For a Michigan intake team, a Cigna card means Evernorth’s national ABA policy (EN0499), Cigna’s autism resource guide for the operational rules, Michigan’s autism mandate (MCL 500.3406s), and the plan’s funding type. Cigna is easy at the front door (no prior authorization on assessments) and exacting on treatment-plan data.
EN0499 (effective May 15, 2026) covers ABA for a confirmed ASD diagnosis (F84.0–F84.9, excluding F84.2 Rett syndrome) made by an independently licensed clinician, with the diagnosing clinician’s name, credentials and the date of the most recent diagnosis. The ABA assessment must use a current, standardized instrument covering the DSM-5-TR domains, and baseline data must be collected within 60 days before treatment. Case supervision runs one to two hours per ten hours of direct treatment. Cigna’s autism resource guide adds the operational rules: no prior authorization for 97151, 97152 or 0362T when the provider is independently licensed or a BCBA; only one provider bills a unit of time except the 97153/97154 plus 97155 pairing; unlicensed staff are billed under the supervising provider; and all ABA codes may be delivered by telehealth.[1][2]
Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum disorders and treatment of autism spectrum disorders," including behavioral health treatment such as applied behavior analysis, and bar the carrier from limiting the number of visits, from denying coverage because treatment "is educational or habilitative in nature," and from applying dollar limits, copays, deductibles or coinsurance that do not apply to physical illness generally.[3][4]
Unlike newer mandates, Michigan’s still carries age and dollar ceilings the carrier may choose to apply: coverage for treatment may be limited "through 18 years of age" and to a maximum annual benefit of $50,000 through age 6, $40,000 from 7 through 12, and $30,000 from 13 through 18. Treatment must be "prescribed or ordered" by a licensed physician or licensed psychologist who finds it medically necessary, behavioral health treatment must be "provided or supervised by a board certified behavior analyst or a licensed psychologist," and the diagnosis means assessments "including the autism diagnostic observation schedule, performed by a licensed physician or a licensed psychologist." While a member is in treatment the carrier may require a treatment plan and treatment review, request the ADOS results, request that the ADOS be repeated no more than once every three years, and request an annual development evaluation. Utilization review, medical-necessity review, network requirements and coordination of benefits still apply. Exempt: self-funded ERISA employer plans (outside state insurance law), exchange qualified health plans to the extent the coverage exceeds essential health benefits, and, under 500.3406s, short-term policies of six months or less.[3][4]
Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior analysts have their own LARA license and supervision verification. Technicians are not licensed by the state. Cigna does not publish commercial ABA rates for Michigan; they are contract terms.[5][6][7]
The questions that decide whether a family can start with Cigna / Evernorth in Michigan, and what they have to bring. Each maps onto something intake should ask on the first call.
EN0499 requires "The date on which the diagnosis was most recently made" and the diagnosing clinician’s name, credentials and licensure, but sets no maximum age for the diagnosis. The standardized assessment and baseline data must be within 60 days before treatment starts. On fully insured Michigan plans the mandate lets the carrier request a repeat ADOS no more than once every three years.[1][3]
A confirmed ASD diagnosis (F84.0–F84.9, except F84.2 Rett syndrome) based on DSM-5-TR "by a healthcare professional who is licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice." For fully insured Michigan plans the mandate names a licensed physician or licensed psychologist.[1][3]
EN0499 names no diagnostic instrument; it requires the ABA assessment to use a reliable, valid, standardized instrument covering the DSM-5-TR ASD domains, completed in full, current version (e.g., Vineland-3, not Vineland-II), administered by a trained person, dated and naming the respondent, within 60 days before treatment starts.[1]
Cigna’s national ABA policy requires no referral; ABA assessments (97151, 97152, 0362T) need no prior authorization when the provider is independently licensed or a BCBA and the policy covers ABA, and treatment is requested on the ABA Prior Authorization Form after the assessment. 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.[2][3]
"All ABA CPT codes are covered telehealth services," per Cigna’s autism resource guide, with EN0499 governing the documentation for services delivered via telehealth.[2][1]
EN0499 sets no age cap. 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.[1][3][4]
Ask the plan: Cigna Coverage Confirmation Grid or the Autism Care Coordinator team (877-279-7603): fully insured vs. self-funded, and any certificate age or 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.[8][9]
Ask the plan: At benefits verification ask whether the plan is fully insured (Michigan-regulated) or self-funded (ERISA), then confirm the Cigna/Evernorth turnaround and reauthorization lead time (the Evernorth Autism Care Coordinator team, 877-279-7603).
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, Cigna 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 Cigna’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).[10][3][11][12][13]
Ask the plan: Ask Cigna at benefits verification for the member’s coordination-of-benefits order (the Evernorth Autism Care Coordinator team, 877-279-7603); self-funded plans set their own COB terms in the plan document. Record every other coverage the child has.
Coverage decides whether Cigna / Evernorth in Michigan 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 trained in ABA, with direct and indirect case supervision "consistent with the general accepted standard of care of one to two hours per ten hours of direct treatment"; when direct treatment is 10 hours a week or less, at least one to two hours a week of direct case supervision. The supervisor’s name and credentials must be documented.[1]
Allowed only for the named pairs: "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)."[2]
Setting-neutral with conditions: where services are delivered in environments such as an academic setting, a vocational placement or via telehealth, the documentation must show the service is direct ABA treatment in line with the treatment plan and that ABA is "not utilized to replace or replicate activities that are the responsibility of the setting" (for example a classroom aide, 1:1 teacher or tutor). Treatment plans list the settings (home, clinic, school, community).[1]
"Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider." ABA must be billed with 97151–97158, 0362T and 0373T only; the resource guide lists who may provide and bill each code (BCBA-D, BCBA or licensed mental health provider for the analyst codes).[2]
Cigna publishes no per-day unit ceiling. Hours are authorized on EN0499 medical-necessity criteria from the submitted treatment plan (baseline data within 60 days of the treatment start, measurable goals, stakeholder training); multiple ABA agencies in one authorization period are not medically necessary unless coordinated and non-duplicative.[1]
Ask the plan: The Evernorth authorization determination, or the Autism Care Coordinator team, 877-279-7603.
Not addressed in EN0499 or the autism resource guide beyond requiring the name and credentials of the supervisor and stakeholder trainer to be documented.[1][2]
Ask the plan: The Cigna/Evernorth provider agreement and administrative guidelines, or Provider Services, 800-926-2273.
No, for 97151, 97152 and 0362T when the provider is independently licensed or a BCBA and the member’s policy covers ABA. Treatment requires prior authorization.
Cigna’s autism resource guide says all ABA CPT codes are covered telehealth services, with EN0499 documentation rules.
Only to fully insured plans. Many Cigna employer plans are self-funded and exempt; verify funding type first.
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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