Texas Medicaid & ABA Therapy: What You Need to Know

Texas Medicaid began covering Applied Behavior Analysis (ABA) therapy in February 2022 for children and young adults under 21 with Autism Spectrum Disorder (ASD). To qualify, the child must have a recent ASD diagnosis and a physician’s referral.

ABA therapy is offered in various settings, including homes and clinics, and is part of a larger service package that may also include physical, occupational, and speech therapy. Managed Care Organizations (MCOs) like Superior HealthPlan and Parkland Community Health Plan currently participate, with more expected to join soon. Efforts are underway to update provider reimbursement rates and improve access for families.

Texas Medicaid covers various ABA services for children and young adults with ASD to improve social, communication, and behavioral skills. Key services covered include behavioral assessments to create personalized treatment plans; skill development for communication, social interaction, and self-care; behavioral interventions to address challenging behaviors like aggression; parent and caregiver training to support progress outside therapy; and coordinated therapies, such as physical, occupational, and speech therapy, delivered alongside ABA as needed.

Eligibility Requirements

To be eligible for ABA therapy under Texas Medicaid, children and young adults must meet specific criteria:

• Age: The child must be under 21 years of age.
  
  
• Diagnosis: A recent diagnosis of ASD is required, which must be made within the last three years. The diagnosis should include the severity level of autism.
  
  
• Referral: A referral for ABA therapy must be made by a qualified physician. These physicians typically include pediatricians, child psychiatrists, and neurologists.
  
  
• Medically Necessary Services: ABA therapy must be deemed medically necessary. Under Texas Medicaid, “medically necessary” services are those required to prevent, diagnose, or treat an illness, injury, condition, or disease.

These eligibility criteria ensure that only those who meet the specific needs associated with ASD receive coverage for ABA services through Texas Medicaid. For more detailed information, you can visit the Texas Health and Human Services website.

As well as these restrictions, there are a few more requirements that need to be met. For example, providers may need to obtain prior authorization for ABA services to confirm that the therapy is deemed medically necessary. This process involves submitting documentation that outlines the child’s diagnosis and the proposed treatment plan.

Application Process

Here’s a summary of the process for applying for ABA therapy benefits under Texas Medicaid:

1. Verify Eligibility: Ensure the child is under 21, has a recent diagnosis of ASD, and obtain a referral from a qualified physician.
   
   
2. Choose a Managed Care Organization (MCO): Identify the enrolled MCO and contact them to check provider acceptance. Your Medicaid card usually lists your assigned MCO. This is the easiest way to determine which organization you are enrolled with.
   
   
3. Contact a Provider: Contact an ABA provider within your MCO network to discuss available services.
   
   
4. Schedule a Behavioral Assessment: The provider will conduct a comprehensive assessment to evaluate the child’s skills and challenges.
   
   
5. Submit Documentation: The ABA provider must submit the necessary documentation to the MCO, including the referral, diagnosis, assessment results, and treatment plan.
   
   
6. Obtain Prior Authorization: The MCO may require prior authorization before treatment can begin.
   
   
7. Begin Therapy: After authorization, schedule therapy sessions and involve parents and caregivers in training to reinforce skills.
   
   
8. Stay Informed: Maintain communication with the provider and MCO to stay updated on coverage and policy changes.

For more information, you can call the Texas Health and Human Services Commission (HHSC) at 2-1-1 or 1-877-541-7905. They can provide information about your MCO and assist with any questions regarding your benefits.

How to Submit

The paperwork submission is carried out by the ABA providers and can be carried out in a number of ways:

• Via MCO Provider Portal: Most MCOs have an online provider portal where ABA providers can submit documentation electronically.
  
  
• Direct Submission: Providers may also submit documents directly to the MCO’s office via mail or fax. The specific submission methods can vary by MCO, so the provider needs to confirm the correct process.

Providers should contact the MCO directly for detailed instructions on submission processes, including the preferred method (portal, mail, fax) and any specific forms that may need to be completed.

Here are links to the provider resources for major Texas Medicaid MCOs:

• Superior HealthPlan: Superior HealthPlan Provider Information
• Amerigroup: Amerigroup Provider Information
• Parkland Community Health Plan: Parkland Provider Information

Understanding the Benefits & Out-of-Pocket Costs

Next, we will discuss the extent of coverage provided by Texas Medicaid, including therapy hours, duration of therapy, and the types of services covered.

The number of therapy hours required will vary from child to child and their individual needs. Texas Medicaid generally allows for up to 40 hours per week of ABA therapy, which is usually the maximum number of hours that would be prescribed to a child. However, this is contingent on the child’s specific treatment needs, as determined through assessments and the proposed treatment plan.

ABA therapy is usually a long-term therapy, and children typically participate for several years, depending on the child’s progress and evolving needs. Regular reassessments are required to adjust the treatment plan and the number of hours covered as necessary. Authorizations and progress reports need to be submitted twice a year for coverage to be maintained throughout the years of therapy.

In addition to ABA therapy, Texas Medicaid may cover other related services, such as physical, occupational, and speech therapy, if deemed medically necessary. This approach ensures a comprehensive support system for the child’s developmental needs.

Many MCOs require a co-pay for services, including ABA therapy. These co-pays can vary widely but typically range from $0 to $30 per visit, depending on the specific MCO and the type of service provided. Some MCOs may offer a sliding scale based on family income or may waive co-pays for low-income families. Some families might also have to meet a deductible before their Medicaid benefits kick in.

While Texas Medicaid covers ABA therapy, there may be limitations on the total number of hours covered per week or per month, which could impact overall costs if additional hours are needed beyond what Medicaid covers. Furthermore, if other services, such as speech therapy or occupational therapy, are needed in conjunction with ABA therapy, families may incur additional costs associated with those services, depending on their coverage specifics.

Challenges and Limitations

There are a number of potential challenges faced by families obtaining ABA services through Texas Medicaid.

The application process for ABA therapy can be intricate, requiring multiple forms of documentation, including determining eligibility, diagnosis verification, a physician’s referral, and assessment results. Families may find it challenging to navigate this process, especially if they are unfamiliar with Medicaid regulations, and it can be frustrating if documentation is incomplete or not correctly submitted.

There may be limitations on the number of hours of therapy covered per week or month, which can hinder a child’s progress. Families might have to fight for additional hours based on the child’s needs, which can be a challenging and time-consuming process.

Once approval is granted, finding an in-network ABA provider can be difficult, particularly in rural or underserved areas. Limited availability may force families to travel long distances for therapy, impacting consistency and accessibility.

If coverage is denied or families encounter challenges during the application process, they may have to navigate the appeals process. This can be overwhelming, particularly if they are not familiar with the procedures and timelines involved.

Even with Medicaid coverage, families may encounter co-pays or other out-of-pocket expenses that can be financially burdensome. Understanding these costs can be challenging, leading to unexpected financial strain.

Note: For more information on financial support for families with autistic children, see our article here.

Advocacy and Additional Support

Navigating Medicaid coverage for ABA therapy can be complex, but various advocacy groups and organizations can assist families in understanding their rights, accessing services, and securing necessary support. Here are some key organizations and resources:

1. Autism Society of America
   
   The Autism Society provides resources and advocacy for individuals with autism and their families. They offer guidance on accessing services, including Medicaid, and can help families understand their rights regarding ABA therapy.
   
   
2. Disability Rights Texas
   
   This nonprofit organization offers legal advocacy and assistance for individuals with disabilities. They can help families navigate the complexities of Medicaid, including appeals processes and coverage issues related to ABA therapy.
   
   
3. The Arc of Texas
   
   The Arc advocates for individuals with intellectual and developmental disabilities. They provide resources and support for families, including information on Medicaid services and accessing ABA therapy.
   
   
4. Texas Health and Human Services (HHSC)
   
   HHSC provides official information regarding Medicaid services in Texas. Families can contact their local Medicaid office for assistance and clarification on the application process for ABA therapy.

In addition to advocacy groups, several resources and support systems are available in Texas for families navigating Medicaid coverage for ABA therapy.

Here are some key options:

1. Local Early Childhood Intervention (ECI) Programs
   
   ECI provides services for children under three years old with developmental delays or disabilities, including autism. They offer assessments and referrals for appropriate therapies, including ABA. Families can find their local ECI program by visiting the Texas Health and Human Services website or calling 1-800-250-2246.
   
   
2. Texas Parent to Parent
   
   This organization offers support and resources for families of children with disabilities. They provide information about services, advocacy, and community support, including resources specific to ABA therapy.
   
   
3. Parent Training and Information Centers (PTIs)
   
   PTIs provide information and training to parents of children with disabilities. They can help families understand their rights under the Individuals with Disabilities Education Act (IDEA) and assist with navigating services, including Medicaid.

These resources and support systems are valuable for Texas families seeking assistance with Medicaid coverage for ABA therapy. Engaging with these organizations can help families access the necessary services, understand their rights, and connect with community support. For further information, consider visiting the provided links or contacting these organizations directly.

Real-Life Experiences

To help you understand some of the possible challenges of obtaining Medicaid coverage for ABA in Texas, we’ve highlighted the stories of two families.

A mother of a 6-year-old, non-verbal, level 3 ASD daughter lost Medicaid coverage due to household income and switched to her employer’s BCBS insurance. This significantly raised premiums to over $1,200 per month, and therapies such as ABA, speech, and occupational therapy, which were once fully covered, now cost an additional $1,500 monthly. Despite working multiple jobs, the family is struggling to manage costs. It was recommended that this family apply for a Medicaid waiver in order to cover costs and transition their speech and occupational therapy services to school to avoid those extra costs.

Another Texas family is scrambling after their child with multiple conditions, including autism, lost Medicaid coverage during the state’s extensive post-pandemic Medicaid eligibility review. The family depended on Medicaid for their child’s essential therapies and services, and the loss of coverage has left them struggling to find alternatives. The family lost coverage due to having an income that is too high to qualify, and they have since applied for Medicaid “buy-in” coverage, which allows for slightly higher income.

Of course, these are two stories out of thousands across the state receiving ABA therapy through Medicaid. If you’re new to the process, these shouldn’t dishearten you, only make you aware of possible complications so that you can prepare yourself for the challenges that may lie ahead.

Final Thoughts

Navigating the Texas Medicaid system for ABA therapy presents both challenges and opportunities for families. While the process can be complex, the inclusion of ABA services is a significant step toward supporting children with ASD. Families often experience improvements in communication, social skills, and overall well-being through dedicated therapy. Ongoing advocacy and clear communication with providers are crucial for success.

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