For an intake team in Montana, an Aetna card means three layers: Aetna’s national ABA criteria, Montana’s autism mandate in MCA 33-22-515, and the plan’s funding type, which decides whether the mandate applies at all. Montana’s mandate is narrower than most (group coverage, through age 18, with dollar caps allowed), so the plan document matters more here than in many states.
Aetna’s ABA medical necessity guide requires a DSM-5 ASD diagnosis (F84.0, F84.3–F84.9) "obtained by an appropriate provider," functional impairment on a standardized scale from the past 12 months at least one standard deviation below the mean (or a significant risk of harm), and services "provided directly or billed by licensed behavior analysts (in states with behavior analyst licensure laws), board-certified behavior analysts, or licensed psychologists." CPB 0554 (last review 10/14/2026) only says ABA is experimental for non-ASD indications. Aetna’s behavioral health precertification list names all ten ABA codes, 97151 through 97158, 0362T and 0373T. The guide’s only state exhibit is Maryland’s; it notes that "Other state laws and regulations may apply in other states," and nothing in it addresses Montana.[1][2][4]
Montana’s autism mandate is MCA 33-22-515, enacted in 2009. It reaches "each group disability policy, certificate of insurance, or membership contract" delivered, issued, renewed, extended or modified in Montana, and requires "coverage for diagnosis and treatment of autism spectrum disorders for a covered child 18 years of age or younger." Health service corporations (MCA 33-30-102 applies chapter 22 to them) and HMOs (MCA 33-31-111 lists 33-22-515 among the provisions that bind them) are covered too. The covered diagnoses are written in older DSM terms: autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified, "as defined by the most recent edition" of the DSM. Habilitative and rehabilitative care "includes medically necessary interactive therapies derived from evidence-based research, including applied behavior analysis," and it must be "prescribed, provided, or ordered by a licensed physician or licensed psychologist." ABA under the statute "must be provided by an individual who is licensed by the behavior analyst certification board or is certified by the department of public health and human services as a family support specialist with an autism endorsement." The statute lets a plan cap the benefit: coverage "may be limited to a maximum benefit of" $50,000 a year for a child 8 or younger and $20,000 a year from 9 through 18. Ordinary deductibles, coinsurance and copays may apply, but special cost sharing for autism care may not. When treatment is ongoing, the insurer "may request that the treating physician provide a treatment plan" (diagnosis, treatment by type and frequency, anticipated duration and outcomes, and why it is medically necessary) and may ask for an update "every 6 months." The section also binds the state and university employee plans, local-government employee plans and non-ERISA self-funded MEWAs. Two gaps matter at intake: the text speaks only of group coverage, and ERISA self-funded employer plans sit outside state insurance law altogether.[8][9][10]
Montana licenses behavior analysts. Since 2017 (Ch. 425, L. 2017), MCA Title 37, chapter 17, part 4 has the Board of Psychologists license behavior analysts and assistant behavior analysts; the BACB’s licensure table lists Montana (2017, MT Board of Psychologists). "An individual may not represent to the public that the individual is an assistant behavior analyst or a behavior analyst without a license," and a license requires current BACB certification at the matching level (BCBA or BCaBA), a fingerprint background check and the Board’s coursework rules (MCA 37-17-403). A behavior technician supervised by a licensed behavior analyst does not need a license, and neither do school district staff, licensed psychologists and those acting under their authority, licensed clinical professional counselors, licensed social workers and family support specialists with an autism endorsement (MCA 37-17-404). A BCaBA or technician must be supervised by a licensed behavior analyst or by a licensed psychologist board-certified by ABPP in behavioral and cognitive psychology (MCA 37-17-405). For telehealth, MCA 37-2-305 lets "a person licensed under this title" treat by telehealth when it is appropriate and meets the standard of care; it creates no registration for providers licensed only in another state. So a BCBA licensed elsewhere should plan on a Montana license before treating a child located in Montana, including by video. Commercial ABA rates are negotiated and unpublished; the public benchmark is the Montana Medicaid ABA fee schedule (July 1, 2025: 97153 $11.36 and 97155 $20.46 per 15-minute unit).[25][16][17][18][19][20][26][24]
Montana’s prompt-pay statute, MCA 33-18-232, says an insurer "shall pay or deny a claim within 30 days after receipt of a proof of loss" unless it makes a reasonable request for more information, and then within 60 days. A late insurer owes the claim "plus 10% annual interest" from the date it was due (interest under $5 is not payable). The statute governs insurers; a self-funded ERISA plan follows its own plan document and federal claims rules. Timely filing limits are set by each carrier’s contract, not by Montana statute.[12][6][24][2][7][1][5]
Aetna publishes no ABA rate table. Its provider manual (6/26) says "The rates and compensation under your agreement are subject to the Aetna coding/claim edit policies," and when a member’s benefits run out the provider "cannot charge them more than the contracted rate." Get the rates and the filing limit from your Aetna agreement or Aetna provider services. The only public Montana benchmark is Montana Medicaid’s ABA fee schedule (97153 $11.36 per 15 minutes, July 2025).[12][6][24][2][7][1][5]
Billing details from Aetna’s own documents. Codes: Aetna’s ABA policy (CPB 0554) lists only CPT 97151–97158, 0362T and 0373T and no HCPCS code, so H0031, H0032 or H2019 are not ABA codes at Aetna. Telehealth: its Telemedicine and Direct Patient Contact Payment Policy names modifiers GT, 95 and FR but no place-of-service code, and none of Aetna’s documents says the precertification must flag telehealth; ask which POS (02 or 10) it wants when you precertify. Filing: the Health Care Professional Toolkit (6/26) prints no timely-filing deadline, so your agreement sets it, and its definition of a clean claim excludes any claim that involves coordination of benefits. Reauthorization: the ABA medical necessity guide calls for "Repeated measurement with standardized measures to assess progress" and says "A member’s progress is to be evaluated every six months"; it does not mention graphs. Supervision: the Network Participation Criteria set one hour of face-to-face supervision per 10 hours of paraprofessional ABA and publish no cap on technicians per BCBA.[12][6][24][2][7][1][5]
The questions that decide whether a family can start with Aetna in Montana, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the ASD diagnosis, but medical necessity requires functional impairment on a standardized scale administered in the past 12 months (at least one standard deviation below the mean) or a significant risk of harm.[1]
An appropriate provider: "licensed psychologist/psychiatrist, physician or other health care professional qualified to diagnose mental health conditions within their scope of practice."[1]
CPB 0648 names ADI-R, ADOS-2, CARS-2 and the Asperger Syndrome Diagnostic Scale as tools used with clinical assessment. The ABA guide requires a standardized functional measure from the past 12 months (Vineland-3, ABAS, VB-MAPP or ABLLS as examples).[3][1]
Aetna’s national ABA policies require no referral; they require precertification of all ten ABA codes. For a fully insured Montana group plan, MCA 33-22-515 covers ABA "prescribed, provided, or ordered by a licensed physician or licensed psychologist," and lets the insurer ask the treating physician for a treatment plan, updated every 6 months. Self-funded ERISA plans sit outside the statute.[4][1][8]
Aetna’s national ABA guide sets no age cap; its age ranges are typical, not limiting. For fully insured Montana group plans, MCA 33-22-515 requires coverage "for a covered child 18 years of age or younger" and lets the plan cap the autism benefit at $50,000 a year through age 8 and $20,000 a year from 9 through 18. Self-funded ERISA plans and individual policies are outside the statute’s text, so funding type and plan type decide whether that binds.[1][8]
Ask the plan: Live benefits verification on the member ID: establish fully insured group vs. self-funded or individual, then the plan’s own age and dollar terms.
Aetna’s Telemedicine and Direct Patient Contact Payment Policy lists 97151, 97153, 97155, 97156 and 97157 as telehealth-eligible on commercial plans with modifier GT, 95 or FR (97152, 97154 and 97158 carry a single check, which reads as Medicare Advantage only); the posted policy shows a last review of June 2021, so treat the list as perishable. Aetna’s provider manual says Aetna Behavioral Health "offers telehealth services to all commercial fully insured members and to all commercial self-insured plan sponsors, unless those self-insured plan sponsors opt out," and that providers must "ensure that they have the proper licensure based on state requirements." For state-regulated plans, MCA 33-22-138 requires coverage of otherwise-covered services delivered by telehealth, "equivalent to the coverage for services that are provided in person," with no restriction on where the patient or provider is; its provider list includes Title 37, chapter 17 licensees (psychologists and behavior analysts). Aetna’s Telemedicine and Direct Patient Contact Payment Policy (posted policy shows last review June 2021) marks 97151, 97153, 97155, 97156 and 97157 as telehealth-eligible on commercial plans with modifier GT, 95 or FR; neither it nor the provider toolkit names a telehealth place-of-service code or says the precertification must flag telehealth.[7][6][11]
Ask the plan: Availity or the precertification line on the card: ask whether the plan is fully insured in Montana or self-funded (and opted out of telehealth), and which ABA codes, POS and modifier Aetna pays by telehealth.
Depends on how the plan is funded. Fully insured Montana plans fall under MCA 33-32-211: for a prospective (prior-authorization) review the insurer must decide and notify "not later than 7 business days after the date the health insurance issuer receives the request" or after it receives all necessary information, with one extension of up to 7 business days for matters beyond its control; a request that fails the filing procedure must be flagged within 3 days. Urgent care requests are decided within 48 hours (MCA 33-32-212). A reduction or termination of an approved course of treatment before it ends is an adverse determination that must be noticed in advance, and the service continues pending the internal review. Once approved, a certification "is valid for at least 6 months," and 12 months for treatment of a chronic condition (MCA 33-32-107). Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1 instead: pre-service decisions "not later than 15 days after receipt of the claim," with one 15-day extension. Aetna publishes no Montana-specific ABA turnaround or reauthorization lead time.[14][15][13][21]
Ask the plan: At benefits verification ask whether the plan is fully insured (Montana-regulated) or self-funded (ERISA), and what reauthorization lead time Aetna expects.
If the child also has Montana Medicaid, the commercial plan pays first: Montana Healthcare Programs requires providers to "bill other insurance carriers before billing Montana Healthcare Programs" in most cases, and Medicaid is the payer of last resort under 42 CFR 433.139. If the other insurer has not responded in 90 days, Medicaid can be billed with proof the claim was sent. When a child is on two commercial plans, the order of benefits comes from Montana’s coordination-of-benefits rules for state-regulated plans and from the plan document for self-funded plans; we could not open the Montana rule text this run (rules.mt.gov returned a captcha), so get the order from the carrier.[22][23]
Ask the plan: Ask Aetna at benefits verification for the member’s coordination-of-benefits order, and record every other coverage the child has.
Coverage decides whether Aetna in Montana 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’s Network Participation Criteria (5/26): ABA services "must be provided directly or supervised by individuals licensed by the state or certified by the Behavior Analyst Certification Board"; supervised staff may be a BCaBA "or a paraprofessional"; "A minimum of one hour of face-to-face supervision" of an unlicensed or noncertified paraprofessional is required "for each 10 hours of applied behavior analysis," plus the supervisor "onsite with the child at least one hour a month"; and all staff "must meet state requirements." In Montana that means a licensed behavior analyst (or ABPP-certified behavioral psychologist) supervises BCaBAs and technicians (MCA 37-17-405). Aetna’s guide and Network Participation Criteria publish no cap on the number of technicians one BCBA may supervise.[5][1][18]
No per-day or per-week cap is published. The guide gives typical intensities of 10–25 hours a week for comprehensive and 1–20 for focused programs, with hours justified by the severity assessment; progress is evaluated every six months. Separately, a Montana group plan may impose the mandate’s annual dollar caps.[1][8]
Outpatient ABA is setting-neutral in Aetna’s guide; in inpatient, residential or partial hospitalization settings that level of care’s criteria apply and no separate ABA authorization is needed. The guide expects coordination with existing providers and the school district.[1]
Services must be "provided directly or billed by" a licensed behavior analyst (in states that license them), a BCBA, or a licensed psychologist where in scope. Montana licenses behavior analysts, so the Montana-licensed BCBA (or psychologist) is the billing credential.[1][16]
Not addressed in Aetna’s published ABA policies (the medical necessity guide, CPB 0554, CPB 0648).[1][2]
Ask the plan: Aetna provider services, the participating-provider agreement, or a written coding determination from Aetna Behavioral Health.
Not addressed. Aetna sets treatment-plan content, not who signs a session note or by when.[1]
Ask the plan: The participating-provider agreement and Aetna’s behavioral health documentation standards.
No. Aetna’s ABA policy lists only CPT 97151–97158, 0362T and 0373T.
Its ABA guide asks for repeated measurement with standardized measures and a progress evaluation every six months; it does not mention graphs.
Aetna’s provider toolkit (6/26) does not print one; the filing limit is in your Aetna agreement.
Yes, under its national ABA guide for ASD. Fully insured Montana group plans must also meet MCA 33-22-515 for children 18 and under; self-funded employer plans follow their own documents.
It allows caps: a group plan may limit autism treatment to $50,000 a year through age 8 and $20,000 a year from 9 through 18. Ask the plan whether it uses them.
Yes. 97151 and 97152 are on Aetna’s behavioral health precertification list with the treatment codes.
Montana licenses behavior analysts, and Aetna’s guide looks to the licensed behavior analyst in licensure states. Treating a child in Montana, including by telehealth, should be done under a Montana license.
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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