Does Medicaid Cover ABA Therapy in Texas? Limits and Appeals

Yes, Texas Medicaid does cover ABA therapy. The benefit took effect on February 1, 2022, and is available to Medicaid enrollees age 20 and younger who have a qualifying autism spectrum disorder diagnosis.¹ To use it, a family needs a formal ASD diagnosis, a referral from a Medicaid-enrolled provider, and prior authorization from the child’s managed care plan before therapy can start.

One boundary to note up front: children enrolled in CHIP are not covered under this benefit, only children in Medicaid or the Medicaid Buy-In program.²

Who Qualifies

A child or young adult must meet all of the following:

Be 20 years old or younger.³
Have an ASD diagnosis made within the last three years, including a DSM severity classification of Level 1, 2, or 3.¹
Have ABA services prescribed by a Medicaid-enrolled doctor, psychologist, nurse practitioner, or similar medical professional.
Be enrolled in Medicaid or the Medicaid Buy-In program.²

Coverage runs through all three of the state’s children’s managed care programs: STAR, STAR Kids (for children with disabilities tied to SSI or a waiver), and STAR Health (for children in foster care).⁴

What Counts as a Qualifying Diagnosis

A screening tool like the M-CHAT-R is not enough. The evaluation must use a validated, standardized diagnostic instrument such as the Autism Diagnostic Observation Schedule (ADOS) or the Childhood Autism Rating Scale, and the written results must document the DSM diagnostic criteria and the severity level.⁵

The diagnosis can come from a developmental pediatrician, neurologist, psychiatrist, licensed psychologist, or an interdisciplinary team with autism expertise. If a child needs ABA services more than three years after the original diagnosis, a comprehensive reevaluation of symptom severity is required to keep eligibility active.⁵

How to Start Services

Once a qualifying diagnosis is in hand, the process generally works like this:

Get a signed, dated referral for ABA from the child’s primary care provider, the diagnosing physician, or another allowed practitioner such as a physician assistant or nurse practitioner.⁵
Identify the child’s managed care organization. The MCO is listed on the Medicaid card, and the number on the back of the card reaches member services.⁶
Find a Licensed Behavior Analyst in the MCO’s network. The TMHP Online Provider Look-up at opl.tmhp.com lists enrolled LBAs.⁶
Complete an initial behavioral assessment with the LBA, who writes a treatment plan.
Have the LBA submit the diagnosis, referral, assessment, and treatment plan to the MCO for prior authorization. Services cannot start until the plan approves them.⁷
Begin therapy in the home, community, or a clinic. Parent and caregiver involvement is required.⁶

Prior authorization decisions typically turn around in three business days. Initial authorizations run 90 days; providers can request 90-day extensions and 180-day recertifications with updated documentation.⁷ Since April 2025, the prescribing provider’s signature is no longer required on the authorization form when requesting a 90-day extension, though the initial treatment plan must still be signed and cover a full 180 days.⁸

What’s Covered and the Limits

Texas Medicaid pays for ABA evaluation and treatment and for interdisciplinary team meetings used to coordinate care. Covered procedure codes include 97151 for the evaluation, plus 97153, 97154, 97155, 97156, 97158, and 99366 for treatment and coordination.³

Direct treatment is capped at eight hours (32 billing units) per day across the main treatment codes. The initial evaluation is authorized for up to six hours (24 units), and the re-evaluations that occur every 180 days are also limited to six hours.⁹ These daily limits can be exceeded with documented medical necessity.

Attendance matters. Treatment plans must include measurable discharge criteria and a transition plan, and families are expected to attend at least 85% of scheduled sessions. Lower attendance triggers physician review of whether continued services at the approved frequency are medically necessary.¹⁰

Who Can Deliver the Therapy

Only Licensed Behavior Analysts can enroll in Texas Medicaid and bill for ABA. An LBA must hold a license from the Texas Department of Licensing and Regulation and have a National Provider Identifier. Licensed assistant behavior analysts and behavior technicians can deliver treatment under direct LBA supervision, but they cannot enroll in Medicaid on their own, and the supervising LBA stays the rendering and billing provider on all claims.¹¹ As of December 2024, the Qualified Behavior Analyst credential is also an accepted pathway for licensure.

After enrolling through TMHP, an LBA still has to credential separately with every MCO they want to accept, a process that can take up to 180 days per plan.⁴

Telehealth

Some ABA services can be delivered over a synchronous audio-video platform. The evaluation code (97151) and treatment codes 97155, 97156, 97158, and 99366 are eligible for telehealth, and claims must include Modifier 95. Only LBAs may deliver ABA services remotely; assistant behavior analysts and behavior technicians may not.⁷

Under broader Texas Medicaid telehealth policy, a patient’s home can be the telehealth site, documentation standards match in-person care, and MCOs cannot deny reimbursement for covered services solely because they were delivered remotely.¹²

If the MCO Denies or Reduces Services

Any denial or reduction must come with a written notice explaining the decision. Families have two paths to challenge it:

An internal appeal, in which the MCO assigns a different physician to review the original decision.
A Medicaid fair hearing, in which an impartial hearings officer at the Texas Health and Human Services Commission reviews both sides against Medicaid policy.¹³

The timing is critical. If a family files an appeal or fair hearing request within 10 days of the denial letter or the proposed action date, the MCO must keep authorizing services at the pre-denial level until the challenge is resolved. After that 10-day window, the reduction takes effect, though families still have up to 90 days to file.¹⁴ Disability Rights Texas (1-800-252-9108) can help families navigate the process.

What Happens at Age 21

The ABA Medicaid benefit ends at 21, and Texas does not offer an equivalent adult ABA benefit through Medicaid. Several home and community-based waiver programs provide related supports for adults with autism and other developmental disabilities, though none list ABA as a covered service.

The main option is the HCS waiver, which provides habilitation, respite, and employment support for people with intellectual and developmental disabilities living at home or in small group settings.¹⁵ STAR+PLUS serves adults 21 and older with disabilities and includes personal assistance, occupational, physical, and speech-language therapy, and other long-term supports.¹⁶ The Community First Choice program offers attendant care and habilitation without a waiting list and can bridge the gap while waiver interest lists move. TxHmL, CLASS, and DBMD waivers have interest lists that can run 10 to 20 years, so families are generally advised to join every relevant list as early as possible and start transition planning with the HHSC caseworker well before the child turns 18.

Why Access Can Still Be Hard

Coverage on paper is not the same as a therapist on the schedule. Reimbursement remains low: the children’s conversion factor is roughly $28.07, and individual code rates run from about $14.50 to $27.56 per 15-minute unit depending on the service and provider level.¹⁷ Many providers report that these rates do not cover wages, supervision, overhead, and compliance costs, so they either skip Medicaid credentialing or cap how many Medicaid clients they accept. Combined with the plan-by-plan credentialing process, the result is long waitlists.⁴

Texas does not publicly report how many children receive Medicaid-funded ABA, how many are waiting, or average wait times. Advocacy groups have pressed for mandated data reporting; during the 89th Legislative Session, which ended June 2, 2025, autism advocates also requested $70 million per year in additional funding, and neither request was enacted.

Key Contacts

TMHP Contact Center: 800-925-9126 for Medicaid provider and benefit questions.⁶
The child’s MCO: the number on the back of the Medicaid card, for authorization and network questions.
Texas Health and Human Services: 2-1-1 or 1-877-541-7905 for general Medicaid and MCO information.
Early Childhood Intervention: 1-800-250-2246 for children under three.
Disability Rights Texas: 1-800-252-9108 for help with denials and fair hearings.¹³
TMHP Online Provider Look-up: opl.tmhp.com to find enrolled Licensed Behavior Analysts.

1
Autism Speaks. New Texas ABA Medicaid Benefit
2
Texas Autism Society. Medicaid Coverage for ABA Begins 2-1-22
3
TMHP. HHSC Release Autism Services Benefits Effective February 1, 2022
4
Acuity News. Texas Medicaid ABA Rates, STAR Kids, LBA Licensure
5
TMHP. Clarification Language Autism Services Effective April 1, 2023
6
Texas HHS. Applied Behavior Analysis Flyer
7
Community Health Choice. Medicaid ABA Services
8
TMHP. Update Prior Authorization Requirement Autism Services Effective April 1, 2025
9
Community First Health Plans. Autism Services Billing Guidelines
10
Texas Children’s Health Plan. Autism Services Guideline
11
TMHP. Licensed Behavior Analyst Enrollment
12
TMHP. Telecommunication Services
13
Disability Rights Texas. Dealing with Denials or Reductions of Children’s Medicaid Services
14
Texas Law Help. Dealing with Denials or Reductions of Medicaid Services
15
The Arc of Texas. Medicaid Waivers
16
Texas HHS. STAR+PLUS
17
TMHP. Texas Medicaid Fee Schedule for Autism Services