Does Medicaid Cover ABA Therapy in Texas? Eligibility and Limits

Yes. Texas Medicaid does cover ABA therapy in Texas for children and young adults age 20 and younger who have a qualifying autism spectrum disorder diagnosis. The benefit took effect on February 1, 2022, and is delivered through the state’s managed care plans and fee-for-service Medicaid.¹ Getting services approved requires a formal diagnosis, a referral from a Medicaid-enrolled provider, and prior authorization from your child’s managed care organization.

Who Qualifies

Four things have to line up for a child to be eligible:

The individual is 20 years old or younger.¹
The individual has an autism spectrum disorder diagnosis made within the last three years, with a documented severity level of 1, 2, or 3.²
A physician, psychologist, nurse practitioner, or other Medicaid-enrolled medical professional prescribes ABA services.
The individual is enrolled in Medicaid or the Medicaid Buy-In program. Children on CHIP are not covered by this benefit.³

The benefit is available under STAR, STAR Kids, and STAR Health, the state’s three main Medicaid managed care programs for children.⁴

The Diagnosis Has to Meet Specific Standards

A general screening tool like the M-CHAT-R is not enough on its own. Texas Medicaid requires a comprehensive diagnostic evaluation using a validated, standardized instrument such as the Autism Diagnostic Observation Schedule (ADOS) or the Childhood Autism Rating Scale. The evaluation must document the diagnostic criteria and severity level from the current edition of the DSM.⁵

The clinician making the diagnosis has to be a developmental pediatrician, neurologist, psychiatrist, licensed psychologist, or an interdisciplinary diagnostic team with autism expertise. If your child continues to need ABA more than three years after the original diagnosis, a comprehensive reevaluation of symptom severity is required to keep eligibility active.⁵

How to Actually Start Services

Once your child has a qualifying diagnosis, the process runs roughly like this:

Get a signed, dated referral for ABA from the child’s primary care provider, the diagnosing physician, a physician assistant, or a certified nurse practitioner.⁵
Check the child’s Medicaid card to identify the managed care organization, then call the number on the back of the card.⁶
Find a Licensed Behavior Analyst in the MCO’s network. The TMHP Online Provider Look-up at opl.tmhp.com lists LBAs enrolled in Medicaid.⁶
The LBA performs an initial behavioral assessment and builds a treatment plan.
The provider submits the diagnosis, referral, assessment, and treatment plan to the MCO for prior authorization. Therapy cannot begin until the MCO approves.⁷
Once authorized, sessions can happen at home, in the community, or in a clinic. Parent and caregiver participation is required.⁶

Authorization decisions typically come back within three business days. Initial approvals last 90 days, with 90-day extensions and 180-day recertifications available on updated documentation.⁷ As of April 2025, the prescribing provider no longer has to sign the prior authorization form for a 90-day treatment extension, though the original treatment plan still needs a signature covering the full 180-day period.⁸

What’s Covered and How Much

Coverage includes ABA evaluations, direct treatment, and interdisciplinary team meetings to coordinate care. The covered procedure codes are 97151 (evaluation), 97153, 97154, 97155, 97156, 97158, and 99366.¹ Services are billed in 15-minute units.

Direct treatment is capped at eight hours (32 units) per day across the main treatment codes. Initial evaluations are limited to six hours (24 units), and the re-evaluations that happen every 180 days carry the same six-hour cap.⁹ Those daily limits can be exceeded when documentation shows medical necessity.

Treatment plans have to include measurable discharge criteria and a transition plan. Families are expected to attend at least 85% of scheduled sessions. If attendance falls below that, the case goes to physician review to decide whether continued services at the approved frequency are still medically necessary.¹⁰

Telehealth Sessions

Some ABA services can be delivered by synchronous audio-video. The eligible codes are 97151 (evaluation), 97155, 97156, 97158, and 99366, and claims must include Modifier 95. Only LBAs can provide ABA remotely; assistant behavior analysts and behavior technicians cannot deliver telehealth services.⁷ A patient’s home counts as a valid telehealth site, and MCOs cannot deny reimbursement for a covered service simply because it was delivered remotely.¹¹

Why Coverage on Paper Doesn’t Always Mean Coverage in Practice

The benefit exists, but getting into services is often the hard part. Reimbursement rates are low: the state’s conversion factor for children’s services sits at roughly $28.07, and individual code rates run from about $14.50 to $27.56 per 15-minute unit.¹² Many providers say those rates don’t cover wages, supervision, overhead, and compliance, so they either don’t credential with Medicaid at all or cap the number of Medicaid clients they see.

Credentialing itself is a bottleneck. Each MCO runs its own authorization and credentialing process, and a Licensed Behavior Analyst who wants to serve patients across multiple plans has to credential separately with each one, a process that can take up to 180 days per MCO. Thousands of families end up on waitlists as a result.⁴ Texas does not publicly report how many children are receiving ABA through Medicaid or how long average waits are.

If Services Are Denied or Reduced

When an MCO denies or cuts back ABA services, it has to send a written notice explaining the decision. You have two ways to push back:

An internal appeal within the MCO, which assigns a different doctor to review the original decision.
A Medicaid fair hearing, in which an impartial hearings officer at the Texas Health and Human Services Commission reviews the evidence and decides whether the MCO followed Medicaid policy.¹³

The 10-day window matters. If you request an appeal or fair hearing 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 10 days, the cut takes effect, though you can still file an appeal or hearing request for up to 90 days.¹⁴ Disability Rights Texas assists with the process at 1-800-252-9108.

What Happens When a Child Turns 21

The Medicaid ABA benefit ends at age 21, and Texas does not offer an equivalent ABA benefit for adults through its Medicaid programs. Adults with autism can access related supports through home and community-based waivers, though none specifically list ABA as a covered service.

The Home and Community-based Services (HCS) waiver provides habilitation, respite, and employment support for people with intellectual and developmental disabilities.¹⁵ STAR+PLUS serves adults 21 and older with disabilities and covers personal assistance and therapies including occupational, physical, and speech-language therapy.¹⁶ Community First Choice offers attendant care and habilitation with no waiting list. Other waivers such as TxHmL, CLASS, and DBMD have interest lists that can stretch 10 to 20 years, so families are advised to join relevant lists early and to contact their HHSC caseworker well before the child turns 18 to start transition planning.

Numbers to Keep Handy

Your child’s MCO: the phone number on the back of the Medicaid ID card.
Texas Health and Human Services: 2-1-1 or 1-877-541-7905 for general Medicaid and MCO questions.
TMHP Contact Center: 800-925-9126 for benefit and provider questions.⁶
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 Medicaid-enrolled LBAs.

1
TMHP. HHSC Release Autism Services Benefits Effective February 1, 2022
2
Autism Speaks. New Texas ABA Medicaid Benefit
3
Texas Autism Society. Medicaid Coverage for ABA Begins 2-1-22
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. Telecommunication Services
12
TMHP. Texas Medicaid Fee Schedule for Autism 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