ABA criteria require no physician referral; what they require is precertification, and the behavioral health precertification list names all ABA codes (97151–97158, 0362T, 0373T). For a fully insured Michigan policy the mandate adds an order requirement: covered treatment is care "prescribed or ordered for an individual diagnosed with 1 of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary," and the treatment plan is developed "when the treatment of an autism spectrum disorder is first prescribed or ordered." Self-funded ERISA plans sit outside the statute.^[4][3][5]

Aetna’s national ABA policies set no age cap; its guide lists typical, not limiting, age ranges (comprehensive ABA typically 0–7, focused ABA all ages). Michigan’s mandate lets a fully insured carrier limit autism treatment coverage to members "through 18 years of age" and cap it at $50,000 a year through age 6, $40,000 for ages 7–12 and $30,000 for ages 13–18; whether a given plan uses those limits is in its certificate. Self-funded ERISA plans set their own terms.^[3][5][6]

Ask the plan: Live benefits verification on the member ID: fully insured vs. self-funded, and whether the certificate applies the mandate’s age-18 and annual-dollar limits.

Turns on how the plan is funded. Fully insured Michigan insurance and HMO plans follow MCL 500.2212e: after May 31, 2024 a non-urgent prior authorization request "is considered granted" if the insurer does not grant it, deny it, or ask for more information "within 7 calendar days after the date and time of submission," and again within 7 calendar days after additional information is submitted; a request the provider certifies as urgent is considered granted if not acted on within 72 hours. An approved authorization "is valid for not less than 60 calendar days or for a duration that is clinically appropriate, whichever is later." The statute’s "health benefit plan" covers individual and group insurance, HMO contracts, and self-funded plans of the state or local governments, not private self-funded employer plans, which follow ERISA: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension, urgent claims within 72 hours.^[10][11]

Ask the plan: At benefits verification ask whether the plan is fully insured (Michigan-regulated) or self-funded (ERISA), then confirm the Aetna turnaround and reauthorization lead time (precertification via Availity or the number on the member ID card).

Which plan pays first is set by Michigan’s Coordination of Benefits Act for state-regulated plans: for a dependent child whose parents are married or living together, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday: the plan covering the parent longer); for divorced or separated parents a court order assigning health coverage controls, then the order in MCL 550.253. The autism mandate adds that a member with two policies covering autism gets benefits "subject to the limits of this section when coordinating benefits." If the child also has Michigan Medicaid, Aetna pays first: Medicaid is payer of last resort and "is not liable for payment of services denied because coverage rules of the primary health insurance were not followed," so get Aetna’s authorization even when Medicaid (the PIHP) will pay secondary. TRICARE pays after other coverage except Medicaid (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).^{[12][5][13][14][15]}

Ask the plan: Ask Aetna at benefits verification for the member’s coordination-of-benefits order (precertification via Availity or the number on the member ID card); self-funded plans set their own COB terms in the plan document. Record every other coverage the child has.

Not addressed. CPB 0554, CPB 0648 and the ABA medical necessity guide set no telehealth rules or place-of-service codes for ABA.^[1][3]

Ask the plan: Availity or the precertification line on the member ID card — ask which ABA codes Aetna will pay via telehealth on this plan, with which POS and modifier.

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 behavior analysis is within their scope of practice definition, unless state mandates, plan documents or contracts require otherwise." Where unlicensed or non-certified staff are authorized, "there must be supervision and direction of the unlicensed or non-certified providers in line with practice standards." Aetna publishes no numeric supervision ratio. Michigan is a licensure state, so the supervising analyst must hold a LARA license.^[3][7]

Aetna publishes no per-day or per-week unit ceiling. Its guide lists typical intensities (comprehensive ABA 10–25 hours a week, typically ages 0–7 for 1–2 years; focused ABA 1–20 hours a week, all ages) and says "Authorized hours will be based on documented severity of impairments"; progress is evaluated every six months. For fully insured Michigan plans the mandate bars visit limits but allows annual dollar maximums of $50,000 (through age 6), $40,000 (7–12) and $30,000 (13–18).^[3][5]

Outpatient ABA is setting-agnostic in Aetna’s guide. If treatment is in an inpatient, residential or partial hospitalization setting, that level of care’s criteria apply and "specific authorization for ABA is not needed in addition." The guide expects coordination with existing providers and the school district; its statement that Aetna will not deny ABA solely because the location is a child’s educational setting sits in a state-specific exhibit, not the national criteria.^[3]

"Services must be provided directly or billed by the appropriately licensed provider": licensed behavior analysts in licensure states (Michigan is one), board-certified behavior analysts, or licensed psychologists within scope, unless state mandates, plan documents or contracts require otherwise.^[3]

Not addressed in Aetna’s published ABA policies — CPB 0554, CPB 0648 and the ABA medical necessity guide are silent on billing 97153 and 97155 for the same clock time.^[1][3]

Ask the plan: Aetna provider services / the participating-provider agreement, or a written coding determination from Aetna Behavioral Health.

Not addressed. Aetna’s published ABA policies set treatment-plan content (target behaviors, baselines, quantifiable progress criteria, generalization, transition and discharge planning) but do not say who signs a session note or by when.^[3]

Ask the plan: The participating-provider agreement and the Aetna Behavioral Health Provider Manual documentation section.