---
title: "Aetna ABA coverage in Maryland: the intake guide."
url: "https://carelu.com/payers/aetna-maryland"
markdown_url: "https://carelu.com/payers/aetna-maryland.md"
state: MD (Maryland)
payer: Aetna in Maryland
kind: Commercial insurance
description: "How Aetna covers ABA for Maryland families — the national clinical policy, prior authorization, Maryland's habilitative services mandate (Md. Ins. § 15-835 + COMAR 31.10.39.03 with 25/10 hour floors), Maryland LBA licensure, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Aetna ABA coverage in Maryland: the intake guide.

_Payer Guide · Aetna · Maryland · Last updated September 2026 · 9 primary sources_

> CPB 0554 (ABA) + CPB 0648 (ASD) + Maryland's habilitative-services mandate with 25/10-hr floors.

For an intake team in Maryland, an Aetna card means three layers at once: the carrier's national clinical policy, Maryland's habilitative-services mandate (Md. Code Ann., Insurance § 15-835, implemented by COMAR 31.10.39.03), and the plan's funding type deciding which of the two actually binds. Maryland's mandate is unusual — it carries hour FLOORS below which ABA can't be denied. This guide stacks the layers in order.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — precertification (form GR-69017-4), per Aetna's behavioral health precertification list (eff. 8/1/2024) — CPB 0554 itself sets no precertification rule [7][8]
- **Prior auth for treatment**: Required — precertification; reauthorization commonly ~6 months (verify per plan) [7][8]

## At a glance

- **Covers ABA?:** Yes — for ASD, per the national Aetna policy
- **State mandate:** Md. Ins. § 15-835 + COMAR 31.10.39.03 (habilitative services)
- **Mandate age:** Through at least the month the enrollee turns 19; hour floors span 18 months–18 years
- **Mandate floors:** No denial solely on hours up to 25 hrs/wk (18 mo–5 yrs) or 10 hrs/wk (6–18); no dollar cap
- **Exempt from mandate:** Self-funded ERISA plans; early-intervention/school-delivered services
- **Licensure:** MD Licensed Behavior Analyst (Board of Professional Counselors & Therapists)

## The national policy, applied in Maryland

Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is national — what changes in Maryland is the legal floor underneath it: the state mandate below governs what fully-insured plans must cover, while self-funded employer plans answer to ERISA and federal parity instead. Plan funding type is therefore the first fact to establish on every benefits check. One Maryland-specific caution: there are indications in Aetna's ABA materials that Maryland-regulated plans get distinct medical-necessity handling and that the standard ABA precert form may not apply to Maryland — we could not verify the primary documents, so confirm the correct Maryland submission path with Aetna or in Availity before filing rather than assuming the national form. [1][2]

## The Maryland mandate: hour floors, not caps

Maryland has no standalone "autism mandate" — ABA is covered as a habilitative service for children with ASD under Insurance § 15-835, with the ABA-specific rules in COMAR 31.10.39.03 (effective April 3, 2014). The statute requires Maryland-regulated insurers, nonprofit health service plans, and HMOs to cover habilitative services until at least the end of the month the enrollee turns 19. The COMAR layer is where the teeth are: ABA may not be denied solely on the basis of prescribed hours up to 25 hours/week for ages 18 months through 5 years and up to 10 hours/week for ages 6 through 18 — with additional hours authorized when medically necessary — and ABA may not be denied as experimental or investigational. There is no dollar cap. The entry requirements: a comprehensive evaluation, a prescription with treatment goals from the PCP or a specialty physician, and annual review by the prescriber — so the prescription and its renewal date are intake data. Carriers aren't required to reimburse services delivered through early intervention or the schools, and self-funded ERISA plans are exempt — for those, MHPAEA parity is the fallback lever, and the hour floors don't apply. [3][4]

## Aetna Medicaid in Maryland: the card that doesn't matter for ABA

A family saying "we have Aetna" in Maryland may be on Aetna Better Health of Maryland, a HealthChoice MCO — but unlike other states, that changes nothing for ABA. Maryland carves ABA (and all specialty behavioral health) out of the MCOs entirely: authorizations and claims go to Carelon Behavioral Health, the state's BHASO, under the Medicaid fee-for-service rules. If the card is Aetna Better Health, use our Maryland Medicaid guide and route everything to Carelon — Aetna's Medicaid plan never touches ABA. [6]

## Licensure & rates in Maryland

Maryland has required licensure to practice behavior analysis since January 2015: the Licensed Behavior Analyst (LBA) credential, administered by the Behavior Analyst Advisory Committee of the State Board of Professional Counselors and Therapists (Health Occupations Title 17, Subtitle 6A; COMAR 10.58.16), built on current BACB certification, a qualifying master's degree, and a criminal-history check. The mandate's COMAR criteria likewise expect licensed delivery. On rates: Aetna does not publish commercial ABA fee schedules for Maryland (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Maryland's Medicaid fee schedule (effective February 1, 2026 — e.g., 97153 at $24.41/15-min BCBA tier) is the public benchmark to negotiate against. [5]

## Intake gates

The questions that decide whether a family can start with Aetna in Maryland, and what they have to bring.

- **Who may diagnose**: The diagnosis must come from a provider qualified to diagnose within their scope — a licensed psychologist, psychiatrist or physician. Aetna's precertification form (GR-69017-4, effective 1/1/2026) asks for the DSM-5 diagnosis code, the diagnosing provider and their credentials, so the diagnosing clinician's name and credential are submission data, not background. [1][2]
- **Telehealth**: Aetna covers telehealth for 97151, 97153, 97155, 97156 and 97157 — 97152 is excluded — billed with GT, 95 or FR modifiers per its telemedicine payment policy. Treat the answer as perishable: Aetna announced it would end ABA telehealth coverage in late 2023 and rescinded the change within weeks, so confirm the current position on every benefits check rather than reusing last quarter's answer. Note that this is the carrier rule; Maryland's Medicaid telehealth floor (25 percent in person on 97155/97156/97157) is a different program and does not apply to a commercial Aetna plan. [1]
- **Age limit** _(plan-dependent)_: Two answers, and plan funding type picks between them. The carrier's national ABA policy states no age limit. Maryland's habilitative-services mandate does: for Maryland-regulated insurers, nonprofit health service plans and HMOs, habilitative services must be covered “until at least the end of the month the enrollee turns 19,” and COMAR 31.10.39.03 pins its no-denial hour floors to age bands — up to 25 hours/week for ages 18 months through 5 years and up to 10 hours/week for ages 6 through 18, with more when medically necessary. Self-funded ERISA plans are exempt from all of it, so establish funding type before quoting either bound. [3][4]
  - Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — ask whether the plan is Maryland-regulated (an insurer, nonprofit health service plan or HMO, which the habilitative-services mandate and COMAR 31.10.39.03 age bands reach) or a self-funded ERISA plan (exempt). If it is self-funded, ask what age limit and weekly hour limit the plan document sets for ABA before you quote either bound to the family.
- **Referral required?** _(plan-dependent)_: On a fully-insured Maryland plan, yes — and it is a prescription, not a note. COMAR 31.10.39.03 conditions the mandated benefit on a comprehensive evaluation, a prescription with treatment goals from the PCP or a specialty physician, and annual review by the prescriber. Capture the prescriber and the prescription date at intake, and diary the annual renewal: a lapsed prescription is a coverage problem, not a paperwork one. Self-funded ERISA plans are outside the mandate, and for those the carrier's own authorization requirements are the only gate. [3][4]
  - Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — confirm funding type first. On a Maryland-regulated plan, capture the prescriber and prescription date and diary the annual prescriber review COMAR 31.10.39.03 requires. On a self-funded ERISA plan, ask the carrier whether it requires a referral or prescription at all, since the mandate does not reach it and only the carrier’s own authorization rules apply.
- **Prior-auth decision time** _(plan-dependent)_: Aetna requires prior authorization for ABA but publishes no decision clock of its own, and its national ABA request form says “Don’t use this form for Maryland and Massachusetts” — in Maryland the treatment plan goes on the state uniform form. The clock depends on how the plan is funded. If the child’s plan is fully insured in Maryland, Insurance §15-10B-06 sets the clock: an initial request is decided “within 2 working days after receipt of the information necessary to make the determination,” “additional visits or days of care submitted as part of an existing course of treatment or treatment plan within 1 working day,” emergency requests within 24 hours, and a reviewer missing information must say so within 3 calendar days. Maryland’s teeth: “If a private review agent fails to make a determination within the time limits required under this section, the request shall be deemed approved.” Mental-health treatment plans must be accepted on the MIA uniform treatment plan form. If the employer self-funds, ERISA’s floor applies instead: pre-service decisions “not later than 15 days after receipt of the claim” (one 15-day extension allowed), urgent claims within 72 hours. Aetna publishes no reauth lead time; Maryland lets carriers require “An annual review by the prescribing primary care provider or specialty physician.” [10][11][8][12]
  - Ask the plan: the member services or behavioral health number on the ID card — ask whether the plan is fully insured (and in which state) or self-funded, and for its UM decision timeframes
- **Other insurance (who pays first)** _(plan-dependent)_: Aetna says: “We coordinate benefits as allowed by state or federal law following the National Associations of Insurance Commissioners (NAIC) guidelines. If there is no applicable law, then we coordinate according to the member’s plan,” and its order of benefits includes the “Dependent Child/Parents Not Separated or Divorced Rule (Birthday Rule)” — the parent whose birthday falls earlier in the year is primary. Maryland has not yet adopted a COB regulation: the Insurance Administration says contract COB provisions “have historically been reviewed for consistency with the NAIC Model, but the Model has not been formally adopted to date,” and its draft COMAR 31.10.53 (comments closed August 2026) would codify the NAIC birthday rule (“The plan of the parent whose birthday falls earlier in the calendar year is the primary plan”) and exclude Medicaid from the definition of a plan — so Maryland Medicaid always pays after the commercial plan. Self-funded plans often use Maintenance of Benefits when secondary. Bill the primary first and send its EOB with the secondary claim. [13][14][15]
  - Ask the plan: the carrier’s eligibility response (Availity or the ID-card number) for an other-insurance record, and both parents’ birth dates and custody arrangements at intake; a self-funded plan follows its own plan document
- **Diagnosis recency** _(ask the plan)_: Aetna publishes no recency rule for the ASD diagnostic evaluation. The only currency requirement that binds a fully-insured Maryland plan sits on the prescription rather than the diagnosis: COMAR 31.10.39.03 requires annual review by the prescribing PCP or specialty physician. Capture the evaluation date anyway — the precertification package asks for it. [1][3]
  - Ask the plan: The precertification call or Availity, when submitting form GR-69017-4 — ask whether an evaluation of this age will be accepted for this plan.
- **Diagnostic tools required** _(ask the plan)_: No instrument is named. CPB 0554 does not require or reference a specific diagnostic tool, and the precertification form asks for the DSM-5 diagnosis code, the diagnosing provider and their credentials rather than for an instrument and score. Where a Maryland-regulated plan applies the mandate, COMAR 31.10.39.03 asks for a comprehensive evaluation without naming instruments either. [1][4]
  - Ask the plan: Aetna precertification (Availity or the number on the card) — ask whether a specific instrument is expected for this plan before scheduling testing.

## Delivery and billing rules

Coverage decides whether Aetna in Maryland 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**: Practitioners delivering ABA under CPB 0554 need BACB national certification or state behavior-analyst licensure, with unlicensed staff working under supervision per practice standards. In Maryland that licensure floor is concrete: the Licensed Behavior Analyst credential from the Board of Professional Counselors and Therapists has been required to practice behavior analysis since January 2015, and the mandate's COMAR criteria likewise expect licensed delivery. Aetna publishes no numeric supervision ratio for ABA. [1][2][5]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not published. Neither CPB 0554 nor CPB 0648 states whether 97155 and 97153 may be billed for the same clock time; Aetna handles code-pair questions through claim-editing and reimbursement policy rather than through the clinical policy bulletin. [1]
  - Ask the plan: Availity Essentials for the plan's reimbursement and claim-editing policies, or the provider-services number on the member's card. Ask specifically about 97153 billed alongside 97155.
- **Daily limits / MUEs** _(ask the plan)_: Not published. CPB 0554 lists the covered ABA codes but sets no per-day unit ceiling, and Aetna publishes no ABA-specific MUE table. The operative ceiling is the precertification itself, which requires requested hours to be listed code by code — so the authorization, not a policy, is what bounds the day. CPB 0648 references intensive-intervention research norms of 25 hours a week, 12 months a year as clinical context rather than as a limit. [1]
  - Ask the plan: The authorization letter itself, plus Availity Essentials for the plan's claim-editing and reimbursement policies. Ask whether CMS MUE limits are applied to ABA codes on this plan.
- **Session-note signature** _(ask the plan)_: Not published. CPB 0554 and CPB 0648 set coverage criteria and precertification content; neither states what a session note must contain, who signs it, or by when. [1]
  - Ask the plan: Aetna provider services or Availity — ask for the documentation standard applied at audit, and keep to the precertification form's own data elements in the meantime.
- **Place of service** _(ask the plan)_: Not published as a payable-settings list. What CPB 0554 does make a submission requirement is adjacent and useful: the precertification form asks for concurrent services — PT, OT, speech and school services — plus how care is coordinated across them, so the school picture is data Aetna collects even though it publishes no school-versus-home rule. [1]
  - Ask the plan: Benefits verification on the specific plan — ask which places of service are payable for ABA and whether school-based delivery is excluded.
- **Bill as provider** _(ask the plan)_: Not published for ABA. CPB 0554 sets who may deliver the service (BACB-certified or state-licensed behavior analysts, with unlicensed staff supervised) but does not state whose NPI carries a technician-delivered 97153 claim, and no Maryland-specific Aetna ABA form or supplement exists. [1]
  - Ask the plan: Aetna provider services or Availity — confirm the rendering-versus-billing NPI convention and any required degree-level modifiers before the first claim. Note the guide's standing Maryland caution: confirm the correct Maryland precertification submission path rather than assuming the national form.

## What intake should collect for Aetna in Maryland

- **Plan funding type:** Fully insured (mandate + hour floors apply) vs. self-funded ERISA (exempt) — it decides which rulebook governs. Ask for the employer and check the card.
- **Line of business:** Commercial Aetna vs. Aetna Better Health of Maryland (Medicaid) — Medicaid ABA goes to Carelon, not Aetna at all.
- **ABA prescription + goals:** COMAR requires a prescription with treatment goals from the PCP or a specialty physician, reviewed annually — capture the prescriber and date.
- **Member ID + card photo:** Enough to run a live benefits verification — the only reliable answer on limits and cost-sharing.
- **Diagnosis report:** DSM-5 ASD diagnosis, diagnosing provider and credentials, evaluation date.

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

## Verification of benefits (VOB) data

How Aetna in Maryland ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (Availity):** 60054
- **Payer ID (Change Healthcare / Optum):** 60054
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — precertification (form GR-69017-4, per Aetna's national CPB 0554 policy) | — | — | — | — |
| 97152 | Yes | Required — precertification (form GR-69017-4, per Aetna's national CPB 0554 policy) | — | — | — | — |
| 97153 | Yes | Required — precertification (form GR-69017-4, per Aetna's national CPB 0554 policy) | — | — | — | — |
| 97154 | Yes | Required — precertification (form GR-69017-4, per Aetna's national CPB 0554 policy) | — | — | — | — |
| 97155 | Yes | Required — precertification (form GR-69017-4, per Aetna's national CPB 0554 policy) | — | — | — | — |
| 97156 | Yes | Required — precertification (form GR-69017-4, per Aetna's national CPB 0554 policy) | — | — | — | — |
| 97157 | Yes | Required — precertification (form GR-69017-4, per Aetna's national CPB 0554 policy) | — | — | — | — |
| 97158 | Yes | Required — precertification (form GR-69017-4, per Aetna's national CPB 0554 policy) | — | — | — | — |
| 0362T | Yes | Required — precertification (form GR-69017-4, per Aetna's national CPB 0554 policy) | — | — | — | — |
| 0373T | Yes | Required — precertification (form GR-69017-4, per Aetna's national CPB 0554 policy) | — | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Verify via: Aetna provider services / precertification — CPB 0554 & 0648 are medical-necessity policies only; no ABA coding/reimbursement policy or Maryland-specific exhibit could be located. Maryland's habilitative-services mandate (COMAR 31.10.39.03) bars denial solely on prescribed hours up to 25/week (ages 18mo–5) or 10/week (6–18) for fully-insured plans — that is a mandate floor, not a payer-published per-code cap, and doesn't resolve this field. QA 2026-07-23: paRequired downgraded verified->unverified — CPB 0554, re-read in full, contains no precertification/prior-authorization language and no form 'GR-69017-4'; the precert requirement is plausibly true via Aetna's national process but is not stated in the cited policy.

### Contacts

- **Portal:** [Availity Essentials (Aetna provider portal)](https://www.availity.com/aetnaproviders)

Questions to ask on a verification call:

- What are the daily or weekly unit caps for ABA codes 97151–97158, 0362T, and 0373T under this member's plan?
- Which places of service (home, office, school, telehealth) are authorized for ABA under this plan?
- Is telehealth (GT or 95 modifier) allowed for any ABA codes, and if so which ones?
- Are licensure-tier billing modifiers (HN/HO/HM/HP) required to distinguish BCBA vs. RBT/BT rendering providers?
- Does Aetna administer ABA benefits in-house or through a separate behavioral-health carve-out administrator for this Maryland plan?
- Since Aetna's national ABA precertification form (GR-69017-4) explicitly excludes Maryland, what is the correct Maryland-specific precertification process or form, and what phone/fax should we use?

### VOB data sources

- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.uhcprovider.com/content/dam/provider/docs/public/resources/edi/Payer-List-UHC-Affiliates-Strategic-Alliances.pdf (accessed 2026-07-23)
- https://pverify.com/payer-list/ (accessed 2026-07-23; source document older than 18 months)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://www.aetnaseniorproducts.com/ssi/assets/pdf/Aetna%20SSI%20EDI%20270-271%20Companion%20guide.pdf (accessed 2026-07-23)
- https://www.aetna.com/cpb/medical/data/500_599/0554.html (accessed 2026-07-23)
- https://www.aetna.com/cpb/medical/data/600_699/0648.html (accessed 2026-07-23)
- https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/pharmacy-insurance/healthcare-professional/documents/outpatient-behavioral-health-BH-ABA-assessment-precert.pdf (accessed 2026-07-23)

## Common questions

### Does Aetna cover ABA therapy in Maryland?

Yes — under the carrier's national policy for ASD, layered on Maryland's habilitative-services mandate (Md. Ins. § 15-835 + COMAR 31.10.39.03) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.

### What does the Maryland mandate require for ABA?

For fully-insured plans: coverage of habilitative services through at least the month the enrollee turns 19, no denial of ABA solely on prescribed hours up to 25 hrs/week (ages 18 months–5) or 10 hrs/week (ages 6–18), no experimental/investigational denials, and no dollar cap — entered via a comprehensive evaluation plus a physician prescription reviewed annually.

### What does Aetna pay for ABA in Maryland?

Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against Maryland Medicaid's February 2026 fee schedule and treat rate-setting as part of contracting.

## Primary sources

1. [Aetna CPB 0554 — Applied Behavior Analysis](https://www.aetna.com/cpb/medical/data/500_599/0554.html)
2. [Aetna CPB 0648 — Autism Spectrum Disorders](https://www.aetna.com/cpb/medical/data/600_699/0648.html)
3. [Md. Insurance Article § 15-835 (Maryland General Assembly)](https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gin&section=15-835&enactments=false)
4. [Optum BH803ABA State Mandates — COMAR 31.10.39.03 criteria (corroborating text)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf)
5. [MDH Board of Professional Counselors & Therapists — Behavior Analyst License](https://health.maryland.gov/bopc/pages/analysts.aspx)
6. [MDH HealthChoice — Behavioral Health Coverage (carve-out)](https://health.maryland.gov/mmcp/healthchoice/Pages/BehavioralHealthCoverage.aspx)
7. [Aetna — Participating provider behavioral health precertification list (eff. Aug. 1, 2024) (PDF)](https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/bh_precert_list.pdf)
8. [Aetna — Outpatient BH ABA Treatment Request: Required Information for Precertification, form GR-69017-4 (PDF)](https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/pharmacy-insurance/healthcare-professional/documents/outpatient-behavioral-health-BH-ABA-assessment-precert.pdf)
9. [Aetna — Applied behavior analysis medical necessity guide (PDF)](https://www.aetna.com/content/dam/aetna/pdfs/health-care-professionals/applied-behavioral-analysis-necessity-guide.pdf)
10. [Md. Code, Insurance §15-10B-06 — private review agent determinations](https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gin&section=15-10B-06&enactments=false)
11. [eCFR — 29 CFR 2560.503-1(f)(2), ERISA claims procedure timeframes](https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XXV/subchapter-F/part-2560/section-2560.503-1)
12. [COMAR 31.10.39.03 — habilitative services utilization review](https://www.law.cornell.edu/regulations/maryland/COMAR-31-10-39-03)
13. [Aetna Health Care Professional Toolkit / provider manual (8102800-01-01, June 2026)](https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/health-care-professionals/office_manual_hcp.pdf)
14. [Maryland Insurance Administration — Regulatory Activity (NAIC COB model not yet adopted)](https://insurance.maryland.gov/Pages/newscenter/RegulatoryActivity.aspx)
15. [MIA draft COMAR 31.10.53 Coordination of Benefits (posted July 2026)](https://insurance.maryland.gov/Documents/newscenter/legislativeinformation/3.10.53-Draft-712026.pdf)

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.

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