Texas Medicaid added ABA as a defined benefit on February 1, 2022 — "Autism Services" under the Texas Health Steps Comprehensive Care Program (THSteps-CCP), the state's EPSDT vehicle. It is one statewide rulebook: HHSC writes the medical-necessity criteria into the Texas Medicaid Provider Procedures Manual (TMPPM), and every delivery channel — fee-for-service through TMHP and all the STAR, STAR Kids, and STAR Health managed-care plans — applies the same criteria. The benefit covers ages birth through 20 (eligibility ends on the 21st birthday; CHIP is explicitly excluded), requires prior authorization on everything from the initial evaluation forward, and runs on a distinctive 90/90/180-day authorization cadence. The MCO guides below cover per-plan submission mechanics; the clinical rules on this page apply everywhere.
Autism Services is an EPSDT benefit: THSteps-CCP covers medically necessary ABA for members from birth through age 20, with eligibility ending on the 21st birthday. The gate is an ASD diagnosis — but not any diagnosis, from anyone, at any time. The TMPPM requires the diagnosis to come from a developmental pediatrician, neurologist, psychiatrist, licensed psychologist, or an interdisciplinary team (a physician, PA, or NP in consultation with qualified child specialists with autism expertise), documented with DSM diagnostic criteria and a symptom severity level, and made or reconfirmed within the 3 years before the PA request. A diagnosis alone is not sufficient to establish medical necessity — the evaluation builds that case. For intake, the 3-year recency rule is the trap to screen for early: a child diagnosed at 2 who shows up at 7 needs a diagnostic reconfirmation before the PA can go in.[2][3]
Everything is prior-authorized. The ABA evaluation (97151, limited to 24 units / 6 hours per evaluation, billed with the HO modifier by the LBA) needs a PA that includes a signed referral from the prescribing provider plus the diagnosis documentation, submitted on the CCP Prior Authorization Request Form. Treatment then authorizes in two consecutive 90-day periods — the initial 180-day treatment plan must be signed and dated by the prescribing provider — followed by recertifications in increments of up to 180 days.[3][4]
The friction-reducer worth knowing: effective April 1, 2025, TMHP dropped the prescribing-provider signature requirement on the CCP PA form for the 90-day treatment extension. The initial plan still needs the prescriber's signature, but the mid-cycle extension no longer stalls on chasing a physician's pen — a real cycle-time win for practices that learned the benefit in its first three years. What a renewal must carry: the 90-day extension needs “an attendance log that also includes a calculation of the percentage of planned sessions completed for the child or youth and their parent or caregiver, and a progress summary”; the 180-day recertification rests on the 97151 re-evaluation, which also carries the attendance log. The TMPPM does not ask for graphs in the request itself, but every session note must include “direct observation measures that record data during every treatment session to allow the LBA to graph data across time for analysis.”[3][4]
HHSC raised ABA rates roughly 11.5% across the board effective September 1, 2025 — the first adjustment since the benefit launched. Per 15-minute unit: 97151 evaluation pays $27.56 (was $24.71); 97153 direct treatment by a behavior technician pays $14.50 (was $13.00); 97155 protocol modification pays $20.08–$25.10 and 97156 family training $18.40–$23.01, tiered by credential modifier. Texas flags credentials with modifiers — HO for the Licensed Behavior Analyst (LBA), HN for the Licensed assistant Behavior Analyst (LaBA), HM for behavior technicians — though 97153 itself takes no credential modifier. Two structural notes: only LBAs can enroll in Texas Medicaid (LaBAs and BTs bill under the LBA's supervision), and MCO reimbursement is contract-specific even though it generally tracks the HHSC fee schedule. The rate figures here come from the HHSC rate-hearing packet; confirm current values in the TMHP Online Fee Lookup before building revenue models. The code set is CPT only: TMPPM § 2.3.12 lists 97151 (evaluation and re-evaluation), 97153 and 97155 (individual), 97154 and 97158 (group), 97156 (caregiver training) and 99366 (interdisciplinary team meeting) as the procedure codes that “may be reimbursed” for ABA; 97152, 97157, 0362T, 0373T and HCPCS H-codes such as H0031, H0032 or H2019 are not on that list.[3][5][15][6]
Direct treatment is capped at 8 hours (32 units) per day combined across 97153, 97154, 97155, and 97158. Telehealth (synchronous audio-visual, modifier 95) is allowed for 97151, 97155, 97156, 97158, and 99366 — but 1:1 direct treatment delivered by a BT or LaBA must be in person; no telehealth. Interdisciplinary team meetings are billable under 99366 with an ABA PA on file.[3][14][2]
On the delivery side, Texas runs a hybrid: fee-for-service through TMHP, and managed care through STAR (most children), STAR Kids (disability-related Medicaid), and STAR Health (foster care, statewide through Superior). Texas has 15+ Medicaid MCOs across its service delivery areas — including BCBSTX, Community Health Choice, Cook Children's, El Paso Health, and Parkland alongside the plans profiled below — and all of them apply the same TMPPM criteria. What varies per plan is the PA intake machinery: forms, portals, fax lines. Capture the child's plan at intake and use the matching MCO guide. HHSC's January 2026 service-area roster confirms the per-plan footprints throughout this section are still current — e.g., Harris County STAR runs through Community Health Choice, Molina, Texas Children's, United, and Wellpoint; Bexar STAR through Aetna, Community First, Superior, and Wellpoint — superseding the September 2024 archived copy this directory previously rested on.[3][14][2]
Texas certifies behavior technicians but doesn't license them. The TMPPM (§ 2.3.6.3) requires every BT to hold one of three certifications — RBT, BCAT, or ABAT — so the RBT is accepted but explicitly not the only pathway. BTs may not enroll in Texas Medicaid (they render under the enrolled LBA), may not use "therapist" in their job title when interacting with Medicaid families, and may not conduct assessments or modify the treatment plan. There's no state license, registry, or training-hour add-on for BTs: Occupations Code § 506.054 exempts a person designated as a behavior technician from behavior analyst licensure when working under the authority and direction of an LBA or LaBA, so the certification requirement comes from Medicaid policy, not licensure law. For the RBT pathway, the BACB's own floor is what screens your hires: 18+, high-school education, a criminal background check and abuse-registry check no more than 180 days before applying, the 40-hour training, a competency assessment, and the exam.[3][7][8][9][10][11][12][13]
The agency-level screening that actually binds a standalone ABA practice is exclusion screening, not the long-term-care registries. As a condition of enrollment, all providers must screen every employee and contractor every month against both the federal HHS-OIG LEIE and the Texas HHSC-OIG exclusion list (TMPPM Vol. 1, § 1.3.1) — build this into payroll-cycle compliance, not just onboarding. The Employee Misconduct Registry, by contrast, applies only to the facility types listed in Health & Safety Code § 253.001 (nursing facilities, HCSSAs, assisted living, ICF/IID, and similar) — a standalone ABA agency isn't on that list, so EMR pre-hire checks aren't legally required unless you also hold one of those licenses. Fingerprinting is similarly narrow: it attaches at provider enrollment, only for high categorical-risk providers and owners with a 5%+ interest (via IdentoGO, with proof uploaded to PEMS within 30 days of application) — individually licensed behavior analysts are not designated high-risk. At the supervisor level, TDLR requires every LBA and LaBA applicant to pass a criminal history background check as a condition of licensure.[3][7][8][9][10][11][12][13]
Supervision structure follows enrollment structure. Only the LBA enrolls and bills; the LBA must directly employ or contract with every LaBA and BT on the team, and LaBAs can't practice independently — by statute they must be supervised by an LBA per their certifying body's requirements. The TMPPM makes LBAs the direct supervisors of LaBAs and BTs but sets no numeric ratio of its own, deferring to certifying-body minimums — which makes the BACB standard the operative floor for RBT-credentialed staff: supervision of at least 5% of service hours each month, with at least two face-to-face contacts per month (one observing service delivery, one individual). One billing wrinkle to plan around: only direct supervision — the LBA observing the LaBA or BT with the client — is reimbursable, under 97155; indirect supervision (caseload review, data discussion) is unpaid time. And BTs and LaBAs must deliver 1:1 treatment in person — no remote service delivery. MCOs mirror this baseline (Texas Children's Health Plan's autism guideline repeats it nearly verbatim), but only TCHP was checked in depth — confirm each MCO's provider manual for staff-level extras at contracting.[3][7][8][9][10][11][12][13]
TMHP publishes it. The static Autism Services fee schedule (file PRCR615C, run 9/14/2026) lists these per-unit Medicaid fees for clients aged 0–20: 97151-HO $27.56, 97153 $14.50, 97155-HN $20.08, 97155-HO $25.10, 97156-HN $18.40 and 97156-HO $23.01, all effective 9/1/2025; 97154 $1.63, 97158-HN $2.25 and 97158-HO $2.81, effective 3/1/2024; and 99366 team conferences $33.96 (non-facility). Every row shows a last pricing review of 9/1/2025, so the September 2025 increase is still the current rate set. The schedule notes that Medicaid rates are reviewed every two years or as necessary, and the TMPPM says autism services are reimbursed under 1 TAC § 355. For the fee on a particular date of service, use the TMHP Online Fee Lookup.[15][3][6]
Fee-for-service participation means enrolling in Texas Medicaid through TMHP, and only the LBA enrolls (LaBAs and behavior technicians may not). Managed care is a second step with its own gate. The TMPPM's Medicaid Managed Care Handbook says providers "must be enrolled in Texas Medicaid before they can be enrolled by an MCO," that "Individual MCOs and DMOs have their own guidelines for contracting providers," and that "Enrollment in Texas Medicaid does not guarantee that an MCO or DMO will contract enroll or credential a particular provider." Every Medicaid MCO credentials through the Texas Association of Health Plans' contracted credentialing verification organization. Whether a given plan is adding ABA providers is therefore a question for that plan's provider relations team. Where no in-network provider is available, the MCO "must allow a referral to an out-of-network Medicaid provider," requested by an in-network provider and decided within five business days at most.[16][3]
Changing ABA agencies restarts the authorization. Under TMPPM § 2.3.9, when a provider or client stops therapy during an authorized period and the client goes to a new provider outside the current group, "the new provider must start a new request for authorization and submit all documentation required for an initial evaluation." That includes a change-of-therapy-provider letter signed by the responsible adult, giving the date therapy ended with the previous provider (or the last date of service) and the names of both providers. A move to another performing provider within the same group keeps the same evaluation and plan of care, and the authorization period does not change. A gap of 180 days or more with no ABA treatment or re-evaluation also means starting over with an initial request.[3][16]
Changing health plans works differently. "Health plan prior authorizations do not automatically transfer with a client who moves to another plan," but once the client or provider tells the new MCO about an existing prior authorization, the new MCO must continue the services at the same amount, duration and scope until the earliest of: 90 days after the transition, the end of the current authorization, or its own assessment and new decision.[3][16]
TMHP must receive a fee-for-service claim within 95 days of each date of service; appeals of denied claims and adjustment requests must reach TMHP within 120 days of the disposition date on the Remittance and Status (R&S) Report. A 95-day or 120-day deadline that falls on a weekend or holiday moves to the next business day. The federal 365-day limit still caps exceptions such as retroactive eligibility (95 days from the eligibility add date, within 365 days of service).[18][16]
Claims must carry the provider’s complete name, physical address with ZIP+4, NPI, taxonomy code and benefit code (if applicable). Paper claims must show an NPI and taxonomy code for both the billing and the performing provider, and a claim missing either is denied. For a child in a STAR or STAR Kids plan, the claim goes to that MCO instead, which must also receive it within 95 days of the date of service.[18][16]
The questions that decide whether a family can start with Texas Medicaid (THSteps-CCP), and what they have to bring. Each maps onto something intake should ask on the first call.
Birth through 20 years of age on the date of service; clients become ineligible for CCP services the day of their 21st birthday. CHIP is excluded from the ABA benefit entirely.[3]
The ASD diagnosis must be made or reconfirmed within 3 years of initiation or recertification. Past 3 years the TMPPM requires a comprehensive re-evaluation of ASD symptom severity levels per DSM criteria before the PA can proceed.[3]
A developmental pediatrician, neurologist, psychiatrist, licensed psychologist, or an interdisciplinary diagnostic team (a physician, PA or NP in consultation with qualified child specialists with autism expertise). The diagnosis must be documented with DSM criteria and a symptom severity level.[3]
A reliable, valid, standardized diagnostic assessment tool or combination of tools — the TMPPM names the Autism Diagnostic Observation Schedule, the ADI-R and the Childhood Autism Rating Scale as examples. Screening tools alone (STAT, M-CHAT-R) cannot replace a validated diagnostic instrument.[3]
Two signed referrals. For the evaluation: a signed, dated referral from the prescribing provider, signed within 60 calendar days prior to or on the anticipated evaluation date. For treatment: a signed, dated referral from a physician or allowed practitioner (MD/DO, PA, NP, or CNS with properly delegated authority) outlining the frequency and duration of treatment, with a signature current to the service dates — on or before the service start date and no older than three months. Since 4/1/2025 the prescriber signature is no longer required on the CCP PA form for the 90-day treatment extension; the initial 180-day treatment plan still needs it. The LBA’s assessment and treatment plan must also name "the referring prescribing provider." On the claim, TMPPM § 6.4.2.4 says "All Texas Medicaid claims for services that require a physician order or referral must include the ordering or referring provider’s NPI," and that prescriber must be enrolled in Texas Medicaid (as a billing or performing provider, or with an ordering/referring-only enrollment); claims without it, or with an unenrolled NPI, "may be subject to retrospective review and denial." On the CMS-1500 the name goes in block 17 with qualifier DN (referring) and the NPI in 17b. TMHP publishes no separate ABA order form; the referral rides with the CCP prior authorization request.[3][4][18]
Synchronous audio-visual only, modifier 95, and only on 97151, 97155, 97156, 97158 and 99366. That list covers the assessment: 97151 is the initial evaluation and the re-evaluation done every 180 days, both by the LBA. It also covers 97155 when the LBA directly supervises a BT or LaBA working with the child. "LaBAs and RBTs may not deliver any service remotely," and one-on-one services delivered directly to the child by a behavior technician or LaBA must be in person — the TMPPM prohibits telehealth for BT/LaBA-delivered direct service. On the claim the telehealth marker is the modifier: the Telecommunication Services Handbook says “Telemedicine and telehealth services must be billed with modifier 95” and names no telehealth place-of-service code (no POS 02 or 10 rule); the Autism Services section says its remote-delivery rules “supersede” that handbook.[1][3]
Fee-for-service through TMHP: when a CCP request needs physician review, TMHP's Physician Reviewer "will complete the review within three business days of receipt of the completed prior authorization request," with "an additional three business days" when a peer-to-peer with the prescriber is needed. The clock runs from a COMPLETE request: an incomplete one is held while TMHP makes at least three contact attempts, and if the missing information "is not received within 14 business days of the request receipt date, the request will be denied as 'incomplete.'" The federal ceiling for state agencies since 1/1/2026 is 7 calendar days standard and 72 hours expedited (42 CFR 440.230(e)), unless state law sets a shorter one. The windows that actually cost money are the provider-side ones in § 2.3.11: the evaluation PA goes in within 60 days before or on the evaluation date; initial treatment within 3 business days of the start-of-care date (later requests are denied for dates before receipt); the 90-day extension is timely "within 30 days prior to the end of the current authorization period"; and a 180-day recertification must be received "no earlier than 60 days before the current authorization period expires" — anything filed after the end date is denied for the gap. Managed-care members follow their MCO's clock (Texas law: 3 business days, see the MCO guides).[3][19][20]
Medicaid is the payer of last resort: a provider "must seek reimbursement from available third party insurance that the provider knows about or should know about before billing Texas Medicaid." Bill the commercial plan (or TRICARE, which the TMPPM lists as a third party resource) first, then file with TMHP within 95 days of the other insurer's payment or denial and within 365 days of the date of service, with the EOB's disposition date; if the other insurer has not answered after 110 days, TMHP will consider the claim. Get the Medicaid PA even when Medicaid is secondary — § 5.1.4: "If a client's primary coverage is private insurance and Medicaid is secondary but prior authorization is required for Medicaid reimbursement, providers must follow the guidelines and requirements listed in the handbook for that service." The one bill-Medicaid-first option in Section 8 ("THSteps medical and dental providers are not required to bill other insurance before billing Medicaid") names only THSteps medical and dental (checkup) providers; ABA is a CCP service, so bill the other coverage first. Exceptions to last-resort: in STAR Health (foster care) "Medicaid is primary … Providers must not bill other health insurance unless there is a court order," and CHAMPVA pays before Medicaid. The family owes nothing past the other insurer's payment for a Medicaid-covered service.[21][22][23][24]
Coverage decides whether Texas Medicaid (THSteps-CCP) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
The TMPPM sets no numeric ratio of its own: LBAs must directly supervise LaBAs and behavior technicians in accordance with Texas state licensure, which makes the certifying body's floor operative — for RBT-credentialed staff, the BACB minimum of supervision on at least 5% of service hours each calendar month with two face-to-face contacts. Only direct supervision, where the LBA directly observes the LaBA or BT providing services with the child, is reimbursable, under 97155; indirect supervision (caseload review, data discussion) is unpaid time. The LBA may deliver 97155 by synchronous audio-visual telehealth (modifier 95), and 97155 may be used when directly supervising a BT or LaBA working with the child; the supervised staff themselves may not deliver any service remotely ("LaBAs and RBTs may not deliver any service remotely").[3][8]
Prohibited: Texas Medicaid will not reimburse multiple ABA providers during one ABA session with the child when more than one ABA provider is present. The one exception is when the family and the child are receiving separate services and the child is not present in the family session. Providers may request total authorized hours under either 97153 or 97155 and bill the code matching the service actually delivered, but not both for the same clock time with the child present. The autism section does not address ABA billed during a speech, occupational or physical therapy session; it requires the treatment plan to coordinate with an SLP, OT or PT where a co-morbid condition calls for it.[3]
Direct treatment is limited to 8 hours (32 units) per day, inclusive of 97153, 97154, 97155 and 97158. The 97151 evaluation and each re-evaluation are limited to 6 hours (24 units). Group treatment requires at least 2 and no more than 8 children. These are claim edits as well as authorization limits: “If services billed exceed the limitations outlined in this section, the claim will be denied, and may be appealed.” Authorization runs as two consecutive 90-day periods, then recertifications in increments of up to 180 days.[3]
Rendering ABA providers must sign each entry with full signature and credentials, and additional supervisory signatures must be made in accordance with state licensure requirements. Treatment notes for 97153/97154 carry the child's name, date of service, start and stop times, treatment goals addressed, progress and a summary of activities and interventions; 97155/97158 notes add protocol-modification decision points and progress assessments. The 97151 evaluation and the post-90-day progress summary each require a dated signature from the LBA and from the parent or caregiver.[3]
Home, clinic, office and community settings are payable, and ABA may be delivered across settings. Schools are permitted for coordination of care — school personnel of the same discipline participating to coordinate care are not treated as duplicates, and interdisciplinary team meetings bill under 99366 with an ABA PA on file — but services delivered by a behavior technician in the school setting as a shadow, an aide, or to provide general support are excluded. BT and LaBA direct treatment must be in person in any setting.[3]
Only the LBA enrolls in Texas Medicaid and bills. LaBAs and behavior technicians may not enroll; their services are billed under the supervising LBA's NPI with the credential modifier identifying the rendering staff level — HO for the LBA, HN for the LaBA, HM for the behavior technician. 97151 takes the HO modifier only; 97155, 97156 and 97158 take HO or HN; 97153 takes no required credential modifier. The 97155 supervision claim likewise goes out under the LBA's NPI.[3]
Yes — since February 1, 2022, as the Autism Services benefit under THSteps-CCP (EPSDT), for members from birth through age 20 with an ASD diagnosis. Everything requires prior authorization, from the evaluation forward. CHIP is excluded.
The diagnosis — with DSM criteria and a symptom severity level — must be made or reconfirmed within the 3 years before the PA request. Older diagnoses need reconfirmation before the evaluation PA can be approved.
TMHP removed the prescribing-provider signature requirement from the CCP PA form for the 90-day treatment extension. The initial 180-day treatment plan still needs the prescriber's signature; the mid-cycle extension no longer does.
Effective September 1, 2025 (an ~11.5% increase): 97153 direct treatment pays $14.50 per 15-minute unit, 97151 evaluation $27.56, 97155 $20.08–$25.10 and 97156 $18.40–$23.01 depending on the LaBA/LBA modifier tier. Confirm current values in the TMHP Online Fee Lookup.
TMHP publishes a static Autism Services fee schedule (PRCR615C). The run dated 9/14/2026 still carries the 9/1/2025 rates: 97153 $14.50, 97151-HO $27.56, 97155 $20.08/$25.10 and 97156 $18.40/$23.01 per unit. Use the TMHP Online Fee Lookup for a specific date of service.
Yes, by the LBA. 97151 (initial evaluation and re-evaluation) is on the TMPPM telehealth list with modifier 95, synchronous audio-visual only, along with 97155, 97156, 97158 and 99366.
The LBA can deliver 97155, including direct supervision of a BT working with the child, by synchronous audio-visual telehealth with modifier 95. The BT's own sessions must be in person, and only direct supervision is paid.
No. BTs must hold RBT, BCAT or ABAT certification but "may not enroll in Texas Medicaid," and neither may LaBAs. Only the LBA enrolls, and BT services are billed under that LBA.
A new provider outside the current group must submit a new authorization request with initial-evaluation documentation and a change-of-provider letter signed by the responsible adult. A move within the same group keeps the evaluation, plan of care and authorization period.
LBAs enroll in Texas Medicaid through TMHP. Each MCO then decides on contracting, and Medicaid enrollment does not guarantee an MCO contract, so ask each plan's provider relations about its ABA network.
Ninety-five days from each date of service, for TMHP fee-for-service claims and for claims to a Texas Medicaid MCO alike. Appeals to TMHP are due within 120 days of the R&S Report disposition date.
Yes. TMHP requires the NPI and taxonomy code for the billing and the performing provider on paper claims, and asks for NPI, taxonomy and benefit code on every claim. A paper claim without them is denied.
Yes. ABA needs a prescriber referral, and TMPPM § 6.4.2.4 requires every claim for a service that needs a physician order or referral to carry the ordering or referring provider’s NPI (CMS-1500 block 17 with qualifier DN, NPI in 17b). That prescriber must be enrolled in Texas Medicaid, at least as an ordering/referring-only provider; a missing or unenrolled NPI can lead to denial on retrospective review.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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