For a California intake team a Cigna card means Evernorth Behavioral Health’s national ABA policy (EN0499), California’s autism mandate, and the plan’s funding type deciding which binds. Cigna publishes no California-specific ABA rules: EN0499 carves out only Virginia fully insured business, and Evernorth’s California-specific nonprofit criteria (LOCUS, CALOCUS-CASII) cover mental health levels of care, not ABA. Cigna runs no Medi-Cal plan.
Evernorth bases ABA decisions "on the Intensive Behavioral Interventions - (EN0499) coverage policy unless contractual requirements or federal or state law requires the use of other specifically identified clinical criteria." EN0499 (effective May 15, 2026) names no California exception. In-network assessments (97151, 97152, 0362T) need no prior authorization; treatment does. The July 2026 ABA form adds: submit to "ABA@Evernorth.com (preferred) or fax it to 860.687.9230"; authorizations are "written on a per month basis with CPT code 97155 and can be interchanged with ongoing treatment codes 97153–97158 and 0373T," with weekly hours multiplied by 4.33; and assessments such as the AFLS, Essential for Living and PEAK "do not, on their own, sufficiently demonstrate medical necessity." Evernorth’s California criteria page lists LOCUS and CALOCUS-CASII for mental health levels of care; ABA is not on it, and Evernorth "complies with state specific laws, as written."[1][2][3][5]
California’s mandate is Health & Safety Code § 1374.73 for DMHC-regulated health care service plans (every HMO and many PPO/EPO products) and Insurance Code § 10144.51, its word-for-word twin for CDI-regulated insurance policies. Enacted by SB 946 in 2011 with a sunset, made permanent by AB 796 in 2016 and last amended by SB 402 (effective January 1, 2026), it requires every plan covering hospital, medical or surgical care to cover "behavioral health treatment for pervasive developmental disorder or autism" — defined to include "applied behavior analysis and evidence-based behavior intervention programs" — "in the same manner and … subject to the same requirements" as mental health parity under § 1374.72. The statute has no age limit and no dollar or visit cap. Treatment must be "prescribed by a physician and surgeon" or "developed by a psychologist," follow a treatment plan with measurable goals "reviewed no less than once every six months" by the qualified autism service provider, and may not be used for "respite, daycare, or educational services." Plans may still use "case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing."[6][7][9][10][11][12]
Three newer layers matter at intake. SB 855 (§§ 1374.72, 1374.721; Ins. §§ 10144.5, 10144.52) requires medical-necessity decisions under "generally accepted standards," using the criteria of "the nonprofit professional association for the relevant clinical specialty," supplied "at no cost" — and bars limiting coverage because services "should be or could be covered by a public entitlement program, including … special education or an individualized education program, Medicaid." Cigna publishes no California-specific ABA criteria set; for a fully insured member, ask which criteria the review used. SB 402 (carrying AB 951) says a contract issued, amended or renewed on or after January 1, 2026 "shall not require an enrollee previously diagnosed with pervasive developmental disorder or autism to receive a rediagnosis to maintain coverage" and "shall not discontinue or delay existing treatment while waiting for a rediagnosis." Exempt: self-funded ERISA employer plans (outside state law), Medi-Cal plan contracts, specialized plans that do not deliver mental health services, and — for CDI policies — accident-only, specified-disease, hospital-indemnity and Medicare supplement policies.[6][7][9][10][11][12]
California has no behavior analyst license — it is absent from the BACB’s licensure table, and SB 402’s new Business & Professions Code chapter (§§ 4999.200–4999.202) is definitional only. A qualified autism service (QAS) provider is a BCBA ("certified by a national entity, such as the Behavior Analyst Certification Board") or a listed California licensee; a QAS professional (BCaBA-level behavior service providers under 17 CCR § 54342, or — since SB 805 — associate MFTs, ACSWs, APCCs and psychological associates) works under the provider’s supervision; and a QAS paraprofessional — the technician — is "an unlicensed and uncertified individual" supervised "at a level of clinical supervision that meets professionally recognized standards of practice." Cigna does not publish commercial ABA rates; they are negotiated — contact your provider relations representative.[13][14][8][2]
The questions that decide whether a family can start with Cigna in California, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis, but EN0499 wants the date it was most recently made and runs tight clocks on data: an assessment instrument "completed within 60 days prior to the start" of treatment, baseline and current data within 60 days, a standardized instrument not "more than one year prior" for continued treatment, and a new assessment after "any break in treatment greater than 60 calendar days." On fully insured California plans renewed on or after January 1, 2026, § 1374.73(c) bars requiring a rediagnosis to maintain coverage.[1][3][6]
A healthcare professional "who is licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice" (EN0499); the PA form offers medical doctor, licensed psychologist or other.[1][3]
No single diagnostic instrument is named; EN0499 requires a reliable, valid, standardized, current-edition instrument covering the DSM-5-TR domains ("must be the Vineland-3 vs. Vineland-II"). The July 2026 form: assessments that do not meet this standard "will no longer be considered sufficient" — the AFLS, Essential for Living and PEAK "do not, on their own, sufficiently demonstrate medical necessity."[1][3]
No referral, order or prescription in EN0499, the autism resource guide or the PA form — the treatment prior authorization is the front door. On fully insured California plans the mandate keys covered BHT to a physician prescription or a psychologist-developed plan, so collect one.[1][3][6]
Broad: "All ABA CPT codes are covered telehealth services" (autism resource guide); EN0499 allows in-person, telehealth or hybrid delivery, and its line-of-sight supervision rule "does not apply to telehealth services."[2][1]
EN0499 sets no age limit — its glossary says focused intervention access "should not be restricted by age, cognitive level, diagnosis, or co-occurring conditions." For fully insured California plans, H&S § 1374.73 / Ins. § 10144.51 contain no age or dollar limit; self-funded plans follow their plan document.[1][6]
Ask the plan: Benefits verification (Procedure Code Benefit Tool on Provider.Evernorth.com) — fully insured vs. self-funded, then the plan’s own terms.
Cigna publishes no decision clock for ABA; it asks for requests "up to 30 days in advance of or two weeks after the start date of service," warning that a late request "may result in a retrospective review and could delay the determination for up to 30 days." The regulator’s clock applies: DMHC plans, H&S § 1367.01(h) — "not to exceed five business days" from receipt of the information reasonably necessary, 72 hours urgent; CDI policies, Ins. § 10123.135(h), the same; self-funded ERISA plans, 29 CFR 2560.503-1 — 15 days pre-service, one 15-day extension, 72 hours urgent.[2][15][16][17]
Ask the plan: At benefits verification ask whether the plan is DMHC, CDI or self-funded, then confirm the turnaround with the Evernorth Autism Care Coordinator team (877.279.7603).
No Cigna ABA-specific COB rule was read. The California floor: DMHC plans follow 28 CCR § 1300.67.13 and CDI policies 10 CCR § 2232.56 — the employee’s plan before the dependent’s; for a child of non-separated parents, the plan of the parent whose birthday falls earlier in the calendar year; then court decree, custodial parent, stepparent, non-custodial parent. If the child also has Medi-Cal, this plan pays first (W&I § 14124.90) and may not limit coverage because Medicaid could pay (H&S § 1374.72(h)). TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is "the last payer" (38 CFR 17.270(b)). Self-funded plans use their plan document.[18][19][20][21][22]
Ask the plan: Cigna Provider Services (800.926.2273) at benefits verification — the member’s COB order and any other coverage on file.
Coverage decides whether Cigna in California 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.
Case supervision by a BCBA, LBA or independently licensed mental health professional with ABA training at "one to two hours per ten hours of direct treatment," and a minimum of 1–2 hours a week when direct treatment is 10 hours a week or less; the supervisor’s name and credentials must be documented. The PA form separates "97155 – Direct Supervision of RBT" from "97155 – 1:1 Treatment by BCBA."[1][3]
Allowed for direct supervision: "Only one provider can bill for a unit of time, with the exception of CPT codes 97153, 97154, and 97155 (direct supervision when the BCBA/qualified health care provider directs the technician and both are face-to-face with the patient at the same time)." ABA is not reimbursable "at the same time as any other treatment modality (e.g., ABA and speech therapy …)."[2][1]
No per-day cap; ABA is billed in 15-minute units on 97151–97158/0362T/0373T only, and authorizations are monthly (weekly hours × 4.33). On fully insured California plans the statute bars dollar or visit caps.[2][3]
Each service record must include the "Name, credential (if applicable), and signature of ABA provider who rendered the service," start and end date-time, location, focus, intervention, individuals present and service type (EN0499).[1]
Goals and data are reported per setting (home, clinic, school, community); primarily educational or vocational services are not covered. The PA form requires, "for each individual setting," staff proximity, the intervention, hours in that setting, frequency of learning opportunities, the clinical rationale, goal data and caregiver goals. On fully insured California plans, H&S § 1374.72(h) bars limiting coverage because an IEP or special education could provide the service.[1][3][9]
"Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider"; on the CMS-1500, box 31 is the rendering provider and box 33 lists "only a BCBA or other licensed provider" (payer ID 62308). 97152/97153/97154 may be delivered by a BCaBA or technician but are billed by a BCBA-D, BCBA or licensed mental health provider.[2]
Yes — for autism under Evernorth policy EN0499, with California’s mandate on fully insured plans. Self-funded employer plans are exempt from the mandate, so verify funding type first.
Not for standard in-network requests (97151, 97152, 0362T) when the provider is a BCBA or independently licensed and the plan covers ABA. Treatment requires prior authorization via ABA@Evernorth.com or fax 860.687.9230.
No. EN0499 carves out only Virginia fully insured plans; Evernorth’s California criteria list covers mental health levels of care, not ABA. California’s mandate and SB 855 still apply to fully insured plans.
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.
Carelu collects all of this automatically.
Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.
Get a Demo