MDwise Indiana ABA coverage (Hoosier Healthwise / HIP).

Follows the Indiana Medicaid rule: ABA is covered for members 20 years of age and younger. Effective April 1, 2026 coverage runs exclusively through EPSDT, and for dates of service on or after October 1, 2026 IHCP no longer authorizes or reimburses ABA for members 21 and older — a state policy that binds every MCE.^[5][4][6]

Follows the Indiana Medicaid rule: a CDE more than one year old requires an updated statement of need, which must include a referral from an appropriate referring practitioner and an up-to-date behavior assessment completed by the ABA provider. Members continuing current services need no new CDE but do need an updated behavior assessment and treatment plan. A behavior assessment completed within the previous six months should be obtained from the original provider rather than repeated. IHCP states these documentation requirements apply to managed care as well as fee-for-service. BT2026160 (9/29/2026) since narrowed when that paperwork is due: “statement of need” and “referral” now mean the same thing, and one is required only at onset of ABA if the CDE is more than a year old, at reauthorization when an active member’s CDE crosses one year, or with a new PA after a six-month gap in ABA services — not with every reauthorization or annually — while reassessment and an updated treatment plan are still due at least every six months.^[6][5][18]

Historical. MDwise published no ABA clinical policy of its own — its Behavioral Health Reference Guide simply listed every ABA code as prior-authorization-required and pointed to IHCP criteria — so the state rule governed: the CDE performed by a doctoral-level licensed clinical psychologist endorsed as an HSPP, a licensed physician, a licensed APRN, or a licensed physician assistant with specialized training in the current DSM autism criteria. MDwise ended as an HIP/Hoosier Healthwise MCE on January 1, 2026; for a current member, use the Anthem, CareSource or MHS guide.^[6][3][2]

Historical, and inherited: the state's behavior assessment with its three core standardized instruments — the Vineland Comprehensive Parent Interview Form with the Maladaptive Behavior domain, the BASC Parenting Relationship Questionnaire and an age-appropriate objective direct skills assessment — signed by the lead analyst and parent or guardian, with the complete scoring report and graphs submitted with the PA. MDwise added no instrument requirement of its own.^[5][3]

Follows the Indiana Medicaid rule: a physician must make a treatment referral recommending ABA therapy, and the CDE’s own required components include a physician’s referral for autism-specific services. Under BT2026160 (9/29/2026) the referral/statement of need must come from an HSPP-endorsed doctoral psychologist, a licensed physician, a licensed APRN or a licensed physician assistant — a BCaBA, BCBA, PT, SLP or OT cannot complete it. Prior authorization is required on top of the referral for every ABA service, through this plan rather than through Acentra Health.^[5][6][18]

Follows the Indiana Medicaid rule, with no ABA telehealth policy of the plan’s own. Effective April 1, 2026, IHCP no longer allows 97151, 97152, 97153, 97154 or 0373T to be billed with telehealth modifier 95, so the assessment, reassessments and all direct and group treatment are in person. Only 97155 and 97156 remain telehealth-eligible; IHCP’s provider reference module adds that RBTs and BCaBAs may not deliver any ABA service via telehealth, that remote 97155 is payable only when an HSPP, BCBA or BCBA-D supervises an RBT who is delivering 97153 in person, and that audio-only ABA is never reimbursable (modifier 95 plus U3). IHCP Bulletin BT202662 (4/28/2026) adds that supervision “may be rendered via synchronous telehealth and billed using modifier 95” but “is intended to supplement, not replace, the majority of in-person services.” The module is written for fee-for-service and IHCP says MCEs set their own billing requirements, so confirm with the plan before billing remote 97155 or 97156.^[4][5][6][7]

Historical — MDwise left HIP and Hoosier Healthwise on January 1, 2026, and “new authorization requests for DOS on or after Jan. 1, 2026, must go to the member’s new managed care entity” (Anthem, CareSource or MHS — use that guide's clock). MDwise took requests for dates of service on or before 12/31/2025 until March 31, 2026; from April 1, 2026 its PA-UM fax lines and portal stopped accepting submissions. While active, MDwise's September 2025 manual published no decision clock of its own; as a Medicaid risk-based MCE it was bound by IC 27-1-37.5-23 (urgent 24 hours, all other 48 hours, weekends and holidays excluded) from July 1, 2025.^{[19][20][21][16]}

Historical (MDwise left HIP/Hoosier Healthwise 1/1/2026; claims for DOS on or after that date go to the new MCE). MDwise was payer of last resort: providers “must submit claims to the other insurance carrier before submitting to MDwise,” with the primary EOB “within 90 days of the date of the primary explanation of benefits,” and MDwise paid the difference up to its allowable. It paid first and chased the other carrier only for “Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program and preventive pediatric services” and IV-D child-support coverage. On PA it was explicit: with third-party coverage “the provider is still responsible for obtaining prior authorization for the service and any authorization required by the third-party payer.” A 90-day no-response rule let a claim go to MDwise with proof of the billing attempt.^[20][19]

Follows the Indiana Medicaid rule: ABA performed by a BCaBA or credentialed RBT must be under the direct supervision of a BCBA, BCBA-D or HSPP, and since April 1, 2026 at least 1 hour of BCBA (or IHCP-approved qualifying clinician) supervision is required per 8 hours of technician-delivered therapy. Behavior assessments may only be performed by a psychologist, BCBA-D or master's-level BCBA. IHCP states that its ABA documentation requirements apply to both fee-for-service and managed care, and this plan publishes no supervision standard of its own. BT202662 (4/28/2026) defines how the floor is measured: monthly, per member (“not aggregated across technicians or across Medicaid members”), proportionally when a member gets fewer than eight technician hours in the month, and counting both billable 97155 and documented nonbillable case supervision (fidelity checks, session-note review) — but not administrative supervision such as scheduling or staff meetings. Shortfalls are subject to claim audit, postpayment review and recoupment.^[5][4][6][7]

Follows the Indiana Medicaid limits: up to 40 hours per week may be requested with anything beyond that needing an additional PA; IHCP policy limits each ABA PA request to six months; and since April 1, 2026 comprehensive ABA (16+ hours/week, modifier UA) draws from a 4,000-hour (16,000-unit) lifetime allocation per member, with 97155 and 97156 excluded and targeted ABA (≤15 hours/week) exempt. At the state level IHCP applies the Medicaid NCCI MUEs to fee-for-service professional claims per member, per rendering provider, per date of service (CMS Q4 2026 table: 97153 at 32 units, 97155 at 24, 97151 at 32, 97156 at 16); the IHCP NCCI module leaves managed care claims to each MCE, so confirm the plan’s own daily edits. Open question for managed care: IC 27-1-37.5-26(b), in force since July 1, 2025 and reaching Medicaid risk-based managed care through IC 27-1-37.5-5(a)(3), says an authorization "shall be valid for at least one (1) year after the date the health care provider receives the authorization," and CareSource's July 2025 IHCP Works deck lists "Approved Authorization — Valid for 365 calendar days." But IHCP Bulletin BT2026136 (8/18/2026), addressed to the MCOs and the FFS PA-UM contractor alike, still describes ABA as running on a "standard six-month authorization period." No IHCP bulletin or MCE notice we could find reconciles the two, so ask the MCE which span it is issuing before you plan a reauthorization calendar.^{[12][13][5][4][14][15][16][17]}

Follows the Indiana Medicaid rule; the plan publishes no session-note rule of its own. IHCP’s ABA documentation requirements require "session notes, which must be signed by the rendering practitioner," each including the date, time, location and duration of services and the session-specific targeted skills and the member’s response to the treatment plan goals, producible within 72 hours of a request; the behavior assessment and treatment plan must each be signed by the lead analyst and the parent or guardian. IHCP states that "documentation requirements outlined in IHCP policy are applicable to both FFS and managed care." No signing deadline is published.^[5][6]

Follows the Indiana Medicaid rule: the treatment plan must be built around the member's school attendance (including homeschooling) and other daily activities, while services focusing solely on recreational or educational outcomes are not covered, and neither are services duplicative of an IEP that address the same goals using the same techniques as the treatment plan.^[5]

Follows the Indiana Medicaid rule: ABA rendered by a BCaBA or RBT must be billed under the NPI of an IHCP-enrolled ABA therapist or school corporation, on a professional claim. Since July 1, 2025 the rendering practitioner must be enrolled under ABA specialty 615, 624 or 625, and since April 1, 2025 the rendering NPI must align with the credential-level modifier (U1 RBT / U2 BCaBA / U3 BCBA-HSPP). Plan-level claim formatting may still differ — MCEs publish their own billing requirements.^[5][4]

Not published by Indiana Medicaid or by this plan. IHCP is explicit that within managed care “individual managed care entities (MCEs) establish and publish their own billing and reimbursement requirements,” so unlike the clinical criteria, code-pair rules are not inherited from the state by default. The IHCP rule this plan may or may not mirror: BT202662 (4/28/2026) says “CPT code 97155 may be billed concurrently only with CPT codes 97153 and 97154,” and only when the analyst is actively directing the technician through a modified protocol.^[6][7]

Ask the plan: The MCE directly — ask whether 97155 pays alongside 97153 for the same clock time, and request the plan's billing and reimbursement requirements in writing.