Southwest Michigan Behavioral Health (SWMBH) is the PIHP for region 4: Kalamazoo, Calhoun, Berrien, Van Buren, St. Joseph, Branch, Cass and Barry counties, each served by its own CMHSP. SWMBH contracts ABA through those CMHSPs and publishes a four-step path into the Medicaid, Healthy Michigan Plan and MIChild autism benefit. The state rules in our Michigan Medicaid guide are the floor.
Step 1 is screening, by the child’s primary care physician or the local CMHSP access center, with the M-CHAT or the Social Communication Questionnaire. Step 2 is the diagnostic evaluation, which "takes approximately 3 hours and is completed during two appointments" using the ADOS-2, ADI-R and DD-CGAS; "Once completed, the results are sent to the Michigan Department of Health and Human Services for review/approval." Step 3 is choosing an ABA provider and building the IPOS with the case holder (supports coordinator, case manager or independent facilitator), reviewed quarterly, with a skills assessment (ABLLS or VB-MAPP) every six months. Step 4 is starting ABA with behavior technicians, in clinic or home, individually or in groups, supervised "(1 hour per 10 hours) by Board Certified Behavior Analysts (BCBA) or other Qualified Behaviorist," with parent training.[1]
SWMBH describes ABA plans as averaging 5 to 25 hours of direct intervention a week and notes that ABA interventions "require parent/guardian training and participation." Children may also receive speech, occupational and physical therapy, respite, community living supports and medication management through their supports coordinator.[1]
SWMBH lists the county access lines: Integrated Services of Kalamazoo 269-373-6000; Woodlands (Cass) 269-445-2451; Summit Pointe (Calhoun) 269-966-1460; Van Buren Community Mental Health 269-657-5574; Riverwood (Berrien) 269-925-0585; Pines Behavioral Health (Branch) 517-278-2129; St. Joseph County Community Mental Health 269-467-1000; Barry County Community Mental Health 269-948-8041. Authorizations, billing modifiers, telehealth and coordination of benefits follow the MDHHS rules.[1][2][3][4][5]
The federal managed care rule covers this PIHP. When the network “is unable to provide necessary services, covered under the contract, to a particular enrollee,” the PIHP “must adequately and timely cover these services out of network for the enrollee, for as long as” the network cannot provide them. It must require the out-of-network provider “to coordinate with the MCO, PIHP, or PAHP for payment,” and the family’s cost must be no greater than in network (42 CFR 438.206(b)(4)–(5)). Southwest Michigan Behavioral Health’s own out-of-network or single-case-agreement procedure and rate were not reviewed for this guide. Ask its utilization management or provider network team for an out-of-network authorization and the rate before the first session.[11]
What changes on Jan. 1, 2027. CMS records that at its September 2025 meeting the AMA CPT Editorial Panel "deleted CPT codes 0362T" and "0373T," "revised eight existing CPT codes" (97151 through 97158) and "created six new CPT codes" for adaptive behavior services; the AMA released the CPT 2027 code set on Sept. 9, 2026, with changes in effect on January 1. The ABA Coding Coalition’s 2027 guidance gives the final numbers: 97148 and add-on +97149 (behavior identification supporting assessment of harmful behavior, delivered by two technicians, additional technicians on the add-on), 97159 and add-on +97160 (adaptive behavior treatment of harmful behavior, same two-technician structure), 97173 (adaptive behavior treatment with analysis by a physician or other QHP, face-to-face with one patient) and 97180 (non-face-to-face services personally performed by the QHP, such as data review and modifying protocols). "Protocol modification" becomes "analysis" in the descriptors, and "since there is no grace period, 0362T and 0373T are invalid for dates of service on or after January 1, 2027." No state "approves" the codes themselves: they are Category I CPT codes that HIPAA requires on electronic claims, but, as the Coalition notes, HIPAA "does not, however, govern whether a payer covers a code / service, what a payer pays for a code / service, or what a payer requires to authorize" it, so each payer has to load them, price them and say how authorizations that list 0362T or 0373T carry over.[12][13][14][15][4][10]
MDHHS had not announced how Michigan Medicaid will handle the 2027 adaptive-behavior codes as of Nov. 1, 2026. Its bulletins run to MMP 26-48 (issued Oct. 30, 2026); one of them, MMP 26-46, does apply a 2027 CPT change (maternity codes), but none addresses ABA. The SFY 2027 Behavioral Health Code Charts (updated Sept. 30, 2026), the code list for behavioral health encounters, still list 0362T and 0373T and none of the new codes, and none of the proposed policies posted for public comment concerns them. SWMBH reports ABA encounters on those MDHHS code charts, and we found no SWMBH notice on the 2027 codes (its newsletters page, checked Nov. 1, 2026). Ask SWMBH how it will load the new codes and whether authorizations that list 0362T or 0373T carry over to dates of service from Jan. 1, 2027.[12][13][14][15][4][10]
MDHHS publishes no ABA fee screen for the autism benefit; the rate floor is in the Medicaid Provider Manual, Section 18.13: “All PIHPs will reimburse BHT-ABA services at a minimum to the rate outlined with the most recent executed PIHP contract.” The rate a provider is actually paid is the one in its network contract, so the answer to “what does SWMBH pay for 97153?” comes from the contract or rate sheet: ask SWMBH or the county CMHSP that holds your contract (provider network / contracting) for the current ABA rates by code and credential before signing.[3]
The questions that decide whether a family can start with Southwest Michigan Behavioral Health (SWMBH), and what they have to bring. Each maps onto something intake should ask on the first call.
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 2027 code charts note on 97155 and 97156 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]
Coverage decides whether Southwest Michigan Behavioral Health (SWMBH) 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.
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 2027 code charts (from October 1, 2026) say 97155 reported by a licensed behavior analyst "May co-occur with 97153 & 97154," and 97155 reported by a licensed assistant behavior analyst "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 2027 code charts list the qualifying provider types and modifiers for each ABA code: HO for a licensed behavior analyst (master’s level), HN for a licensed assistant behavior analyst (bachelor’s level), and HM for a behavior technician on the technician codes (97153, 97154, 0373T); group codes carry the UN–US group-size modifiers. (The U5 autism modifier the SFY 2026 charts put on 97151 is not in the SFY 2027 modifier list.) Which codes: ABA is billed with CPT codes, not H-codes. The SFY 2027 code charts list 97151, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T for ABA (97152 does not appear); the diagnostic evaluation behind eligibility is reported with 96112, 96113 or 96116 “For reporting BHT/ABA eligibility assessments and re-evaluation assessments related to Autism”; and H0031 with the 6Y modifier is the behavior identification assessment for people outside the ABA benefit (“97151 for non-ABA was removed effective 10/1/24 so the H0031 with the 6Y is for these individuals”). 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 2027 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).
There is no public state fee screen. The Medicaid Provider Manual (Section 18.13) says PIHPs reimburse BHT-ABA “at a minimum to the rate outlined with the most recent executed PIHP contract”; your rate is in your network contract, so ask SWMBH or the county CMHSP that holds your contract for the current ABA rate sheet.
The Medicaid, Healthy Michigan Plan and MIChild autism benefit for children under 21 in Kalamazoo, Calhoun, Berrien, Van Buren, St. Joseph, Branch, Cass and Barry counties.
About three hours over two appointments using the ADOS-2, ADI-R and DD-CGAS; the results go to MDHHS for review and approval.
One hour of BCBA or qualified behaviorist supervision per ten hours of technician treatment, matching the state rule.
Not yet, as of Nov. 1, 2026. MDHHS has not announced the 2027 ABA codes (its SFY 2027 code charts still list 0362T and 0373T), and we found no SWMBH notice. CPT 2027 deletes 0362T and 0373T and adds 97148/97149, 97159/97160, 97173 and 97180 from Jan. 1, 2027; ask SWMBH how authorizations carry over.
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.
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