Mass General Brigham Health Plan (formerly AllWays) fields one ACPP with the Mass General Brigham ACO — and it is the only MassHealth plan whose ABA runs through Optum Behavioral Health. That routes members into Optum's clinical machinery: the United Behavioral Health ABA criteria plus Optum's ABA State Mandates supplement (BH 803ABA STM12026, effective January 2026), which carries explicit Massachusetts Medicaid provisions. Notably, Optum's supplement hard-codes the very 1:10 supervision ratio MassHealth later enforced statewide — and adds a cap no other MA plan publishes: 30 hours per week for Early Intervention members.
Optum's ABA State Mandates supplement carries a Massachusetts Medicaid entry effective October 1, 2021: for Early Intervention members, ABA services should not exceed 30 hours per week, and BCBA-to-paraprofessional supervision must run at 1:10 — with the supervisor and technician possibly both required to be present during home visits. No cap is stated for non-EI members, where the standard no-cap MassHealth benefit applies. The supplement makes MGB the one MA plan where the 1:10 ratio is written policy rather than audit posture — and in the 2026 statewide audit, Optum had not yet issued recoupment letters as of the March 2026 reporting, though the same analysis was run. Plan your under-3 referrals against the EI cap and the EI non-duplication rule together.[2][4]
Because behavioral health is carved to Optum, expect the Optum toolkit — Provider Express is Optum's standard portal, though its use for this plan specifically isn't published, so confirm the submission channel with the plan before the first request. Authorization cadence follows the statewide practice of roughly 6-month periods. Clinically, requests are reviewed against Optum's ABA criteria layered on the MassHealth baseline: EPSDT medical necessity, the DSM-aligned ASD diagnostic gate, and the Down syndrome pathway from January 1, 2026.[2][3]
The questions that decide whether a family can start with Mass General Brigham Health Plan (MassHealth ACPP), and what they have to bring. Each maps onto something intake should ask on the first call.
EPSDT sets the bound, and nothing else does. ABA is covered for MassHealth Standard and CommonHealth members under 21, and for Family Assistance members under 19 — with no lower age bound and no dollar, visit or unit-of-service cap underneath it. For the youngest referrals the binding rule is non-duplication rather than age: ABA cannot duplicate services the child already receives through Early Intervention. From 1/1/2026 the second diagnostic pathway (sole-diagnosis Down syndrome) rides the same age structure. One plan-specific overlay is not an age rule but reads like one at intake: Optum's Massachusetts Medicaid entry (effective 10/1/2021) says ABA "should not exceed 30 hours per week" for Early Intervention members, so establish EI enrollment alongside age.[7][2]
Optum BH decides ABA, and the federal managed-care clock caps it. MGB delegates behavioral-health "Utilization management/care management" and "Service authorization" to Optum BH for all MGB ACO members. MGB's own ACO manual (dated 2026-04-01) still prints its general UM table: non-urgent pre-service "Within 14 calendar days after receipt of the request" plus up to 14 more on request, urgent "Up to 72 hours," and urgent concurrent within 24 hours. For rating periods starting on or after 1/1/2026, however, 42 CFR 438.210(d) caps standard decisions at "7 calendar days after receiving the request for service," with up to 14 more calendar days on request or justification. Expedited decisions are due within 72 hours. WellSense and Carelon moved their MassHealth decisions to 7 days on January 1, 2026. No ABA reauthorization lead time is published in the MGB manual.[9][10][11]
Ask the plan: Optum BH (Provider Express) for MGB ACO: the decision clock it applies to MassHealth ABA requests and its reauthorization lead time.
MGB pays last. "When a patient enrolls with Mass General Brigham ACO Mass General Brigham Health Plan is always the payer of last resort." When MGB is secondary, "all claims must be submitted with a copy of the primary carrier's EOP, remittance advice, or denial letter." Behavioral-health claims "must be submitted to Optum BH directly." Report other coverage to MGB's COB team (617-772-5729) or on a TPL Indicator Form. MassHealth's rule adds that the provider must follow the primary plan's authorization and network rules. A primary denial for missing PA or for being out of network forfeits the secondary payment (130 CMR 450.316). TRICARE pays before MassHealth: "By law, TRICARE pays after all other health insurance, except for: Medicaid."[9][12][13]
Ask the plan: Optum BH for MGB ACO: whether it requires its own ABA PA when MGB is secondary, and its secondary-claim filing window.
Not published. Neither the Massachusetts Standard ABA PA Form nor the Carelon/MBHP performance specification sets a maximum age for the diagnostic evaluation — the form asks for the current ICD-10 diagnosis and, on a "Request for initial evaluation," a copy of the comprehensive assessment, but names no recency window. What the form does date is utilization, not diagnosis: the continued-services page makes the BCBA attest whether at least 75% of the previously authorized direct-service hours were used.[8][2]
Ask the plan: Optum Care Advocate / Provider Express for the Mass General Brigham Health Plan line of business — Optum's published ABA criteria are commercial documents, and the plan does not republish the MassHealth standard-form requirements.
The standard form names them, and the list is broader than "send them to a developmental pediatrician." For autism it requires "A comprehensive assessment completed by a licensed physician (i.e. PCP, etc.), advanced practice registered nurse, physician's assistant, or psychologist experienced in the diagnosis and treatment of ASD with developmental or child/adolescent experience which aligns with DSM criteria across ASD core deficits." For the 1/1/2026 pathway it requires instead "A diagnosis of Down Syndrome (Trisomy 21) confirmed by genetic testing." Note the two signatures are different people: the diagnostician writes the assessment, while the form itself "should" be completed by the BCBA rendering and/or supervising the services — an analyst the performance specification requires to be a LABA licensed under 262 CMR 10.00. Optum's own criteria are broader in wording — a diagnosis "issued by a state licensed physician, psychologist, or other state licensed clinician qualified to make such diagnosis according to the diagnostic criteria based on the DSM-5-TR" — but that is its commercial Supplemental Clinical Criteria, and Optum's Massachusetts state-mandate entries are scoped to the EI hour cap and the 1/1/2026 Down syndrome expansion, neither of which is a diagnostician list for this MassHealth product.[8][2]
Ask the plan: Optum Care Advocate / Provider Express for the Mass General Brigham Health Plan line of business — Optum's published ABA criteria are commercial documents, and the plan does not republish the MassHealth standard-form requirements.
No instrument is mandated. The standard form requires a comprehensive assessment "which aligns with DSM criteria across ASD core deficits" without naming ADOS-2, ADI-R, CARS-2 or any other tool, and the performance specification names no diagnostic battery either; the Down syndrome pathway replaces the instrument question entirely with genetic testing. Massachusetts puts its measurement requirement downstream of intake instead — in progress documentation and medical-necessity review, not in the diagnostic gate. Optum's commercial criteria do name formal diagnostic tools (ADI-R, ADOS/ADOS-2, DISCO), but that list belongs to its commercial ABA criteria and should not be assumed onto this MassHealth product.[8][2]
Ask the plan: Optum Care Advocate / Provider Express for the Mass General Brigham Health Plan line of business — Optum's published ABA criteria are commercial documents, and the plan does not republish the MassHealth standard-form requirements.
No referral and no physician order is a condition of authorization. The Massachusetts Standard ABA PA Form has no referral field and is completed by the rendering or supervising BCBA/LABA, and the performance specification's referral language is about timeliness rather than permission: "Fourteen calendar days from referral is the Medicaid standard of timely provision for services established in accordance with 42 CFR 441.56(e)," with a waitlist duty (and an obligation to hand caregivers other regional providers' contact information) where the provider cannot start inside it. What the state does require is PCP evidence in the chart rather than at the door: the complete medical record must hold "Referral and assessment documentation" and "Documentation confirming physical examinations by a PCP," and the continued-services pages ask for a dated primary-care care-coordination entry.[5][8]
Ask the plan: Optum Care Advocate / Provider Express for the Mass General Brigham Health Plan line of business — Optum's published ABA criteria are commercial documents, and the plan does not republish the MassHealth standard-form requirements.
Permitted at the family's request, with no code list and no POS rule. The ABA provider "may deliver services and consultation via a Health Insurance Portability and Accessibility Act (HIPAA)-compliant telehealth platform at the parent/caregiver's request and if the service can be effectively delivered via telehealth as part of the intervention when appropriate," with the rationale documented and the documentation reflecting "clinical considerations for appropriateness across any service components being delivered via telehealth." Two guardrails ride along: telehealth "must not replace in-person availability," and the member or family "may rescind consent for telehealth at any time without risk of interruption of services." No per-code restriction, modifier or place-of-service code is published. Whether Optum applies the MBHP conditions on this line is not published.[5]
Ask the plan: Optum Care Advocate / Provider Express for the Mass General Brigham Health Plan line of business — Optum's published ABA criteria are commercial documents, and the plan does not republish the MassHealth standard-form requirements.
Coverage decides whether Mass General Brigham Health Plan (MassHealth ACPP) 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.
Mass General Brigham Health Plan routes ABA to Optum, but Optum’s published ABA reimbursement policy is a commercial document and its ABA State Mandates entry for Massachusetts is scoped to Medicaid Early Intervention members — for whom it requires “supervision by a Board-Certified Behavior Analyst (BCBA) to a paraprofessional … at the 1:10 ratio (one hour of supervision to ten hours of direct service),” with services not to exceed 30 hours per week. Neither document states the supervision standard Optum applies to the MassHealth ACPP line, where the MassHealth-wide 10–25% band is the state floor.[2][5]
Ask the plan: Optum Care Advocate / Provider Express for the Mass General Brigham Health Plan line of business.
Massachusetts is a no-cap state that nonetheless has one published per-day number. There are no annual, lifetime or unit-of-service ceilings on the EPSDT benefit, and 101 CMR 358.03 is a rate regulation, not a limit regulation — it fixes per-15-minute rates and states they are “full compensation” including “necessary administration and professional supervision associated with patient care.” The only per-day cap in the performance specification is for group instruction, which “may occur up to 4.5 hours a day as clinically indicated, in groups of 2-8 Members.” No per-code MUE regime is published, so what bites in practice is medical-necessity review and the supervision-ratio audit, not a unit edit. Optum’s own per-day table (97153 32 units, 97155 24 units and so on) belongs to its commercial ABA reimbursement policy and should not be assumed onto this MassHealth product.[6]
Ask the plan: Optum provider services for the MGB Health Plan line.
Home and community, with school carved out. ABA “is delivered by a contracted and credentialed provider in a variety of settings within a Member’s home and community,” and “services provided in a school setting are distinct and separate from those covered by the health plan and are typically covered by the educational system’s special education resources as part of the Individualized Education Program (IEP) pursuant to Public Law 94-142.” Providers “must not direct, limit, or discourage access to other medically necessary or school-based services.” Transition planning contemplates moving a member “from a center based setting to home/community settings,” so centers are in scope. Group homes are not addressed. No MGB-specific deviation is published.[5]
Ask the plan: Optum Care Advocate for the MGB Health Plan line.
Yes — the MassHealth EPSDT benefit, administered through Optum Behavioral Health under Optum's ABA criteria plus its Massachusetts state-mandate supplement. PA is required for assessment and treatment.
Only for Early Intervention members: Optum's supplement limits EI-member ABA to 30 hours/week (effective 10/1/2021) with 1:10 BCBA-to-paraprofessional supervision. No cap is stated for non-EI members.
It's the only plan whose ABA runs through Optum — with the 1:10 supervision ratio codified in written policy and the EI hour cap no other MA plan publishes. Everything else follows the state baseline.
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.
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