FSSA ended MDwise's participation as a managed care entity for Indiana Medicaid's Healthy Indiana Plan (HIP) and Hoosier Healthwise programs effective January 1, 2026 — following a performance review that found MDwise "both the most expensive and the lowest in quality" of the four legacy plans. MDwise members were required to choose a new plan (Anthem, CareSource, or MHS) during a Nov. 1 – Dec. 15, 2025 open-enrollment window, with automatic assignment plus a 90-day plan-change grace period for anyone who didn't choose. MDwise — a McLaren company — publishes no ABA clinical policy of its own: its Behavioral Health Reference Guide simply lists every ABA code as prior-authorization-required and points to IHCP criteria. The rest of this guide is kept for historical/reference purposes; for current Indiana Medicaid ABA authorization, use the Anthem, CareSource, or MHS guides.
The Behavioral Health Reference Guide lists ABA codes 97151–97158, 0362T, and 0373T as PA-required across both Hoosier Healthwise and HIP, with treatment requests routed to the medical management department for the member's delivery system. There's no MDwise-specific ABA form — the IHCP universal PA form plus an outpatient treatment request does the work. Because the historical delivery-system structure means the right PA phone and fax vary, run eligibility first and pull the correct contacts from the Quick Contact Guide at MDwise.org/quickcontact rather than reusing last case's numbers. Out-of-network providers need PA for every service, and claim filing runs 90 days for contracted providers (180 non-contracted).[3][1][2]
The questions that decide whether a family can start with MDwise (Indiana), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the Indiana Medicaid rule: ABA is covered for members 20 years of age and younger. Effective April 1, 2026 coverage runs exclusively through EPSDT, and for dates of service on or after October 1, 2026 IHCP will not authorize or reimburse ABA for members 21 and older — a state policy that binds every MCE.[5][4][6]
Follows the Indiana Medicaid rule: a CDE more than one year old requires an updated statement of need, which must include a referral from an appropriate referring practitioner and an up-to-date behavior assessment completed by the ABA provider. Members continuing current services need no new CDE but do need an updated behavior assessment and treatment plan. A behavior assessment completed within the previous six months should be obtained from the original provider rather than repeated. IHCP states these documentation requirements apply to managed care as well as fee-for-service.[6][5]
Historical. MDwise published no ABA clinical policy of its own — its Behavioral Health Reference Guide simply listed every ABA code as prior-authorization-required and pointed to IHCP criteria — so the state rule governed: the CDE performed by a doctoral-level licensed clinical psychologist endorsed as an HSPP, a licensed physician, a licensed APRN, or a licensed physician assistant with specialized training in the current DSM autism criteria. MDwise ended as an HIP/Hoosier Healthwise MCE on January 1, 2026; for a current member, use the Anthem, CareSource or MHS guide.[6][3][2]
Historical, and inherited: the state's behavior assessment with its three core standardized instruments — the Vineland Comprehensive Parent Interview Form with the Maladaptive Behavior domain, the BASC Parenting Relationship Questionnaire and an age-appropriate objective direct skills assessment — signed by the lead analyst and parent or guardian, with the complete scoring report and graphs submitted with the PA. MDwise added no instrument requirement of its own.[5][3]
Follows the Indiana Medicaid rule: a physician must make a treatment referral recommending ABA therapy, and the CDE’s own required components include a physician’s referral for autism-specific services. Prior authorization is required on top of the referral for every ABA service, through this plan rather than through Acentra Health.[5][6]
Follows the Indiana Medicaid rule: effective April 1, 2026, codes 97151, 97152, 97153, 97154 and 0373T can no longer be billed with telehealth modifier 95 and require in-person delivery. The plan publishes no ABA telehealth policy of its own.[4]
Historical — MDwise left HIP and Hoosier Healthwise on January 1, 2026, and “new authorization requests for DOS on or after Jan. 1, 2026, must go to the member’s new managed care entity” (Anthem, CareSource or MHS — use that guide's clock). MDwise took requests for dates of service on or before 12/31/2025 until March 31, 2026; from April 1, 2026 its PA-UM fax lines and portal stopped accepting submissions. While active, MDwise's September 2025 manual published no decision clock of its own; as a Medicaid risk-based MCE it was bound by IC 27-1-37.5-23 (urgent 24 hours, all other 48 hours, weekends and holidays excluded) from July 1, 2025.[7][8][9][10]
Historical (MDwise left HIP/Hoosier Healthwise 1/1/2026; claims for DOS on or after that date go to the new MCE). MDwise was payer of last resort: providers “must submit claims to the other insurance carrier before submitting to MDwise,” with the primary EOB “within 90 days of the date of the primary explanation of benefits,” and MDwise paid the difference up to its allowable. It paid first and chased the other carrier only for “Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program and preventive pediatric services” and IV-D child-support coverage. On PA it was explicit: with third-party coverage “the provider is still responsible for obtaining prior authorization for the service and any authorization required by the third-party payer.” A 90-day no-response rule let a claim go to MDwise with proof of the billing attempt.[8][7]
Coverage decides whether MDwise (Indiana) 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.
Follows the Indiana Medicaid rule: ABA performed by a BCaBA or credentialed RBT must be under the direct supervision of a BCBA, BCBA-D or HSPP, and since April 1, 2026 at least 1 hour of BCBA (or IHCP-approved qualifying clinician) supervision is required per 8 hours of technician-delivered therapy. Behavior assessments may only be performed by a psychologist, BCBA-D or master's-level BCBA. IHCP states that its ABA documentation requirements apply to both fee-for-service and managed care, and this plan publishes no supervision standard of its own.[5][4][6]
Follows the Indiana Medicaid limits: up to 40 hours per week may be requested with anything beyond that needing an additional PA; each prior authorization is capped at six months; and since April 1, 2026 comprehensive ABA (16+ hours/week, modifier UA) draws from a 4,000-hour (16,000-unit) lifetime allocation per member, with 97155 and 97156 excluded and targeted ABA (≤15 hours/week) exempt. No per-day MUE ceiling is published at either level.[5][4]
Follows the Indiana Medicaid rule: the treatment plan must be built around the member's school attendance (including homeschooling) and other daily activities, while services focusing solely on recreational or educational outcomes are not covered, and neither are services duplicative of an IEP that address the same goals using the same techniques as the treatment plan.[5]
Follows the Indiana Medicaid rule: ABA rendered by a BCaBA or RBT must be billed under the NPI of an IHCP-enrolled ABA therapist or school corporation, on a professional claim. Since July 1, 2025 the rendering practitioner must be enrolled under ABA specialty 615, 624 or 625, and since April 1, 2025 the rendering NPI must align with the credential-level modifier (U1 RBT / U2 BCaBA / U3 BCBA-HSPP). Plan-level claim formatting may still differ — MCEs publish their own billing requirements.[5][4]
Not published by Indiana Medicaid or by this plan. IHCP is explicit that within managed care “individual managed care entities (MCEs) establish and publish their own billing and reimbursement requirements,” so unlike the clinical criteria, code-pair rules are not inherited from the state by default.[6]
Ask the plan: The MCE directly — ask whether 97155 pays alongside 97153 for the same clock time, and request the plan's billing and reimbursement requirements in writing.
Neither Indiana Medicaid nor this plan publishes a session-note signature rule. The state's published signature requirements attach to the plan documents — the behavior assessment and the treatment plan must each be signed by the lead analyst and the parent or guardian — and BT202562, the bulletin titled for ABA documentation requirements, does not reach the individual session note. IHCP states its documentation requirements apply to managed care as well as fee-for-service, but also that MCEs establish and publish their own billing and reimbursement requirements, so the gap is not automatically filled at the state level.[5][6]
Ask the plan: The MCE directly — ask for its ABA documentation and session-note standard in writing. BT202562 also promises a future bulletin clarifying documentation requirements under the updated ABA State Plan Amendment; check for it before relying on this.
No — FSSA ended MDwise's participation as an MCE for HIP and Hoosier Healthwise effective January 1, 2026. Members were reassigned to Anthem, CareSource, or MHS; use those guides for current ABA authorization.
They chose a new plan (Anthem, CareSource, or MHS) during a Nov. 1 – Dec. 15, 2025 open-enrollment window, or were auto-assigned with a 90-day window to switch after January 1, 2026. FSSA states coverage and existing authorizations continue through the transition.
FSSA's review found MDwise was "both the most expensive and the lowest in quality" of the four legacy plans; federal rules require at least three plans, which the state still meets with Anthem, CareSource, and MHS.
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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