Parent Resources
If your child has autism and is covered by Texas Medicaid, you may be wondering whether ABA therapy is included. The short answer is yes. Since February 1, 2022, Texas Medicaid has covered applied behavior analysis (ABA) for children and young people with autism who are 20 years old or younger and meet the program’s requirements.
Knowing that a benefit exists is only the first step, though. For many families, the hard part is figuring out what comes next. This guide walks through who qualifies, what you need, and how the approval process works, in plain language.
What Texas Medicaid covers
Texas Medicaid added Autism Services, including ABA evaluation and treatment, as a benefit of the Texas Health Steps-Comprehensive Care Program (THSteps-CCP). The Texas Medicaid & Healthcare Partnership (TMHP), which handles Texas Medicaid claims and provider information for the state, announced that the benefit took effect for dates of service on or after February 1, 2022. (TMHP announcement) Texas Health and Human Services also confirms on its Children’s Autism Program page that Texas Medicaid covers ABA for children with autism who are Medicaid members.
According to the Texas Medicaid Provider Procedures Manual, the benefit can include:
- An ABA evaluation, to understand your child’s strengths and needs
- ABA treatment based on an individualized treatment plan
- Parent or caregiver training, which Texas Medicaid treats as an important part of the plan
The manual also says ABA must be medically necessary for your child, and that a diagnosis alone is not enough to show medical necessity. That is why the evaluation and treatment plan matter so much. (Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, section 2.3)
Who qualifies
In general, your child may be eligible if they:
- Are enrolled in Texas Medicaid
- Are 20 years old or younger
- Have a diagnosis of autism spectrum disorder (ASD) from a qualified provider
- Need ABA services that are medically necessary, as documented in an evaluation and treatment plan
The diagnosis has to meet certain standards
Texas Medicaid requires a comprehensive diagnostic evaluation. It can be done by a developmental pediatrician, a neurologist, a psychiatrist, a licensed psychologist, or an interdisciplinary diagnostic team. The evaluation has to use a standardized diagnostic tool. A screening checklist on its own is not enough. The diagnosis (or a re-evaluation) also needs to be from within the past three years when ABA services start.
If your child was diagnosed several years ago, ask your doctor whether a re-evaluation is needed before you begin.
How to get started: step by step
1. Get a diagnosis (or gather the one you have)
If your child already has an autism diagnosis, find the full evaluation report. The ABA provider will need it. If you suspect autism but don’t have a diagnosis yet, start with your child’s pediatrician.
2. Get a referral from your child’s doctor
Texas Medicaid requires a signed and dated referral for an ABA evaluation. It can come from your child’s primary care provider or from the diagnosing physician. A nurse practitioner, physician assistant or clinical nurse specialist may also be able to write it.
3. Find an ABA provider that works with your child’s health plan
Many children in Texas Medicaid get their benefits through a managed care health plan, such as STAR, STAR Kids or STAR Health. If your child has one, the ABA provider usually needs to be in network with that plan, and the plan handles authorization. Your child’s Medicaid card shows the plan name. TMHP notes that managed care plans must follow the state’s ABA policy.
4. Prior authorization for the ABA evaluation
Before the first evaluation, the provider asks for approval (called prior authorization) with your child’s diagnosis and the doctor’s referral.
5. The evaluation and treatment plan
Once the evaluation is approved, a behavior analyst meets your child, talks with you, and observes your child in at least one natural setting, like home. They then write a treatment plan with goals that fit your child and your family.
6. Prior authorization for treatment
The provider then requests approval for ABA treatment. This request includes the treatment plan and a doctor’s referral that covers how often and for how long treatment is recommended. Treatment is approved for set periods, and the provider asks for renewal (recertification) with progress updates.
How many hours will my child get?
This is one of the most common questions, and the honest answer is that it depends. The number of hours is based on your child’s evaluation, the goals in the treatment plan, and what Medicaid or your child’s health plan approves. Two children with the same diagnosis can have very different plans.
We can’t promise approval or a certain number of hours. What we can do is make sure the paperwork is complete and the plan clearly explains your child’s needs.
Why parent involvement matters
Texas Medicaid expects parents or caregivers to take part in ABA. The goal is for new skills to carry over into everyday life, at home and in the community. At Evolve ABA Care, parent training is part of every child’s program. Your BCBA will show you strategies you can use during meals, bath time, play and errands.
How Evolve ABA Care can help
Evolve ABA Care accepts Texas Medicaid. We also accept UnitedHealthcare, BCBS, Baylor Scott & White, Aetna, Cigna, Wellpoint and Molina. We offer:
- In-home ABA therapy for families anywhere in Texas
- Clinic-based ABA therapy at our McKinney clinic, 1400 N Coit Rd, Suite 2506
- BCBA-supervised care, with sessions led by Registered Behavior Technicians (RBTs)
- A Spanish-speaking (bilingual) BCBA
When you call, we’ll check your child’s coverage, explain what paperwork is needed, and help you with the next steps.
Frequently asked questions
Does my child need a diagnosis before starting ABA under Medicaid?
Yes. Texas Medicaid requires an autism diagnosis from a comprehensive diagnostic evaluation by a qualified provider.
Is there a cost to families for ABA under Texas Medicaid?
Ask your child’s health plan to confirm. Medicaid-covered services generally don’t involve a bill to the family, but your plan can explain exactly what applies to your child.
My child is 19. Are they still eligible?
The Medicaid ABA benefit covers members who are 20 years old or younger, as long as they meet the other requirements.
Can ABA under Medicaid happen at home?
ABA can take place at home, in a clinic, or in the community, depending on your child’s treatment plan and what is approved. Evolve ABA Care offers both in-home and clinic-based ABA.
Talk with our team
Have questions about Texas Medicaid and ABA? Call Evolve ABA Care at 469-793-6001 or send us a message. We’ll check your child’s coverage and explain the next steps.
Sources
- Texas Medicaid & Healthcare Partnership (TMHP): HHSC Release of Autism Services Benefits Effective February 1, 2022
- TMHP: Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, section 2.3 Autism Services
- Texas Health and Human Services: Children’s Autism Program
This article is general information, not legal, medical or insurance advice. Medicaid rules can change, so check with your child’s health plan for the latest details.
