SWMBH ABA coverage: the Michigan Medicaid autism benefit intake guide.

Under 21, for Medicaid, Healthy Michigan Plan and MIChild members: SWMBH routes eligibility for "the Medicaid/Healthy Michigan/MICHILD Autism benefit" through its CMHSPs, and the manual limits BHT to children under 21.^[1][3]

SWMBH applies the state rule; its published autism material sets nothing different. 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.^[3][1]

SWMBH applies the state rule; its published autism material sets nothing different. 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.^[3][1]

SWMBH: screening with the M-CHAT or the Social Communication Questionnaire (SCQ), then a diagnostic evaluation of about three hours over two appointments using the ADOS-2, ADI-R and DD-CGAS; the results are sent to MDHHS "for review/approval." Skills assessments (ABLLS or VB-MAPP) follow every six months during treatment.^[1][3]

Screening "is completed by the child’s primary care physician or the your local CMHSP Access Center," then the CMHSP arranges the diagnostic evaluation; SWMBH lists each county CMHSP’s access line. The manual still expects a full medical and physical exam before referral for the evaluation.^[1][3]

SWMBH 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."^[5][4][1]

SWMBH applies the state rule; its published autism material sets nothing different. 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.^[3][3][7][1]

SWMBH 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).^[3][3][9][1]

SWMBH: services "are supervised (1 hour per 10 hours) by Board Certified Behavior Analysts (BCBA) or other Qualified Behaviorist," matching the manual’s minimum of one hour of clinical observation and direction for every 10 hours of direct treatment.^[1][3]

SWMBH 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.^[4][1]

SWMBH 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.^[3][3][1]

SWMBH: ABA "can be provided either in the home or in a clinic setting," individually or in groups. The state rule adds community settings and excludes IDEA school services.^[1][3]

SWMBH 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.^[4][3][1]

SWMBH 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.^[3][3][4][1]

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