Texas Medicaid ABA Coverage Structure

Texas Medicaid covers ABA services through the Texas Medicaid & Healthcare Partnership (TMHP), but the specific program a client is enrolled in significantly affects how services are authorized and billed.

The Three Texas Medicaid Programs for ABA

STAR (State of Texas Access Reform)

The standard Medicaid managed care program for most children and families. ABA coverage is provided through managed care organizations (MCOs) including Amerigroup, Molina, Superior Health Plan, and others. Each MCO has its own prior authorization process.

STAR Kids

A specialized Medicaid managed care program for children and young adults under 21 with disabilities, including autism. STAR Kids MCOs include Amerigroup STAR Kids, Driscoll Health Plan, and others. STAR Kids typically has more comprehensive ABA coverage than standard STAR.

STAR+PLUS

For adults with disabilities. ABA coverage under STAR+PLUS is more limited and varies by MCO.

Prior Authorization Requirements

All Texas Medicaid programs require prior authorization for ABA services. The authorization process is managed by the MCO, not TMHP directly.

Key difference from other states: Texas MCOs often require a separate authorization for the initial assessment (97151) and a separate authorization for ongoing therapy. Do not assume that an assessment authorization covers ongoing therapy services.

Documentation Requirements

Texas Medicaid documentation requirements include:

  • ASD diagnosis from a licensed professional (psychologist, physician, or APRN)
  • Functional Behavior Assessment by a BCBA
  • Treatment plan with measurable goals
  • Progress notes with start/stop times
  • BCBA supervision documentation

    • Texas-Specific Requirement: Behavior Support Plan

    Texas Medicaid requires a separate Behavior Support Plan (BSP) in addition to the standard treatment plan. The BSP must:

  • Identify the function of each target behavior
  • Include proactive strategies to prevent problem behaviors
  • Include reactive strategies for managing problem behaviors safely
  • Be reviewed and updated at least every 6 months

    • Billing Codes and Modifiers

    Texas Medicaid uses the standard ABA CPT codes (97151–97158). Texas-specific modifier requirements:

  • U5 — Required for telehealth services (instead of modifier 95 or GT)
  • HM, HN, HO — Standard credential-level modifiers apply

    • TMHP Electronic Visit Verification

    Texas requires EVV for home and community-based ABA services. The state-designated EVV vendor is HHAeXchange. Practices must register with HHAeXchange and ensure their scheduling system integrates with the EVV platform.

    Common Texas Medicaid ABA Issues

    Issue 1: MCO vs. TMHP confusion. Many Texas ABA practices mistakenly submit claims to TMHP when the client is enrolled in a managed care plan. If the client has an MCO, all claims go to the MCO, not TMHP.

    Issue 2: Missing Behavior Support Plan. Texas's BSP requirement is separate from the treatment plan and is often overlooked by practices new to Texas Medicaid.

    Issue 3: U5 modifier for telehealth. Texas requires U5 for telehealth, not the standard 95 or GT modifiers used by commercial payors.

    Issue 4: Authorization for assessment vs. therapy. Texas MCOs frequently require separate authorizations for the assessment phase and the therapy phase. Billing therapy under an assessment authorization will result in denials.