Michigan Blues' 2027 ABA Criteria Require a 20% Gain Within Six Months to Continue

For dates of service on or after January 1, 2027, Blue Cross Blue Shield of Michigan and Blue Care Network will review ABA prior authorizations under a new document, Utilization management criteria for Applied Behavior Analysis treatment of Autism Spectrum Disorder. It covers Blue Cross commercial, Blue Care Network commercial, Medicare Plus Blue and BCN Advantage. Both BCBSM prior-authorization pages list the current ABA Supplemental Policy only through December 31, 2026.

What the new document sets

• A numeric progress test. Continued ABA requires improvement of "at least 20 percent based on objective measurements" within a measurement interval of "at most six months," using scales such as the VB-MAPP (preferred), Vineland, ADOS or Autism Social Skills Profile, not just session data. The text doesn't say what the 20 percent is measured against.
• A hard stop. If progress falls short, Blue Cross may authorize up to six more months. After that, medical review decides.
• Repeat testing. A social skills scale at least every six months. The baseline testing used for diagnosis repeated at least yearly, then again at six months if nothing changed. A second no-change result means the member "may not be benefiting."
• Re-evaluation. After minimal progress, Blue Cross may require a three-year multidisciplinary re-evaluation and annual developmental testing.
• Settings. Home, clinic or community. Anything else needs "clear and convincing reasons."

What the 2026 policy had that this one doesn't

The 2026 policy let continued care rest on expected improvement or on maintaining skills and preventing deterioration. The 2027 continuation list has no maintenance pathway; maintenance appears only in the discharge section, which says lower-intensity care may remain necessary. The 2026 policy's review of authorized hours used below 80 percent over two weeks, its supervision guidance of up to two hours per ten of direct treatment, and its CASP-based coordination-of-care section are also absent.

The limits

We found no Blue Cross provider alert explaining the change; the effective date comes from the two prior-authorization pages. The Michigan autism mandate doesn't reach some self-funded groups. For Medicare Plus Blue and BCN Advantage, the document says providers follow CMS rules on licensure and coverage.

What you must know or do

• Owners and clinical directors: list every Blue Cross or BCN client whose authorization renews on or after January 1. For each, open the last two six-month progress summaries and check whether the assessment scales on file let you state the gain as a percent. If they don't, that file is the exposure.
• BCBAs: confirm a social skills scale was given in the past six months and the diagnostic baseline testing in the past twelve. Put the next dates on the calendar.
• Billing leads: ask Blue Cross Behavioral Health in writing which criteria govern a request filed in December for 2027 dates of service, and how it calculates the 20 percent. The pages key the criteria to dates of service, not filing date.