For an intake team in Connecticut, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 with the Cigna autism resource guide, Connecticut’s autism mandate, and the plan’s funding type. Evernorth’s Administrative Guidelines also include a Connecticut Regulatory Addendum for providers, which it says does not apply to self-funded plans. Many Cigna members are on self-funded employer plans, so check funding first.
Cigna, through Evernorth Behavioral Health, covers ABA under EN0499 (effective May 15, 2026). According to the autism resource guide, “Prior authorization is no longer required for assessment … codes 97151, 97152, or 0362T with a diagnosis of autism, as long as the provider is independently licensed or a Board Certified Behavior Analyst® and the patient’s policy covers ABA services.” For treatment, Evernorth encourages requests “up to 30 days in advance of or two weeks after the start date of service,” and warns that later requests may go to retrospective review and take up to 30 days. Neither document mentions Connecticut, so the national criteria apply. Electronic claims use payer ID 62308.[1][2][3]
Evernorth’s Connecticut Regulatory Addendum (September 2026 Administrative Guidelines) applies Connecticut law to participating providers, except for self-funded plans. It handles continuity of care under § 38a-472f, bars billing members beyond cost-sharing, and allows material fee-schedule changes for non-hospital providers once a year on at least 90 days’ notice. After such notice the provider may accept or end the agreement on 60 days’ notice.[1][2][3]
Connecticut’s autism mandate is two parallel statutes: § 38a-514b for group policies and § 38a-488b for individual policies. Each requires coverage “for the diagnosis and treatment of autism spectrum disorder,” which the law treats as an illness. Covered treatments must be medically necessary and “identified and ordered by a licensed physician, licensed psychologist or licensed clinical social worker,” following a treatment plan written by a licensed behavior analyst, physician, psychologist or licensed clinical social worker after a comprehensive evaluation or reevaluation. “Behavioral therapy,” which expressly includes applied behavior analysis, is covered when it is “Provided to children less than twenty-one years of age” and “provided or supervised by (i) a licensed behavior analyst, (ii) a licensed physician, or (iii) a licensed psychologist.” Supervision is defined as “at least one hour of face-to-face supervision” for every ten hours of behavioral therapy. From January 1, 2027, the age limit rises: Public Act 25-3 of the November 2025 special session changes the text to individuals “under twenty-six years of age.” The statute bans visit limits “on any basis other than a lack of medical necessity” and cost-sharing heavier than for other medical conditions. The 2015 amendment (June Sp. Sess. P.A. 15-5) deleted the old coverage limit, so no dollar cap remains. Two utilization-review protections help intake: outside inpatient care, the carrier may review the treatment plan “not more than once every six months” unless the treating clinician agrees or changes the plan, and “the results of a diagnosis shall be valid for a period of not less than twelve months.” Coverage can still carry the policy’s ordinary terms (coordination of benefits, network rules, limits on services by family or household members). Nothing in the statute requires a plan to pay for special education under an IEP. The mandate binds fully insured policies issued in Connecticut. Self-funded employer plans fall under ERISA instead.[4][5]
Yes. Connecticut licenses behavior analysts, and the license is required to practice. Conn. Gen. Stat. § 20-185j(a) says: “No person may practice behavior analysis unless licensed pursuant to section 20-185k or 20-185l.” Licensure began July 1, 2018 and is run by the Department of Public Health. The route is simple for a current BCBA. Under § 20-185k, DPH “shall grant a license as a behavior analyst to any applicant who furnishes evidence satisfactory to the commissioner that such applicant is certified as a behavior analyst by the Behavior Analyst Certification Board.” The application is online only and costs $350. DPH verifies the BCBA online and requires verification of every other state license you hold or have held. The license renews every year for $180, with current BACB certification and a one-time two hours of training on PTSD, suicide-risk, depression and grief screening and suicide prevention, then repeated every six years. Section 20-185l adds licensure by endorsement for people licensed in a state with substantially similar or higher requirements. Several people do not need the license (§ 20-185j(c)): a BCaBA “working under the supervision of a behavior analyst” under BACB standards; anyone who “implements an intervention based on behavior analysis under the supervision of a behavior analyst” (RBTs and technicians); students in an accredited program under direct supervision; course instructors; family members carrying out a plan; and other licensees acting within their own scope who do not call themselves behavior analysts. The license matters for payment too. The commercial mandate covers behavioral therapy only when it is provided or supervised by a licensed behavior analyst, physician or psychologist, so a BCBA without a Connecticut license cannot be the supervising clinician on a fully insured Connecticut plan.[9][10][11][12][4]
Telehealth from another state does not get around the license. Under § 19a-906(a)(12)(A), a “telehealth provider” means a provider “licensed pursuant to title 20,” the title that contains the behavior analyst chapter. A separate route let behavior analysts licensed in another state treat Connecticut patients by telehealth after registering with DPH and applying for a Connecticut license. In the 2026 Supplement that route applies only “on or before June 30, 2025.” Section 19a-906(j) lets a telehealth provider serve a patient “from any location to a patient in any location,” but only “subject to compliance with … state licensing standards.” A Connecticut agency that contracts with an out-of-state telehealth provider who has no DPH license must check that provider’s DPH registration (§ 19a-906(k)). Our reading, as of the 2026 Supplement: a BCBA must hold a Connecticut license to treat a member located in Connecticut, in person or by telehealth. We did not review 2026-session public acts. Confirm with DPH (dph.counselorsteam@ct.gov) before relying on any exception.[9][10][11][12][4]
Cigna publishes no ABA rate table. Evernorth’s Administrative Guidelines tell ABA providers: “For your fee schedule and a listing of autism spectrum disorder–related services eligible for reimbursement, refer to Exhibit A in your Provider Agreement,” and payment is “the lesser of the billed charge or the applicable fee under Exhibit A.” Fee questions go to Provider Services at 800.926.2273. Virtual services carry modifier 95, which Evernorth says “will not change the reimbursement.” Connecticut’s prompt-pay rule is in its unfair claim settlement statute, § 38a-816(15). An insurer must pay a claim within 60 days of receipt if filed on paper and within 20 days if filed electronically. If information is missing, it must list every deficiency within 30 days (paper) or 10 days (electronic), then pay within 30 or 10 days of receiving what it asked for. A late claim carries interest “at the rate of fifteen per cent per annum.” The statute defines “health care provider” to include anyone licensed under chapters 375 to 383c, a range that takes in licensed behavior analysts (chapter 382a). It applies to insured policies. Self-funded ERISA plans follow federal claim rules instead. For a public benchmark, Connecticut Medicaid’s ASD fee schedule (rates effective January 1, 2026) pays 97153 at $14.00 per 15 minutes. Commercial contracts are negotiated separately.[3][8][18]
Billing details from Evernorth’s own documents. Codes: "All ABA services must be billed with CPT codes 97151–97158, 0362T, and 0373T ONLY," so H-codes are not accepted for ABA. Telehealth: "All ABA CPT codes are covered telehealth services"; on the CMS-1500 use "Modifier 95 in Field 24-D to specify telehealth" and "02 for Place of Service in Field 24-B"; neither document says the authorization must flag telehealth. Filing: claims must be "submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement" unless state law gives longer; for coordination of benefits the 90 days run from the primary payer’s EOB or EOP; a claim Evernorth returns for more information gets a fresh 90 days from its request; corrected claims carry frequency code 7 (replace) or 8 (void) in field 22, without a "Corrected Claim" stamp. Reauthorization (EN0499): an updated treatment plan; "Quantitative baseline, interim and current data" with the dates they were collected for every behavior and skill across all settings; current data collected within 60 days before the continued-treatment start date and within 60 days before the request is received; a standardized assessment no more than one year before the start date; and a written plan to address barriers if progress stalls. EN0499 asks for dated data, not graphs by name. Supervision runs one to two hours per ten hours of direct treatment, with no published cap on technicians per supervisor.[2][3][1]
The questions that decide whether a family can start with Cigna / Evernorth in Connecticut, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis, but the request needs “The date on which the diagnosis was most recently made.” The data clocks run 60 days: instrument within 60 days before treatment, and baseline data within 60 days. Insured Connecticut plans must treat a diagnosis as valid for at least 12 months.[1][4]
A professional “licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice,” applying DSM-5-TR. The ABA assessment itself is done by a BCBA, LBA, or a licensed mental health clinician with ABA training.[1]
No single instrument is mandated. It must be reliable, valid and standardized, cover the DSM-5-TR ASD domains, and be the current edition (“must be the Vineland-3 vs. Vineland-II”), with the date, respondent and form type reported.[1]
EN0499 requires no referral. The assessment codes need no PA for independently licensed providers or BCBAs; treatment needs authorization. For a fully insured Connecticut plan, §§ 38a-514b(c) and 38a-488b(c) cover ABA only when it is “identified and ordered by a licensed physician, licensed psychologist or licensed clinical social worker” and follows a treatment plan by a licensed behavior analyst, physician, psychologist or LCSW. Get that order before the first request. Self-funded ERISA plans are outside the statute.[2][1][4]
“All ABA CPT codes are covered telehealth services” (autism resource guide), and the line-of-sight requirement “does not apply to telehealth services.” For a fully insured Connecticut plan, § 38a-526a (group; § 38a-499a for individual policies) requires coverage of care “provided through telehealth, to the extent coverage is provided for such advice, diagnosis, care or treatment when provided through in-person consultation between the insured and a health care provider licensed in the state.” A plan may not exclude a service “solely because such service is provided only through telehealth … provided telehealth is appropriate for the provision of such service,” and any utilization review must use the same criteria as for in-person care. The section’s own list of “telehealth provider” professions does not name behavior analysts (chapter 382a), so ask the carrier how it treats ABA under it. Self-funded employer plans are outside the statute. On the claim, Evernorth wants "Modifier 95 in Field 24-D to specify telehealth" and "02 for Place of Service in Field 24-B"; its documents do not say the authorization must flag telehealth.[2][1][6][3]
EN0499 sets no age cap and says access to focused intervention “should not be restricted by age.” For fully insured Connecticut plans, the mandate covers behavioral therapy for children under 21 today and for individuals under 26 from January 1, 2027 (Nov. Sp. Sess. P.A. 25-3). It has no dollar cap. Self-funded ERISA plans are outside the statute, so the plan’s funding type decides whether this applies.[1][4][5]
Ask the plan: Live benefits verification: fully insured vs. self-funded ERISA first.
Depends on how the plan is funded. Fully insured Connecticut plans fall under § 38a-591d. For a non-urgent prospective or concurrent request, the carrier must decide “not later than seven calendar days after the date the health carrier receives such request.” It may extend once by up to five calendar days for circumstances beyond its control, or by up to fifteen if the clinician says the service will not start for at least three months. Retrospective requests get 30 days. Urgent requests are decided within 24 hours. A concurrent urgent request to extend a course of treatment counts only if made at least 24 hours before the current authorization ends. After a medical-necessity denial, the carrier must offer your clinician a conference with a clinical peer, who has authority to reverse the denial. 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,” one 15-day extension, urgent care within 72 hours. Cigna/Evernorth publishes no Connecticut-specific ABA turnaround.[7][13]
Ask the plan: At benefits verification ask whether the plan is fully insured (Connecticut-regulated) or self-funded (ERISA), and what reauthorization lead time Cigna/Evernorth expects.
Cigna/Evernorth is primary to Connecticut Medicaid. HUSKY Health is “the payer of last resort,” and if a member has third-party coverage “the benefits of these policies must be fully exhausted prior to claim submission” to Medicaid (42 CFR 433.139). So be in the commercial network and get its authorization as well as the Carelon BH CT authorization. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)). CHAMPVA is “the last payer” (38 CFR 17.270). Connecticut’s autism statutes let insured coverage carry the policy’s ordinary coordination-of-benefits terms (§ 38a-514b(f)). We did not read Connecticut’s coordination-of-benefits regulation, so get the order between two parents’ plans from the carriers.[14][15][16][17][4]
Ask the plan: Ask Cigna/Evernorth at benefits verification for the member’s coordination-of-benefits order between both parents’ plans, and record every other coverage the child has (HUSKY, TRICARE, CHAMPVA).
Coverage decides whether Cigna / Evernorth in Connecticut 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, a Licensed Behavior Analyst, or an independently licensed mental health professional with ABA training. Direct plus indirect case supervision “consistent with the general accepted standard of care of one to two hours per ten hours of direct treatment,” and at 10 hours a week or less, at least one to two hours a week of direct case supervision. Insured Connecticut plans also require a licensed supervisor with at least 1 hour face-to-face per 10 hours. EN0499 publishes no cap on the number of technicians one supervisor may oversee.[1][4]
“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).” Other therapies are a separate rule: EN0499 (eff. 5/15/2026) says “Provision of ABA treatment is not covered or reimbursable when delivered to the same individual, at the same time as any other treatment modality (e.g., ABA and speech therapy, or ABA and occupational therapy).”[2][1]
No per-day cap. ABA codes bill in 15-minute units, using only 97151–97158, 0362T and 0373T. Intensity must reflect severity, goals and response to treatment.[2][1]
A note for each CPT code billed with start and end date and time, location, focus, a detailed description of the intervention, who was present and who rendered the service, with “Signatures and time stamps of when the note was completed.”[1]
Services “primarily educational or vocational in nature” are not covered. Services in academic or vocational settings, or by telehealth, must still meet the direct-treatment definition. Insured Connecticut plans need not pay for special education under an IEP.[1][4]
“Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider.” On a CMS-1500, “List only a BCBA or other licensed provider in box 33.” Electronic claims use payer ID 62308.[2]
No. Evernorth says all ABA services must be billed with CPT 97151–97158, 0362T and 0373T only.
EN0499 asks for dated quantitative baseline, interim and current data (current data within 60 days) and a standardized assessment within a year; it does not name graphs.
90 days from the date of service unless your agreement or state law allows longer; for secondary claims, 90 days from the primary payer’s EOB.
Yes, under national policy EN0499 for ASD, with Connecticut’s mandate added for fully insured plans. Self-funded employer plans follow their own documents.
No, for 97151, 97152 and 0362T with an autism diagnosis when the provider is independently licensed or a BCBA. PA starts at treatment.
Cigna publishes no ABA rates. Your fee schedule is Exhibit A of your Evernorth Provider Agreement; call 800.926.2273 with questions. Connecticut Medicaid’s 97153 rate ($14.00 per 15 minutes) is the only public benchmark.
Yes. Conn. Gen. Stat. § 20-185j says “No person may practice behavior analysis unless licensed.” A current BCBA gets the license from DPH by showing BACB certification ($350, renewed yearly), and § 20-185l offers licensure by endorsement. RBTs, technicians and BCaBAs working under a licensed behavior analyst’s supervision do not need their own license. Telehealth into Connecticut also requires the Connecticut license: the telehealth statute (§ 19a-906) defines a telehealth provider as someone licensed under title 20, and its temporary route for out-of-state behavior analysts applied only on or before June 30, 2025 (2026 Supplement text). On a fully insured plan, the autism mandate covers behavioral therapy only when it is provided or supervised by a licensed behavior analyst, physician or psychologist.
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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