---
title: "Molina Healthcare of Illinois ABA coverage: the intake guide."
url: "https://carelu.com/payers/molina-healthcare-illinois"
markdown_url: "https://carelu.com/payers/molina-healthcare-illinois.md"
state: IL (Illinois)
payer: Molina Healthcare of Illinois
kind: Medicaid managed care plan (MCO)
parent_program: Illinois Medicaid (HealthChoice Illinois)
description: "How Molina Healthcare of Illinois covers ABA (ABS) for HealthChoice Illinois members: no authorization for the assessment or the first 48 units a year, concurrent review from the 49th unit, Availity-only submission, claims and appeal deadlines."
last_reviewed: October 2026
---

# Molina Healthcare of Illinois ABA coverage: the intake guide.

_Payer Guide · Molina Healthcare · Illinois · Last updated October 2026 · 11 primary sources_

> HealthChoice plan: no auth for the ABA assessment or the first 48 therapy units a year; concurrent review from unit 49 (2026).

Molina Healthcare of Illinois is a statewide HealthChoice Illinois plan and has covered ABS since November 1, 2020. Of the Illinois plans, it went furthest in reading Public Act 104-0028: from January 1, 2026 ABA has no prior authorization at all, only concurrent review that starts once a child passes 48 therapy units in the calendar year.

This plan administers the **Illinois Medicaid (HealthChoice Illinois)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Illinois Medicaid (HFS) guide](https://carelu.com/payers/illinois-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: No. “Authorization is not required for an Applied Behavioral Analysis (ABA) initial assessment, evaluation, or the first 48 units per calendar year for ABA therapy” (memo, Jan. 22, 2026) [2]
- **Prior auth for treatment**: Concurrent review only: “ABA services are no longer eligible for prior authorization and require concurrent review only effective January 1, 2026.” Submit concurrent clinical “no later than 24 hours after the initiation of the 49th unit” (units counted across 0373T, 97153–97158) [2]
- **Autism diagnosis required?**: Yes. Molina’s ABS memo: services for individuals under 21 “diagnosed with an Autism Spectrum Disorder (ASD) as indicated by a Comprehensive Diagnostic Evaluation,” referred by a physician, with ongoing services recommended by a BCBA on a BATP [4][5]

## At a glance

- **Covers ABA?:** Yes, as ABS for members under 21 with ASD
- **Assessment:** No authorization for the initial assessment or evaluation
- **Treatment:** First 48 units per calendar year without authorization; concurrent review clinical due within 24 hours of the 49th unit
- **Submit via:** Availity Essentials only
- **Decision clock:** Standard 5 calendar days; expedited 48 hours
- **Timely filing:** 180 days (Medicaid)

## Authorization: 48 free units, then concurrent review

Molina’s January 22, 2026 memo: “authorization is not required for an Applied Behavioral Analysis (ABA) initial assessment, evaluation, or the first 48 units per calendar year for ABA therapy (cumulative of 0373T, 97153, 97154, 97155, 97156, 97157, 97158). Due to Illinois Public Act 104-0028, ABA services are no longer eligible for prior authorization and require concurrent review only effective January 1, 2026. Note: Providers must submit concurrent clinical no later than 24 hours after the initiation of the 49th unit for concurrent review.” Forty-eight units is 12 hours, so for a typical intensive program the clock starts in the first week. “Availity Essentials is the exclusive provider portal for Molina Healthcare—and the only way to submit authorization requests,” and clinical documents must accompany every request. [12][13][2][14][15][16][17]

Illinois Public Act 104-0028 (HB 3019) changed behavioral health utilization management from January 1, 2026, and each HealthChoice Illinois plan has read it differently for ABA. Molina says ABA “services are no longer eligible for prior authorization and require concurrent review only” (no authorization for the initial assessment or the first 48 units of therapy a calendar year). Aetna Better Health approves 97151/97152 without medical-necessity review if notified within one business day, then runs concurrent review. Blue Cross Community Health Plans and YouthCare ask for notification within 24 hours of starting ABA services or the initial assessment. Meridian requires notice within 24 hours of 97151/97152 from May 1, 2026 and keeps prior authorization on treatment. CountyCare removed PA from 97151/97152 only. The Act itself added subsection (w) to 215 ILCS 5/370c: from January 1, 2026 “No policy shall require prior authorization for outpatient or partial hospitalization services for treatment of mental, emotional, or nervous disorders or conditions,” such coverage “may be subject to concurrent and retrospective review,” and “A Medicaid managed care organization may set a deadline of 24 hours after the initiation of treatment” for notification (one more business day if it cannot accept the notice). It also lets HFS “adopt rules to implement the applicable provisions” for managed care organizations “and the medical assistance fee-for-service program” (new 305 ILCS 5/5-5.28). The statute does not name ABA, which is why the plans differ; this guide reports each plan’s own written rule. [12][13][2][14][15][16][17]

## Claims, decisions and appeals

Molina’s 2026 Medicaid provider manual (updated 09/2026): “Standard timely filing is 180 days for Medicaid.” Standard authorization decisions and notice come “within five (5) calendar days,” expedited within 48 hours. Members may appeal within 60 calendar days of the adverse benefit determination. Molina is the payer of last resort. Molina’s ABS memo tells providers to “refer to the HFS fee schedules for correct codes and rates” and that RBT services are submitted by the supervising provider with the RBT as rendering provider in Loop 2310B; HFS’s current rule adds the supervising BCBA in Loop 2310D. On payment, the manual says “Typically, claims are processed within 30 days,” and that unless otherwise agreed in writing Molina “will process the claim for service within 30 days after receipt of clean claims.” Illinois law sets the payment clock for every HealthChoice Illinois plan: under 305 ILCS 5/5-30.1(g), “The MCO shall pay a claim within 30 days of receiving a claim that contains all the essential information needed to adjudicate the claim,” must notify the billing party within 30 days when it cannot adjudicate a claim, and owes a late-payment penalty at least equal to the Insurance Code’s timely-payment interest, calculated and paid within 30 days after the claim is paid, without the provider having to ask for it. No plan document we read publishes a weekly submission cutoff or check-run day; ask the plan’s provider services for its payment cycle. [3][4][5][1]

## Intake gates

The questions that decide whether a family can start with Molina Healthcare of Illinois, and what they have to bring.

- **Age limit**: Under 21: “ABS services are available to individuals under the age of 21.” [4][18]
- **Diagnosis recency**: Molina publishes nothing of its own. HFS: a CDE more than 24 months old needs current functional-impairment documentation. [4][5]
- **Who may diagnose**: Molina requires ASD “as indicated by a Comprehensive Diagnostic Evaluation”; HFS: the CDE is performed by a physician or clinical psychologist. [4][5]
- **Diagnostic tools required**: Molina publishes nothing of its own. HFS: ADOS, GARS, ADI or CARS. [4][5]
- **Referral required?**: Yes: services for members “who have been referred for ABS services by a physician,” with ongoing services recommended by a BCBA on a BATP. HFS’s physician order is valid one year. [4][5]
- **Telehealth**: Molina’s manual follows CMS and state telehealth requirements and has no ABA-specific rule, so HFS’s applies. HFS’s ABS fee schedule (updated 05/14/2026) marks four codes for remote delivery: 97151 (assessment), 97155 (protocol modification), 97156 (family guidance) and 97157 (multiple-family group). The footnote reads: “Only use the GT or 93 modifier when providing allowable service remotely as a distant site telehealth service along with Place of Service (POS) 02 or 10, as applicable, on the specific service line of the claim.” 97152, 97153, 97154, 97158, 0362T and 0373T carry no telehealth modifier, so technician-delivered treatment is billed as in-person. [3][7]
- **Prior-auth decision time**: Standard authorization: determination and notice “within five (5) calendar days”; expedited within 48 hours. For ABA, concurrent clinical is due within 24 hours after the 49th unit starts. [3][2]
- **Other insurance (who pays first)**: “Medicaid is always the payer of last resort”; bill other coverage first. [3][9]

## Delivery and billing rules

Coverage decides whether Molina Healthcare of Illinois pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Molina publishes no ABA ratio of its own in the documents read (its 2022 memo’s collaborative-agreement language predates HFS’s 2023 change). HFS’s rule applies: RBTs “must receive supervision from a BCBA,” with Case Leadership of 5% or more of direct services in HFS’s ABS guidance. [4][6][5]
- **Daily limits / MUEs**: The only Molina unit rule is the 48-unit annual threshold before concurrent review. Molina points to the HFS fee schedule for codes and rates, whose daily maximums are 97153 32 units, 97155 24, 0373T 24. [2][4][7]
- **Bill as provider**: Molina’s memo: RBT services are “submitted by the collaborating BCBA (supervising Provider) with the RBT identified as the Rendering Provider in Loop 2310B of the 837P.” HFS’s ABS rule also requires the supervising BCBA’s name and NPI in Loop 2310D when an RBT renders. [4][5]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not addressed in Molina’s memo or manual; HFS publishes no rule beyond NCCI edits. [2][3]
  - Ask the plan: Molina Provider Relations (MHILProviderNetworkManagement@MolinaHealthcare.com).
- **Session-note signature** _(ask the plan)_: Not addressed in the Molina documents read. [3]
  - Ask the plan: Molina Provider Relations or the documentation standards in your Molina agreement.
- **Place of service** _(ask the plan)_: No Molina ABA setting rule was found. HFS limits remote ABS to 97151, 97155, 97156 and 97157 with GT/93 and POS 02 or 10. [3][7]
  - Ask the plan: Molina Provider Relations: ask which POS codes it pays for ABA.

## What intake should collect for Molina Healthcare of Illinois

- **Member ID:** Confirm Molina HealthChoice Illinois on the date of service.
- **Units used this year:** The 48 unit-free allowance is per calendar year; ask the family about any other ABA provider this year.
- **Comprehensive Diagnostic Evaluation:** HFS standard: physician or clinical psychologist, with ADOS, GARS, ADI or CARS.
- **Physician referral:** Molina’s memo requires referral by a physician; HFS’s order is valid one year.
- **Other insurance:** Molina is payer of last resort.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Does Molina Illinois require prior authorization for ABA?

No. Since January 1, 2026 ABA has concurrent review only: no authorization for the initial assessment or the first 48 units of therapy per calendar year.

### When does Molina’s concurrent review start?

Submit concurrent clinical no later than 24 hours after starting the 49th unit of the year, counted across 0373T and 97153–97158.

### How do I submit to Molina Illinois?

Through Availity Essentials, which Molina calls the only way to submit authorization requests, with clinical documents attached.

### What does Molina Illinois pay for ABA?

Molina directs providers to the HFS ABS fee schedule (97153 $13.00, 97155 $20.39 per 15 minutes); contracted rates are in your agreement.

## Primary sources

1. [305 ILCS 5/5-30.1 — Illinois Public Aid Code, managed care protections, subsection (g) Timely payment of claims (official text through P.A. 104-470, eff. 6-16-26; read via witnessslips.ilga.gov mirror)](https://witnessslips.ilga.gov/legislation/ilcs/documents/030500050K5-30.1.htm)
2. [Molina Healthcare of Illinois — Provider Memo: Prior Auth Change for Applied Behavioral Analysis (Jan. 22, 2026)](https://myhealthinhand.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/il/2026-Provider-Memos/MHIL_Provider_Memo_Applied_Behavioral_Analysis_Initial_PA_Final508.pdf)
3. [Molina Healthcare of Illinois — Medicaid Provider Manual 2026 (last updated 09/2026)](https://myhealthinhand.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/il/Provider-Manuals/2026_MHIL_Medicaid_Provider_Manual_V1_Final508.pdf)
4. [Molina Healthcare of Illinois — Provider Memo: Adaptive Behavioral Support (ABS) Is a Covered Service (updated Nov. 28, 2022)](https://myhealthinhand.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/il/2022-Provider-Memos/Provider_Memo_ABS_Services_Covered_11-2022_Final508.pdf)
5. [HFS Provider Notice (09/30/2021) — Update to Coverage of Adaptive Behavior Support Services for Children with ASD (eff. 10/1/2021)](https://hfs.illinois.gov/medicalproviders/notices/notice.prn210930b.html)
6. [HFS Provider Notice (08/24/2023) — Updates to ABS Service Provider Qualifications per Public Act 103-0102](https://hfs.illinois.gov/medicalproviders/notices/notice.prn230824a.html)
7. [HFS — Adaptive Behavior Support (ABS) Services Fee Schedule, effective 01/15/2022, updated 05/14/2026](https://hfs.illinois.gov/content/dam/soi/en/web/hfs/medicalproviders/medicaidreimbursement/adaptive/UpdatedABSFeeSchedule51426.pdf)
8. [HFS — Medicaid Managed Care Program Map (January 1, 2026)](https://hfs.illinois.gov/content/dam/soi/en/web/hfs/medicalproviders/cc/documents/managedcaremap.pdf)
9. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
10. [IDFPR — Behavior Analysts (Licensed Behavior Analyst, Licensed Assistant Behavior Analyst; 225 ILCS 6/150 notice)](https://idfpr.illinois.gov/profs/behavior-analysts.html)
11. [Molina Healthcare of Illinois — Provider Communications (provider memos and newsletters by year)](https://www.molinahealthcare.com/providers/il/communications)
12. [Public Act 104-0028 (HB 3019), eff. Jan. 1, 2026 — official text (read via witnessslips.ilga.gov mirror)](https://witnessslips.ilga.gov/legislation/publicacts/104/104-0028.htm)
13. [215 ILCS 5/370c — Mental and emotional disorders (official ILCS text incl. subsection (w), eff. 1/1/2026; read via witnessslips.ilga.gov mirror)](https://witnessslips.ilga.gov/legislation/ilcs/documents/021500050K370c.htm)
14. [Aetna Better Health of Illinois — Utilization Management changes to align with new legislation (Public Act 104-0028), Feb. 20, 2026](https://es.aetnabetterhealth.com/content/dam/aetna/medicaid/illinois/providers/pdf/ABHIL_UM%20updates_02.20.2026.pdf)
15. [BCBSIL — Medicaid Service Authorization Program Details and Notification Requirements (eff. Jan. 1, 2026, updated March 2026)](https://www.bcbsil.com/docs/provider/il/claims/um/bcchp-pa-summary.pdf)
16. [Meridian — Notification requirements for ABA assessments (02/26/26; eff. May 1, 2026)](https://www.ilmeridian.com/newsroom/notification-requirements-for-applied-behavior-analysis--aba--as.html)
17. [CountyCare — Removal of Authorization Requirements for ABA Assessments, eff. January 1, 2026 (notice, February 2026)](https://countycare.com/wp-content/uploads/CCHHS_Provider_Notice_ABA_Feb2026.pdf)
18. [HFS Provider Notice (10/30/2020) — Coverage for ABA Services for Children 0 through 20 Years: Provider Enrollment](https://hfs.illinois.gov/medicalproviders/notices/notice.prn201030c.html)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.