---
title: "SWMBH ABA coverage: the Michigan Medicaid autism benefit intake guide."
url: "https://carelu.com/payers/southwest-michigan-behavioral-health"
markdown_url: "https://carelu.com/payers/southwest-michigan-behavioral-health.md"
state: MI (Michigan)
payer: Southwest Michigan Behavioral Health (SWMBH)
kind: Medicaid managed care plan (MCO)
parent_program: Michigan Medicaid
description: "How Southwest Michigan Behavioral Health runs the Michigan Medicaid autism/ABA benefit across eight counties: M-CHAT/SCQ screening, the three-hour ADOS-2/ADI-R/DD-CGAS evaluation sent to MDHHS, quarterly IPOS reviews, and county CMHSP access lines."
last_reviewed: September 2026
---

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

_Payer Guide · SWMBH · Michigan Medicaid · Last updated September 2026 · 9 primary sources_

> 8-county PIHP: screen with M-CHAT or SCQ, ~3-hour evaluation (ADOS-2, ADI-R, DD-CGAS) sent to MDHHS for approval.

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.

This plan administers the **Michigan Medicaid** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Michigan Medicaid guide](https://carelu.com/payers/michigan-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment** _(plan-dependent)_: Runs through the county CMHSP: screening, then the ADOS-2/ADI-R/DD-CGAS evaluation, then MDHHS approval; SWMBH does not publish whether the ABA agency’s 97151 needs its own authorization. [1]
  - Ask the plan: The county CMHSP access line listed by SWMBH (e.g., Integrated Services of Kalamazoo, 269-373-6000).
- **Prior auth for treatment**: Required — PIHP utilization management authorizes the ABA level of services in the IPOS before delivery (state rule; SWMBH publishes nothing different). [3][1]
- **Autism diagnosis required?**: Yes — ASD confirmed by a diagnostic evaluation (ADOS-2, ADI-R, DD-CGAS) reviewed and approved by MDHHS. [1]

## At a glance

- **Region:** PIHP region 4 — 8 counties, 8 CMHSPs
- **Front door:** The county CMHSP access line (e.g., Integrated Services of Kalamazoo 269-373-6000)
- **Screening:** By the PCP or the CMHSP access center: M-CHAT or SCQ
- **Evaluation:** About 3 hours over two appointments: ADOS-2, ADI-R, DD-CGAS; results sent to MDHHS for approval
- **Plan:** IPOS with the case holder, reviewed quarterly; skills assessment (ABLLS or VB-MAPP) every six months
- **Delivery:** Clinic or home, individual or group; 5–25 hours a week; supervision 1 hour per 10

## SWMBH’s four steps

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]

## CMHSP access lines in region 4

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]

## Intake gates

The questions that decide whether a family can start with Southwest Michigan Behavioral Health (SWMBH), and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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]
- **Referral required?**: 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]
- **Telehealth**: 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]

## Delivery and billing rules

Coverage decides whether Southwest Michigan Behavioral Health (SWMBH) 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**: 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]
- **Concurrent billing (97153 + 97155)**: 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]
- **Daily limits / MUEs**: 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]
- **Place of service**: 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]
- **Bill as provider**: 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]
- **Session-note signature** _(plan-dependent)_: 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).

## What intake should collect for Southwest Michigan Behavioral Health (SWMBH)

- **County of residence:** Picks which of SWMBH’s eight CMHSPs runs the screening and evaluation.
- **Screening result (M-CHAT or SCQ):** From the PCP if already done; otherwise the CMHSP access center screens.
- **Time for two evaluation appointments:** About three hours in total.
- **Parent availability for training:** SWMBH says ABA requires parent/guardian training and participation.

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

## Common questions

### Which autism benefit does SWMBH run?

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.

### What does the evaluation involve?

About three hours over two appointments using the ADOS-2, ADI-R and DD-CGAS; the results go to MDHHS for review and approval.

### How much supervision does SWMBH expect?

One hour of BCBA or qualified behaviorist supervision per ten hours of technician treatment, matching the state rule.

## Primary sources

1. [SWMBH — Autism Services](https://swmbh.org/autism-services/)
2. [MDHHS — PIHP county designations table (FY27 PIHP contract, May 2025)](https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Keeping-Michigan-Healthy/BH-DD/PIHPs/PIHP-Region-Table.pdf)
3. [Michigan Medicaid Provider Manual (July 1, 2026) — Behavioral Health and IDD Supports and Services chapter, Section 18: BHT/ABA](https://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf)
4. [MDHHS SFY 2026 Behavioral Health Code Charts and Provider Qualifications (updated 9/26/2025; archived 10/31/2025)](https://web.archive.org/web/20251031103317/https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Keeping-Michigan-Healthy/BH-DD/Reporting-Requirements/SFY2026_Behavioral_Health_Code_Charts_and_Provider_Qualifications.xlsx?rev=e9481f6c7f6e4628897bbe3ad67c892b)
5. [MDHHS Bureau of Specialty Behavioral Health Services — Telemedicine Database (effective May 12, 2023; archived 1/6/2026)](https://web.archive.org/web/20260106050903/https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Keeping-Michigan-Healthy/BH-DD/Reporting-Requirements/Bureau_of_Specialty_Behavioral_Health_Services-Telemedicine_Database.pdf?rev=39a4677add1f4ed0a2e952bd1c6e5c54)
6. [Michigan Medicaid Provider Manual (July 1, 2026) — Behavioral Health and IDD Supports and Services chapter, Sections 1–2](https://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf)
7. [42 CFR 438.210 — Coverage and authorization of services (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
8. [Michigan Medicaid Provider Manual (July 1, 2026) — Coordination of Benefits chapter](https://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf)
9. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)

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.