ABA billing in Texas: what a small clinic needs to know.

Members age 20 and under with an autism diagnosis from a comprehensive evaluation, through Texas Health Steps–Comprehensive Care Program.

To bill it: An LBA enrolled with TMHP (the LBA's own NPI bills), a contract with each managed care plan in your area, and prior authorization for every service.

Sources: TMPPM Children's Services Handbook §2.3 · 1 TAC §354.5011 · TMPPM Medicaid Managed Care Handbook

STAR+PLUS serves adults 21 and older with a disability, and people 65 and older. The ABA benefit stops at age 20.

To bill it: Not an ABA billing route.

Sources: TMPPM Medicaid Managed Care Handbook · TMPPM Children's Services Handbook §2.3

ABA is not a CHIP benefit. The Texas Health Steps benefit it runs under is not available to children enrolled in CHIP.

To bill it: Tell the family early and discuss other coverage or private pay, before any session is scheduled.

Sources: HHSC Medicaid & CHIP Reference Guide · Texas Children's Health Plan autism guideline

Required when the diagnosis was made before the child's 10th birthday. From age 10, plans may limit ABA to $36,000 a year. Normal cost-sharing applies. Chapter 1507 standard plans are excluded.

To bill it: In-network status or the plan's out-of-network benefit, the plan's prior authorization, and a provider who is Texas-licensed, holds a federally recognized credential or is TRICARE-certified (or is supervised by one).

Sources: Tex. Ins. Code §1355.015 · TDI Order 3841 (28 TAC §21.4401)

State mandates don't apply, and the Texas Department of Insurance says most Texans with a health plan have a self-funded one. The employer decides, within federal mental health parity law, which has been used to challenge ABA exclusions.

To bill it: Read the plan's own benefit document for ABA, check network status, and keep the written answer with its date.

Sources: TDI: fully insured vs self-insured · U.S. DOL mental health parity report, 2022

The state mandate is written for group plans. Texas's benchmark plan lists autism services under habilitation, but it doesn't name ABA, so coverage turns on each plan's terms.

To bill it: Confirm ABA coverage, visit limits and prior authorization with the specific plan before the first session.

Sources: CMS Texas benchmark plan summary, 2025–2027 · Tex. Ins. Code §1355.015

Texas law brings the TRS plans under the autism mandate, and the TRS-ActiveCare booklet lists ABA under autism benefits. Check the current TRS-Care booklet for retirees.

To bill it: The plan's network (administered by BCBSTX for TRS-ActiveCare) and any clinical review the plan asks for.

Sources: TRS-ActiveCare benefits booklet 2025–26 · Tex. Ins. Code §1355.015

HealthSelect's plan year 2027 documents list ABA regardless of treatment setting. A pre-service review is recommended rather than required.

To bill it: BCBSTX network status for HealthSelect, and the plan's recommended pre-service review.

Source: HealthSelect of Texas plan year 2027

Federal plans have been required to cover ABA since plan year 2017. Plans may require prior approval, case management or in-network care.

To bill it: Each carrier's prior approval and network rules.

Source: OPM Carrier Letter 2016-03

TRICARE beneficiaries with an autism diagnosis in an eligible plan, with no age limit. Referrals renew every 2 years and authorizations run 6 months. Texas is in the West region (TriWest).

To bill it: TriWest certification, an ACD participation agreement, network credentialing, a state license for supervisors, and ACD provider education every calendar year.

Sources: TRICARE autism care · TriWest ACD quick reference guide

ABA is mostly a children's service, and we found no Medicare coverage statement for it. Don't plan a practice around Medicare for ABA.

To bill it: Confirm with the specific plan before seeing a Medicare member for ABA.

These waivers offer behavioral support services, which are not the Medicaid ABA benefit.

To bill it: Enrollment as a waiver program provider, under that program's rules.

Source: 26 TAC §263.5 (HCS)

A payer may agree to pay an out-of-network provider for one member, often when its network can't meet that member's needs or for continuity of care. Some payers don't offer them for Medicaid.

To bill it: A written request to the payer with the member's need, and the agreed rate and terms in writing before sessions start.

Source: Example payer single case agreement policy (Carelon)

Families can pay directly when their plan doesn't cover ABA or while coverage is being sorted.

To bill it: A written rate sheet and financial agreement signed before the first session.