Michigan Medicaid covers ABA as part of its Behavioral Health Treatment (BHT) benefit for children under 21 with autism, and the single fact that organizes every Michigan Medicaid intake is where that benefit lives. It is not run by the Medicaid Health Plan printed on the family’s card. The Medicaid Provider Manual assigns the comprehensive diagnostic evaluation, the behavioral assessment and all BHT services, ABA included, to the Prepaid Inpatient Health Plan (PIHP) for the child’s county, which delivers them through its Community Mental Health Services Programs (CMHSPs) and contracted ABA agencies. So the question that routes a Michigan Medicaid family is not "which health plan?" but "which county?" This guide covers the state rules every PIHP must follow; five PIHPs (regions 4, 5, 7, 8 and 9) have their own guides.
Michigan splits Medicaid behavioral health in two. Mild-to-moderate outpatient mental health belongs to the Medicaid Health Plans (MHPs) and fee-for-service; specialty behavioral health, including autism, belongs to the PIHPs. The Medicaid Provider Manual is explicit for autism: once the primary care provider screens a child and decides a referral is necessary, "the PIHP is responsible for the comprehensive diagnostic evaluation, behavioral assessment, BHT services (including ABA) for eligible Medicaid beneficiaries, and for the related EPSDT medically necessary Mental Health Specialty Services." The general eligibility section repeats it: "The PIHP is responsible for further evaluation when severe concerns are suspected (i.e., Autism Spectrum Disorder …)" while "When the assessment is driven by medical need, the MHP is responsible for coverage."[1][1][1][4][5][6]
Two practical consequences. First, the health plan name on the card (Priority Health’s Medicaid plan, Blue Cross Complete, HAP CareSource and the rest) does not route the ABA request; Priority Health’s own autism policy notes that for its Medicaid and Healthy Michigan Plan members these services "are paid through Michigan’s Department of Community Mental Health." Second, speech, occupational and physical therapy follow the child: children the PIHP finds eligible for BHT can get ASD-related OT, PT and ST through the PIHP, while children assessed but found ineligible get them through the MHP or fee-for-service. SWMBH describes the benefit as covering Medicaid, Healthy Michigan Plan and MIChild members alike.[1][1][1][4][5][6]
Each PIHP must be certified as a Community Mental Health Services Program under Section 232a of the Mental Health Code, either a single CMHSP or the lead agency of an affiliation of CMHSPs. The ten current regions: (1) NorthCare Network (Upper Peninsula), (2) Northern Michigan Regional Entity, (3) Lakeshore Regional Entity (Kent via Network180, Ottawa, Muskegon, Allegan, Lake, Mason, Oceana), (4) Southwest Michigan Behavioral Health, (5) Mid-State Health Network, (6) CMH Partnership of Southeast Michigan (Washtenaw, Livingston, Lenawee, Monroe), (7) Detroit Wayne Integrated Health Network, (8) Oakland Community Health Network, (9) Macomb County Community Mental Health, and (10) Region 10 PIHP (Genesee, Lapeer, Sanilac, St. Clair). Carelu has separate guides for regions 4, 5, 7, 8 and 9.[1][1][1][4][5][6]
The manual lays out a fixed order. Screening happens at an EPSDT well-child visit with a validated, standardized tool, and "A full medical and physical examination must be performed before the child is referred for further evaluation." The PCP then refers the child to the PIHP for the county, and the PIHP contacts the family to schedule a comprehensive diagnostic evaluation and behavioral assessment. The evaluation must be done "before the child receives BHT services" by a qualified licensed practitioner (psychiatry or neurology physician, developmental-behavioral pediatrician, pediatrician with ASD expertise, psychologist, APRN or PA with ASD training, or a fully licensed master’s clinical social worker) and should use validated tools; eligibility is then confirmed "through direct observation utilizing valid evaluation tools."[1][7][5][8]
To qualify, the child must meet DSM-5 criteria A (all three social-communication deficits) and B (at least two restricted/repetitive behavior patterns) at a level of substantial functional impairment, be under 21, be medically able to benefit, and have treatment outcomes expected to develop, maintain or restore function. Two eligibility conditions surprise families: services must be coordinated with the school or early intervention program, and "Families of minor children are expected to provide a minimum of eight hours of care per day on average throughout the month." A well-established DSM-IV diagnosis of autistic disorder, Asperger’s or PDD-NOS should be given the ASD diagnosis. The PIHPs then send the evaluation to MDHHS through the Waiver Support Application for approval (Oakland reports MDHHS approval within 12–48 hours), a support coordinator or case manager builds the individual plan of service through person-centered planning, and the family picks an ABA agency from the PIHP network.[1][7][5][8]
Re-evaluations are required "no more than once every three years" unless more are medically necessary, the level of service is re-determined at least every six months, and authorizations run up to 365 days.[1][7][5][8]
BHT must be delivered under the direction of a BCBA/LBA, who is responsible for the behavioral plan of care, for supervising BCaBAs and technicians, and for reporting progress on goals to parents every three to six months. Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (licensure law enacted 2016): the license requires current BACB certification in good standing, a criminal background check, human-trafficking and implicit-bias training, and renews every four years ($452.40 for application plus four-year license). The Medicaid manual requires supervisors to be BACB-certified and LARA-licensed, and BCaBAs to be licensed through LARA as assistant behavior analysts.[1][9][10][11][12]
Behavior technicians do not need a license or a BACB registration: they must receive BACB-approved RBT training from a BCBA/LBA, BCaBA or QBHP, be at least 18, be certified in basic first aid, be trained in the child’s plan of care, and work with "minimally one hour of clinical observation and direction for every 10 hours of direct treatment." The older pathways are closing: licensed psychologists and QBHPs had to be certified and licensed as a BCBA/LBA by September 30, 2025, and the SFY 2026 code charts list QBHP as a qualifying provider only until October 1, 2025.[1][9][10][11][12]
ABA is billed to the PIHP or CMHSP under your network contract, not to CHAMPS fee-for-service. MDHHS’s SFY 2026 Behavioral Health Code Charts set the reporting rules every PIHP uses: all ABA codes are per 15 minutes; staff-level modifiers identify the rendering provider (HO licensed behavior analyst, HN licensed assistant behavior analyst, HM behavior technician); 97151 carries the U5 autism modifier; and 97155 "Must co-occur with 97153, 97154, and 0373T in order to be reported." The same-time rules allow 97153 and 97155 together when delivered by two different people, and 97156 to the caregiver while the technician runs 97153.[9][13][1]
Telehealth is narrow. The Bureau of Specialty Behavioral Health Services Telemedicine Database allows 97155, 97156, 97157 and 97158 by simultaneous audio/video (POS 02 or 10), and removed 97151, 97153, 97154 and 0362T in April 2023. On rates, the manual says only that "All PIHPs will reimburse BHT-ABA services at a minimum to the rate outlined with the most recent executed PIHP contract" — the floor lives in the MDHHS/PIHP contract, not in a public fee screen, and each PIHP negotiates its own network rate above it.[9][13][1]
MDHHS ran a competitive procurement for the PIHP contracts, with an RFP issued in August 2025 (bids due September 29, 2025) and a stated goal of a service start date of October 1, 2026. The RFP was limited to nonprofit organizations with additional consideration for public entities, and the PIHP "must contract with CMHSPs to provide a comprehensive array of mental health services as required by the Mental Health Code." MDHHS’s county designations table for the FY27 contract maps today’s ten regions onto new Northern, Central and Metro regions (Wayne, Oakland and Macomb into Metro). We could not confirm at review time which entities hold the contracts from October 1, 2026 onward; until MDHHS publishes the award, confirm the PIHP for the family’s county before routing a referral or an authorization.[14][15][6]
The questions that decide whether a family can start with Michigan Medicaid, and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21. BHT/ABA is covered "for children under 21 years of age diagnosed with Autism Spectrum Disorder" as an EPSDT benefit, and the first eligibility criterion is "Child is under 21 years of age." No minimum age is set; the manual stresses early screening at EPSDT well-child visits.[1]
No expiry on the diagnosis itself. "Comprehensive diagnostic re-evaluations are required no more than once every three years, unless determined medically necessary more frequently" by a physician or other licensed practitioner, with frequency based on age, developmental level, comorbidities, severity and adaptive deficits. The level of service is re-determined at least every six months, and BHT authorizations run up to 365 days.[1]
A qualified licensed practitioner "qualified and experienced in diagnosing ASD": a physician with a specialty in psychiatry or neurology; a physician with a subspecialty in developmental pediatrics, developmental-behavioral pediatrics or a related discipline; a physician with a specialty in pediatrics or other appropriate specialty with ASD training, experience or expertise; a psychologist; an advanced practice registered nurse or a physician assistant with ASD and/or behavioral health training; or a master’s-level, fully licensed clinical social worker qualified and experienced in diagnosing ASD. The PIHP is responsible for arranging the comprehensive diagnostic evaluation.[1]
The manual names no instrument but requires "valid evaluation tools": the comprehensive diagnostic evaluation is "a neurodevelopmental review of cognitive, behavioral, emotional, adaptive, and social functioning" that should include validated tools, integrating caregiver reports, records, collateral reports, standardized psychological tools and an observational assessment ("No one piece of data determines the ASD diagnosis"). Eligibility must be determined "through direct observation utilizing valid evaluation tools." In practice the PIHPs publish the same battery: ADOS-2, ADI-R and the DD-CGAS (Developmental Disability Children’s Global Assessment Scale), plus cognitive and adaptive testing.[1][17][7][5]
Yes, through the PIHP. Screening "typically occurs during an EPSDT well child visit" with the primary care provider using a validated screening tool, and "A full medical and physical examination must be performed before the child is referred for further evaluation." The PCP "must refer the child to the PIHP in the geographic service area," and each PIHP identifies a specific point of access for ASD referrals. Medical necessity and the recommendation for BHT are determined by a physician or other licensed practitioner working within scope. PIHPs also accept family self-referral ("no wrong door") and then route the child back to the PCP for the medical exam where needed.[1][18]
Only the analyst-level codes. The MDHHS Bureau of Specialty Behavioral Health Services Telemedicine Database lists 97155, 97156, 97157 and 97158 as allowed via simultaneous audio/visual telemedicine (reported with POS 02 or POS 10, no modifier), and its revision log records that 0362T, 97151, 97153 and 97154 were removed from the database on 4/28/23 — so technician-delivered direct treatment and the behavior identification assessment are in-person. The diagnostic-evaluation codes 96112/96113 and 96116 remain allowed via audio/visual "for reporting BHT/ABA eligibility assessments and re-evaluation assessments related to Autism." The SFY 2026 code charts note on 97155 to use POS 02 "if MDHHS has authorized tele-practice for an individual."[13][9]
The PIHP decides, under the federal managed-care clock. Section 18 says "The PIHP’s Utilization Management will authorize the level of services prior to the delivery of services," and the manual requires determinations "Made within federal and state standards for timeliness." Under 42 CFR 438.210(d) a PIHP must decide a standard request within state-set timeframes that "may not exceed 14 calendar days" for rating periods that start before January 1, 2026 and "may not exceed 7 calendar days" for rating periods starting on or after that date, extendable by up to 14 calendar days at the enrollee’s or provider’s request or with justification; expedited decisions are due within 72 hours. Which cap binds depends on the PIHP contract’s rating-period start date. BHT authorizations run for up to 365 days and are re-authorized annually.[1][1][19]
Medicaid pays last. "Medicaid is considered the payer of last resort. If a beneficiary with Medicare or Other Insurance coverage is enrolled in a Medicaid Health Plan (MHP), or is receiving services under a Prepaid Inpatient Health Plan (PIHP) or Community Mental Health Services Program (CMHSP), that entity is responsible for the Medicaid payment liability." Providers "must utilize other payment sources to their fullest extent" before billing Medicaid, and "Medicaid is not liable for payment of services denied because coverage rules of the primary health insurance were not followed" — so get the commercial plan’s prior authorization and use its network. The ABA section adds that the IPOS must not duplicate services that are the responsibility of "a private insurance or other funding authority." Nothing in Section 18 exempts a child with other coverage from the PIHP’s own eligibility determination and pre-service authorization. Federally, the agency rejects a claim when third-party liability is established and pays only the amount its schedule exceeds the third party’s payment (42 CFR 433.139).[1][1][21]
Coverage decides whether Michigan Medicaid 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.
The behavior technician works under the supervision of the BCBA/LBA or other professional (BCaBA or QBHP) overseeing the behavioral plan of care, "with minimally one hour of clinical observation and direction for every 10 hours of direct treatment." BHT services "must be provided under the direction of a BCBA/LBA or a Master’s prepared QBHP," and the BCBA/LBA is responsible for clinical skill development and supervision of BCaBAs, QBHPs and technicians and for communicating progress on goals to parents or guardians at least every three to six months. The manual gave licensed psychologists (LP/LLP) and QBHPs a deadline to be certified and licensed as a BCBA/LBA by September 30, 2025, and the SFY 2026 code charts now list QBHP as a qualifying provider only "until October 1, 2025."[1][9]
Allowed for the pairs MDHHS names. The SFY 2026 code charts say 97155 "Must co-occur with 97153, 97154, and 0373T in order to be reported," and the same-time reporting rules state that 97153 and 97155 "can occur at the same time, just not by the same person" (the technician delivers 97153 while the BCBA/LBA supervising delivers 97155); 97156 may be delivered by the BCBA/LBA to the caregiver while a technician delivers 97153 to the child; a 97151 reassessment may be reported at the same time as 97153, 97154, 0373T (and potentially 97157/97158) "IF there are two separate providers"; and 0362T may be reported at the same time as 0373T. Targeted case management may also run at the same time as a direct ABA service.[9]
No per-day or per-week unit cap is published. The manual sets planning averages, not ceilings: focused behavioral intervention averages 5–15 hours a week and comprehensive behavioral intervention 16–25 hours a week, with actual hours set by the behavioral plan of care. A PIHP "may not deny services based solely on preset limits of the cost, amount, scope, and duration of services," and the level of service is re-determined at least every six months on measurable progress. Authorizations may run up to 365 days.[1][1]
Home and community. Eligibility requires that "Services are able to be provided in the child’s home and community, including centers and clinics," and BHT is "designed to be delivered primarily in the home and in other community settings." Services "are not intended to supplant responsibilities of educational or other authorities," and the IPOS must not include special education and related services available through the local education agency under IDEA; coordination with the school or early intervention program (IEP/IFSP meetings, communication logs) is an eligibility element. For office or site-based services the primary provider must be within 30 minutes/30 miles in urban areas and 60 minutes/60 miles in rural areas of the beneficiary’s residence.[1][1]
Services are reported to the PIHP/CMHSP under the provider’s network contract, with a modifier naming the rendering staff level. The SFY 2026 code charts list the qualifying provider types and modifiers for each ABA code: HO for a licensed behavior analyst (master’s level) or QBHP, HN for a licensed assistant behavior analyst (bachelor’s level), and HM for a behavior technician on the technician codes (97153, 97154, 0373T); 97151 carries the state-defined U5 "Autism" modifier and group codes carry the UN–US group-size modifiers. A technician does not need a license or BACB registration, but must complete BACB-approved RBT training and work under the BCBA/LBA’s supervision.[9][1]
Section 18 of the Medicaid Provider Manual and the SFY 2026 code charts do not state who signs an ABA session note or by when. The manual requires the individual plan of service (IPOS) to specify amount, scope and duration of each authorized service and permits electronic signatures for the beneficiary on the plan of service and consents; session-note signature standards sit in each PIHP’s provider contract and documentation standards.[1][1][9]
Blocked on: The contracting PIHP or CMHSP provider manual / documentation standards (ask the PIHP’s autism benefit or provider network office for the ABA progress-note requirements).
Yes, for children under 21 with autism, through the Behavioral Health Treatment benefit. It is delivered by the regional PIHP and its Community Mental Health programs after a PCP screening, a full medical exam and a comprehensive diagnostic evaluation.
No. The manual assigns the autism evaluation and all BHT/ABA services to the PIHP for the child’s county. The health plan covers the PCP screening and, if the PIHP finds the child ineligible, related speech, occupational and physical therapy.
No preset cap. The manual describes focused intervention averaging 5–15 hours a week and comprehensive intervention averaging 16–25, and says a PIHP may not deny services based solely on preset limits.
Only analyst-level services: 97155, 97156, 97157 and 97158. Technician-delivered 97153/97154, the 97151 assessment and 0362T were removed from the MDHHS telemedicine database in 2023.
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