For a Pennsylvania intake team, an Aetna card brings three layers. There is Aetna’s national ABA policy set, Pennsylvania’s autism mandate (Act 62 of 2008), and the plan’s size and funding type, which decide whether the mandate binds at all. This guide takes them in that order.
Aetna’s ABA rules are national. Its ABA medical necessity guide sets the criteria: a DSM-5 ASD diagnosis, functional impairment on a standardized scale in the past 12 months, a measurable treatment plan, and progress reviewed every six months. CPB 0648 covers the autism evaluation and CPB 0554 calls ABA unproven for non-ASD indications. Aetna’s participating-provider behavioral health precertification list puts every ABA code under precertification, assessment included: 97151–97158, 0362T and 0373T. None of that changes at the Pennsylvania border. What changes is the legal floor underneath it, and whether that floor applies to this family’s plan.[1][3][2][4]
Pennsylvania’s autism mandate is Act 62 of 2008 (Insurance Company Law § 635.2, 40 P.S. § 764h). For covered individuals “under twenty-one (21) years of age” it requires coverage of the diagnostic assessment of autism spectrum disorder and of its treatment, and treatment includes rehabilitative care such as applied behavior analysis identified in a treatment plan. Coverage is subject to the plan’s copays, deductibles and coinsurance like any other medical service. A plan does not have to cover a service solely because it appears in an IEP, but coverage “shall not be contingent upon a coordination of services with an individualized education program”.[6][7][8][9]
Reach is the part intake gets wrong. Act 62 applies to health insurance policies offered, issued or renewed on or after July 1, 2009 “to groups of fifty-one (51) or more employees”, and to CHIP contracts. It does not reach individual policies, small-group policies (50 or fewer employees), self-funded employer plans governed by ERISA, or excepted coverage such as accident-only, fixed-indemnity and limited-benefit policies. So the first two questions on every benefits check are the group size and whether the plan is fully insured or self-funded.[6][7][8][9]
The statute sets an annual maximum benefit, adjusted each year for inflation: $51,908 for policies issued or renewed in 2026 and $53,310 for 2027, with no limit on the number of visits. The cap matters less than it looks. The Insurance Department treats autism as a mental health condition under the federal parity law (MHPAEA, adopted into Pennsylvania law by Act 14 of 2010). It told insurers to handle autism claims in a parity-compliant way no later than January 1, 2024, and says the annual adjustment “is not expected to have any impact on the coverage of autism services in this Commonwealth.”[6][7][8][9]
The “diagnostic assessment” is performed by a licensed physician, licensed physician assistant, licensed psychologist or certified registered nurse practitioner.[6]
“The results of a diagnostic assessment of autism spectrum disorder shall be valid for a period of twelve (12) months”, unless a licensed physician or licensed psychologist decides an earlier assessment is needed.[6]
The treatment plan is developed by a licensed physician or licensed psychologist after a comprehensive evaluation or reevaluation. Treatment is prescribed, ordered or provided by a licensed physician, physician assistant, psychologist, clinical social worker or CRNP.[6]
The insurer may review a treatment plan once every six months, subject to utilization review including concurrent review. A different interval can be agreed with the physician or psychologist who wrote the plan.[6]
The insurer must contract with, and accept as a participating provider, any autism service provider in its service area that is enrolled in Medical Assistance and accepts its terms.[6]
A denial gets an expedited internal review, then an expedited independent external review by the Insurance Department.[6]
We checked. Aetna’s ABA medical necessity guide carries exactly one state exhibit, Exhibit A for Maryland plans under COMAR 31.10.39, and nothing for Pennsylvania. Its cover note says only that “Other state laws and regulations may apply in other states.” The behavioral health precertification list has no Pennsylvania carve-out either; its only state note exempts fully insured members in Indiana from precertification programs. For an Act 62 plan, the statute’s rules in the section above sit on top of the national criteria. For a self-funded plan, the national criteria plus the plan document are the whole picture.[1][4][17]
Aetna Better Health of Pennsylvania is a different product: a Medical Assistance physical-health plan. In HealthChoices, behavioral health services are assigned to a behavioral health MCO by county, so ABA for a child on Medical Assistance runs through that BH-MCO as IBHS. We could not open Aetna Better Health of Pennsylvania’s own pages (aetnabetterhealth.com returned Access Denied), so confirm the line of business on the card before you apply this guide.[1][4][17]
Aetna’s guide says services “must be provided directly or billed by” licensed behavior analysts (in states with licensure laws), board-certified behavior analysts, or licensed psychologists whose scope covers behavior analysis, “unless state mandates, plan documents or contracts require otherwise”. Anyone else needs supervision in line with practice standards. The provider manual adds that ABA practitioners need BACB certification or a state behavior-analyst license. Pennsylvania has no behavior-analyst license, so in practice that means a BCBA or a licensed psychologist. Pennsylvania’s own license is the Behavior Specialist, and Act 62 counts state-licensed autism service providers. Aetna publishes nothing on whether it credentials a Pennsylvania Behavior Specialist who is not a BCBA, so ask Aetna network management before building a schedule around one.[1][5][6][12]
Many Pennsylvania children with commercial coverage also carry Medical Assistance as a second payer. PH-95 (“Medicaid for Children with Special Needs”) covers children under 18 with SSA-standard disabilities, and “Parental income must be verified but will be excluded in this category”. Medical Assistance pays last. Other private or governmental health insurance must be used before billing the MA Program, and DHS tells providers to bill the child’s private insurance before submitting an MA claim for ASD diagnostic assessment or treatment. On the Medicaid side, ABA is delivered as Intensive Behavioral Health Services (IBHS) and managed by the behavioral health MCO assigned to the family’s county, with its own order and authorization rules. Get the commercial plan’s authorization first: a claim the primary plan denied for a missed authorization is a weak one to send to MA.[16][14][15][18][17]
Pennsylvania has no behavior-analyst licensure law: the BACB’s U.S. licensure table carries no Pennsylvania entry. Act 62 had the State Board of Medicine license “behavior specialists” instead. The license requires a master’s degree in a listed field (behavioral analysis included), one year of functional-behavior-assessment experience with individuals under 21, 1,000 hours of clinical experience and 90 hours of coursework. There is no exam, and the fee is $75. The Board’s rules say they are not meant to require a second license of someone whose existing license already covers autism assessment and treatment.[11][12][13]
On rates, Aetna publishes no Pennsylvania commercial ABA fee schedule. Commercial rates are negotiated and sit in your participating-provider agreement.[11][12][13]
The questions that decide whether a family can start with Aetna in Pennsylvania, and what they have to bring. Each maps onto something intake should ask on the first call.
Aetna puts no expiry on the ASD diagnosis itself, but runs a 12-month clock on functional evidence. Medical necessity requires functional impairment on a standardized scale of functioning “in the past 12 months”, at least one standard deviation below the population mean, or a significant risk of harm. Progress is re-evaluated every six months. On Act 62 plans, the diagnostic assessment is “valid for a period of twelve (12) months, unless a licensed physician or licensed psychologist determines an earlier assessment is necessary.”[1][6]
Aetna requires a DSM-5 ASD diagnosis (ICD-10 F84.0, F84.3–F84.9) from an appropriate provider: a licensed psychologist or psychiatrist, a physician, or another health care professional qualified to diagnose mental health conditions within their scope of practice. CPB 0648 lists the professionals appropriate to an autism evaluation: board certified behavior analyst, developmental pediatrician, neurologist, occupational therapist, physical therapist, primary care provider, psychiatrist, psychologist, and speech-language pathologist and audiologist. On Act 62 plans, the statutory diagnostic assessment is performed by a licensed physician, licensed physician assistant, licensed psychologist or certified registered nurse practitioner.[1][3][6]
CPB 0648 names the diagnostic tools used with clinical assessment to establish autism: ADI-R, ADOS-2, CARS-2 and the Asperger Syndrome Diagnostic Scale. The ABA medical necessity guide then requires a standardized scale of functioning from the past 12 months, for example Vineland-3, ABAS, VB-MAPP or ABLLS.[3][1]
Aetna’s national ABA policies require no physician referral or prescription; the only prescription rule in the guide is the Maryland exhibit. What Aetna requires is precertification on all ten ABA codes (97151–97158, 0362T, 0373T). Act 62 plans add an ordering layer: treatment is identified in a treatment plan developed by a licensed physician or licensed psychologist, and prescribed, ordered or provided by a licensed physician, physician assistant, psychologist, clinical social worker or CRNP. Self-funded ERISA, individual and small-group plans are outside the statute.[4][1][6]
Aetna’s national ABA policies set no age cap. The medical necessity guide lists typical, not limiting, parameters: comprehensive ABA at 10–25 hours a week is typical for ages 0–7 over 1–2 years, and focused ABA at 1–20 hours a week is listed for all ages. In Pennsylvania, Act 62 covers individuals under 21 on fully insured policies issued to groups of 51 or more employees (and CHIP). Individual, small-group and self-funded ERISA plans sit outside it, so for them the plan document alone sets any age term.[1][6]
Ask the plan: Live benefits check on the member ID. Establish group size and fully insured vs. self-funded ERISA, then the plan’s own age and benefit terms.
Depends on how the plan is funded. Fully insured Pennsylvania plans follow Act 146 of 2022 (Insurance Company Law § 2155, effective January 1, 2024). An urgent request for care not yet started is decided “as soon as possible, but not more than 72 hours” after receipt. An ongoing urgent course asked to continue at least 24 hours before it would be cut back or ended is decided within 24 hours. Every other prior authorization request is decided “within 15 days”; the insurer can extend that only if it promptly flagged missing information, and the provider then has at least 45 days to supply it. Act 146 also makes insurers post their prior-authorization list and offer a peer-to-peer on denial. Self-funded ERISA plans follow 29 CFR 2560.503-1 instead: pre-service decisions within 15 days, one 15-day extension, and 72 hours for urgent care. Aetna’s provider manual says only that the timing of review “incorporates state, federal, Centers for Medicare and Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA) requirements.”[10][19]
Ask the plan: At benefits verification, ask whether the plan is fully insured (Pennsylvania-regulated) or self-funded (ERISA), then confirm the authorization turnaround and any continuation lead time with Aetna (Availity or the number on the ID card).
Which of two parents’ plans pays first is set by the plans’ own coordination terms. We found no Pennsylvania regulation fixing the order for a child on both parents’ plans, so ask each plan which one is primary. If the child also has Medical Assistance (including PH-95), Aetna pays first. MA is payer of last resort (42 CFR 433.139): other private or governmental insurance “shall be utilized before billing the MA Program” (55 Pa. Code § 1101.64), and IBHS is not paid when payment is available through a third party (55 Pa. Code § 1155.31(e)). DHS tells providers to bill private insurance before submitting an MA claim for ASD assessment or treatment. Get Aetna’s authorization even when MA is secondary. If the child also has TRICARE, TRICARE pays after this plan (10 U.S.C. 1079(i)(1)). CHAMPVA is the last payer after other health insurance (38 CFR 17.270).[14][18][15][20][21][22]
Ask the plan: Ask Aetna at benefits verification for the member’s coordination-of-benefits order (and whether a self-funded plan uses the birthday rule), and record every other coverage the child has, including Medical Assistance/PH-95.
Not addressed for ABA. CPB 0554, CPB 0648 and the ABA medical necessity guide set no telehealth rules or place-of-service codes for ABA. The behavioral health provider manual says Aetna Behavioral Health offers telemedicine to all commercial fully insured members, and to self-insured plan sponsors unless they opt out. It does not say which ABA codes may be delivered remotely.[2][1][5]
Ask the plan: Availity, or the precertification line on the member’s ID card: ask which ABA codes Aetna pays via telehealth on this plan, and with which POS code and modifier.
Coverage decides whether Aetna in Pennsylvania 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 licensure laws), board-certified behavior analysts, or licensed psychologists whose scope covers behavior analysis, unless state mandates, plan documents or contracts require otherwise. Anyone else needs supervision and direction in line with practice standards. Aetna publishes no fixed supervision ratio. Its severity table allows extra authorization for QHP protocol modification and direction at 1 to 2 hours per 10 hours of treatment by protocol. Pennsylvania has no behavior-analyst license, so the licensed-behavior-analyst route does not exist here.[1][11]
Aetna publishes no per-day or per-week unit ceiling. Authorized hours follow documented severity of maladaptive behavior, social communication and self-care impairment on the guide’s severity table (1–4 hours/week at mild, 4–7 at moderate, 7–10 at severe impairment). Typical intensity is 10–25 hours/week for comprehensive and 1–20 for focused programs. On Act 62 plans the statute bars visit limits, and its CPI-adjusted dollar maximum ($51,908 for 2026 policies, $53,310 for 2027) is, per the Insurance Department, not expected to affect coverage under parity.[1][6][7]
Aetna’s published ABA policies do not set a session-note rule. Its behavioral health treatment-record review criteria ask whether every entry is dated and carries “the author’s signature or electronic identifier with title (if applicable) and degree”. No deadline for signing is stated.[5]
Outpatient ABA is not tied to a setting 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 the school district where applicable and a taper toward other supports such as school. CPB 0648 notes that many Aetna plans exclude educational services, e.g. ABA during class. On Act 62 plans, coverage cannot hinge on coordination with an IEP, but the plan need not cover a service solely because it is in an IEP.[1][3][6]
Services must be provided directly or billed by the appropriately licensed provider: a licensed behavior analyst where licensure exists (not in Pennsylvania), a board-certified behavior analyst, or a licensed psychologist whose scope covers behavior analysis, unless state mandates, plan documents or contracts require otherwise.[1]
Not addressed in Aetna’s published ABA policies. CPB 0554, CPB 0648 and the ABA medical necessity guide say nothing about billing 97153 and 97155 for the same clock time.[2][1]
Ask the plan: Aetna provider services or the participating-provider agreement, or a written coding determination from Aetna Behavioral Health.
Yes, for autism spectrum disorder under Aetna’s national ABA medical necessity guide. On fully insured policies for groups of 51 or more employees, Pennsylvania’s Act 62 adds a legal floor for members under 21. Self-funded, individual and small-group plans follow their own plan terms, so check group size and funding type first.
Yes. Aetna’s behavioral health precertification list includes 97151, 97152 and 0362T alongside the treatment codes. Precertify through Availity or the number on the member’s ID card.
The statute has a CPI-adjusted annual maximum ($51,908 for 2026 policies, $53,310 for 2027) and no visit limits. The Insurance Department treats autism as a mental health condition under federal parity and expects the cap to have no impact on coverage.
Commercial ABA rates are not published. They are negotiated in your participating-provider agreement.
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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