Mid-State Health Network ABA coverage: the Michigan Medicaid autism benefit intake guide.

Mid-State Health Network applies the state rule; its published autism material sets nothing different. 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.^[4][1][3][5]

MSHN accepts an outside comprehensive diagnostic evaluation if it "was completed within the last three years and prior to beginning BHT services" and meets the content and practitioner requirements; the CMHSP may request review by a PIHP qualified licensed practitioner. Re-evaluations are required "no more than once every three years, unless determined medically necessary more frequently."^[1]

MSHN lists the manual’s qualified licensed practitioners: psychiatry or neurology physicians, developmental or developmental-behavioral pediatricians, pediatricians or other physicians with ASD expertise, psychologists, APRNs and PAs with ASD or behavioral-health training, and fully licensed master’s clinical social workers experienced in diagnosing ASD. The same list governs whether an outside evaluation is accepted.^[1][4]

Mid-State Health Network applies the state rule; its published autism material sets nothing different. 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.^{[4][9][10][11][1][3][5]}

The PCP screens and must complete a full medical and physical examination before referral, then refers to the CMHSP for the child’s area; MSHN adds that "There is no “wrong door” for a referral": a self-referred family or one without a PCP can start eligibility at the PIHP/CMHSP while being referred to a PCP for screening and the medical exam.^[1]

Mid-State Health Network applies the state rule; its published autism material sets nothing different. 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."^{[12][7][1][3][5]}

MSHN’s Utilization Management procedure (reviewed 05.07.2024): notice of a decision that denies or limits services is due "within 14-days following receipt of the request for service for standard authorization decisions, or within 72-hours" for expedited decisions; a decision not reached in time is a denial requiring an adverse benefit determination notice, and the CMHSP may extend by up to 14 calendar days. Federal law (42 CFR 438.210(d)) caps standard decisions at 7 calendar days for rating periods starting on or after January 1, 2026, which postdates MSHN’s procedure.^[5][6]

Mid-State Health Network applies the state rule; its published autism material sets nothing different. 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).^{[4][4][14][1][3][5]}

MSHN restates the manual: technicians work under the BCBA/LBA or BCaBA "with minimally one hour of clinical observation and direction for every ten hours of direct treatment. This is often referred to as the “minimum 10% supervision requirement.”" BHT must be provided under the direction of a BCBA/LBA, who reports progress to parents at least every three to six months; MSHN’s procedure lists BCBA-D/BCBA and BCaBA as LARA-licensed supervisors.^[1][4]

Mid-State Health Network applies the state rule; its published autism material sets nothing different. 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.^[7][1][3][5]

Mid-State Health Network applies the state rule; its published autism material sets nothing different. 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.^{[4][4][1][3][5]}

Mid-State Health Network applies the state rule; its published autism material sets nothing different. 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.^{[4][4][1][3][5]}

Mid-State Health Network applies the state rule; its published autism material sets nothing different. 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.^{[7][4][1][3][5]}

Mid-State Health Network applies the state rule; its published autism material sets nothing different. 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.^{[4][4][7][1][3][5]}

Blocked on: Mid-State Health Network (or its CMHSP) provider manual / documentation standards (ask the PIHP’s autism benefit or provider network office for the ABA progress-note requirements).