Texas made history by becoming the 50th state to cover autism services through Medicaid in 2022. This breakthrough follows the path of Illinois, where Medicaid now covers these vital services for children and young adults under 21.

Getting ABA therapy through Medicaid might look complicated at first glance. The good news is that recent changes have made the process easier. Both Illinois and Texas now let you access up to 40 hours of ABA therapy each week, based on what your child needs. Federal EPSDT rules also make sure children under 21 can get these needed medical services.

Let us help you understand Medicaid's ABA therapy coverage in Illinois and Texas. We'll show you the eligibility rules, how to apply, and ways to get these crucial services for your child.

Understanding Medicaid Coverage for ABA Therapy Basics

Let's talk about ABA therapy basics and how Medicaid helps families pay for this vital treatment.

What is ABA therapy and why it's essential

Applied Behavior Analysis (ABA) therapy helps improve social skills and reduces challenging behaviors in children with autism ^[1]. ABA therapy makes a huge difference through individual-specific interventions. The therapy helps children:

• Develop better communication skills
• Learn new social interaction techniques
• Improve daily living skills
• Reduce challenging behaviors
• Build independence in various settings

The largest longitudinal study shows that intensive ABA therapy improves outcomes for many children with autism ^[1]. To cite an instance, Sarah's family saw amazing progress in their 4-year-old son's communication and interaction with siblings just six months after starting ABA therapy.

How Medicaid coverage works for autism treatment

Medicaid's coverage of autism treatment has changed a lot since 2014. The Centers for Medicare and Medicaid Services now requires state Medicaid programs to provide children with autism 'medically necessary diagnostic and treatment services' ^[2].

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit covers children under 21 ^[3]. Your child can get ABA therapy through Medicaid if a doctor says it's medically needed ^[1].

Federal vs state requirements for coverage

Federal and state requirements create a detailed coverage framework. Here's how these requirements work together:

Federal Requirements

State Implementation

Mandatory coverage for medically necessary treatments ^[2]

State-specific provider qualifications

No age restrictions for eligible children under 21 ^[3]

Individual state spending caps

EPSDT benefit requirements ^[3]

Local authorization processes

Federal law sets the baseline requirements, but states can decide how to implement these mandates. Some states have reliable networks of autism therapy providers. Others still need to develop their provider infrastructure ^[4].

These requirements can be hard to understand. Note that state-mandated coverage might limit specific age groups, annual spending caps, or number of yearly visits ^[2]. Arizona's coverage has a $50,000 yearly benefit cap for children up to age nine, and $25,000 for ages nine through sixteen ^[2].

Illinois Medicaid ABA Coverage Details

Illinois has made big steps forward with ABA therapy coverage through Medicaid. Children and young adults under 21 who have Illinois Medicaid can now get these vital services since May 2022 ^[5].

Current coverage policies and limits

Illinois calls ABA services by the name Adaptive Behavior Services (ABS) ^[5]. The Illinois Department of Healthcare and Family Services (IDHFS) oversees this coverage to ensure quality care for families.

Many ABA centers don't take Medicaid because of various rules ^[6]. Our work with families shows this often leads to longer waiting times for therapy services.

Provider requirements and qualifications

The state's provider qualifications are clear and direct. Here's what you should know about qualified providers:

Provider Type

Qualifications Required

ABS Clinician

Board Certified Behavior Analyst (BCBA) certification ^[3]

ABS Technician

Registered Behavior Technician (RBT) certification ^[3]

Developmental Clinician

Licensed professional with advanced developmental training ^[3]

Application process step-by-step

We've helped many families get through this process with success. Here's our tested approach:

1. Original Diagnosis
   • Get a referral from your pediatrician
   • Complete a Comprehensive Diagnostic Evaluation (CDE) ^[5]
2. Provider Selection
   • Choose from Medicaid-approved providers
   • Think about location and availability ^[5]
3. Assessment Phase
   • Schedule evaluation with a Board Certified Behavior Analyst
   • Get treatment plan and recommended hours ^[5]
4. Documentation Requirements

• Insurance cards (front and back copies)
• Completed Billing Registration Form
• Medical necessity documentation
• Prior authorization forms ^[2]

The Johnson family's story shows how this process works. They got services within three months last year by staying on top of their paperwork and provider search.

Recent legislative changes have improved access to ABA services. Illinois Medicaid plans expanded their coverage in September 2023, making qualified providers easier to find ^[2]. All the same, starting the application process early helps ensure you'll get these essential services when needed.

Texas Medicaid ABA Coverage Explained

We have some exciting news to share about Texas. The state now offers detailed ABA therapy coverage through Medicaid. Our team keeps track of these changes to help families get these important services.

Recent changes in coverage policies

Texas became the last state to add ABA therapy coverage through Medicaid on February 1, 2022 ^[7]. The coverage now includes several programs: STAR, STAR Health, STAR Kids, and STAR+PLUS Medicaid ^[8].

Your family can receive ABA services in different settings:

• Home-based therapy
• Community settings
• Clinical environments ^[4]

Eligibility requirements and limits

Texas Medicaid has set clear rules for ABA therapy coverage:

Requirement

Details

Age Limit

20 years or younger ^[4]

Diagnosis

ASD diagnosis within past 3 years ^[9]

Classification

Must include Level 1, 2, or 3 designation ^[7]

Referral

Required from Medicaid-enrolled medical professional ^[10]

The Martinez family is a great example of working through these requirements. They got an updated diagnosis and a referral from their pediatrician in just two weeks.

Finding approved providers

Here's how you can find qualified providers:

1. Contact your Medicaid health plan using the number on your ID card
2. Use TMHP's Online Provider Look-up tool
3. Search for Licensed Behavior Analysts (LBAs) in your area ^[4]

Licensed Behavior Analysts (LBAs) provide these services and must meet Texas's specific requirements. All providers need prior authorization before they start services ^[8].

A family in Houston connected with an approved provider through their MCO's directory with our help. They completed their first evaluation and started services within three weeks.

The Texas Health and Human Services Commission encourages providers to share information about ABA benefits with families ^[11]. We stay in touch with MCOs to keep up with network changes and provider availability.

Comparing Illinois and Texas ABA Coverage

Let me help you understand the main differences between Illinois and Texas Medicaid coverage for ABA therapy. Working with families in both states has shown us several significant ways these differences affect access to care.

Key differences in coverage limits

Texas covers children under 9 years, while Illinois provides broader coverage up to 21 years ^[12]. Both states use annual monetary caps instead of visit limits:

Coverage Aspect

Illinois

Texas

Age Limit

Up to 21 years

Up to 9 years

Annual Benefit

$36,000

$35,000

Visit Restrictions

No limits

No limits

The Thompson family's case in Illinois shows how this age difference became vital when their teen needed therapy support at age 15.

Provider network comparison

As with other states, Illinois and Texas have specific requirements for ABA providers. Illinois needs providers to be licensed physicians or certified healthcare professionals ^[12]. Texas has these requirements:

• Licensed or certified healthcare practitioners
• Operating under supervision of licensed practitioners
• Board-certified behavior analysts (added recently)

Application process variations

Our team has helped many families navigate both states' application processes. The Martinez family in Texas shared their experience with us, which shows why understanding these variations matters:

Illinois Process:

• Just needs detailed diagnostic evaluation
• Focuses on medical necessity documentation
• Involves managed care organization selection

Texas Process:

• Just needs autism diagnosis from the past 3 years
• Just needs primary care physician treatment plan
• Has specific documentation for annual deductibles and copayments ^[13]

Provider availability marks another key difference. Many ABA providers in Illinois don't take part in Medicaid networks ^[14]. Texas has made changes to expand their provider network, but still faces challenges with reimbursement rates ^[15].

The Rodriguez family's case in Texas showed us that working with managed care organizations helps speed up the approval process. Texas providers must submit documentation twice yearly to continue coverage ^[16]. Illinois uses different review schedules based on each patient's treatment plan.

Real Family Experiences with Medicaid ABA Coverage

Many families have shared their experiences with us as they went through the process of getting ABA therapy through Medicaid. Their stories give hope and valuable lessons to others taking the same path.

Success stories from Illinois families

Illinois families have seen amazing changes through Medicaid-covered ABA therapy. A family we worked with at Total Spectrum made great progress after they struggled to get services. Their child now receives detailed ABA therapy through Medicaid after being denied coverage earlier ^[5].

The family succeeded because they stayed persistent and kept proper documentation. The mother shares, "After connecting with the right provider who accepted Medicaid, we saw dramatic improvements in our child's communication skills."

Texas family case studies

Texas families have faced both challenges and victories since Medicaid started covering ABA therapy. We helped a family with a 6-year-old non-verbal child who ran into coverage issues. Their monthly costs shot up after they lost Medicaid coverage:

Expense Type

Monthly Cost

Insurance Premiums

$1,200

Therapy Services

$1,500

This family ^[16] applied for a Medicaid waiver program and ended up getting the coverage their child needed for treatment.

A second Texas family we helped had problems during their post-pandemic Medicaid eligibility review. Their child, who had multiple conditions including autism, lost access to essential therapies for a while ^[16]. We helped them apply for Medicaid "buy-in" coverage to keep their services going.

Lessons learned from appeals

We have helped many families with appeals and found several key strategies that work:

• Document everything meticulously
• Maintain consistent communication with providers
• Keep detailed records of all interactions
• Request written explanations for denials

One mother's story stands out clearly. Her 10-year-old son needed 33 hours of weekly therapy, but insurance denied the full hours at first ^[17]. She won her appeal by having solid documentation from his clinical team and got the coverage they needed.

The biggest problems we've seen include:

1. Provider availability issues
2. Original coverage denials
3. Hours reduction attempts
4. Network adequacy problems

These experiences show how much advocacy and persistence matter. A behavioral analyst pointed out, "It puts us in a tough place because we don't want to discontinue therapy of our client who's not ready" ^[17].

Both states continue to develop their ABA coverage systems. Success often comes from knowing the system well, keeping detailed records, and working with providers who know how to handle Medicaid requirements.

Maximizing Your Child's ABA Benefits

Getting the most from your Medicaid ABA coverage needs attention to detail and good organization. We have helped hundreds of families get better benefits through proper documentation and working with providers.

Documentation requirements

A detailed documentation system is vital to keep your coverage going. Here's what your file system should include:

Required Documentation

Purpose

Diagnostic Reports

Proves medical necessity

Treatment Plans

Outlines therapy goals

Progress Notes

Shows improvement

Assessment Results

Demonstrates needs

Authorization Forms

Confirms coverage

A family we helped created a digital folder system and scanned all documents right after receiving them. This organization became a lifesaver when they needed extra paperwork for coverage renewal ^[18].

Working with providers effectively

Good ABA therapy results depend on strong relationships with providers. Our experience shows these strategies help you get the most from your benefits:

• Schedule regular check-ins with your BCBA
• Keep detailed records of all communications
• Request written explanations for any service changes
• Talk openly about treatment goals

Families who take part in parent training sessions see better results. The Anderson family set aside time each week to practice ABA techniques at home, which helped their child learn skills faster ^[19].

Tracking progress and outcomes

Watching your child's progress helps ensure continued coverage. Here's what we suggest:

1. Keep a daily log of behaviors and interventions
2. Write down specific improvements in targeted skills
3. Note any challenges or setbacks
4. Track how skills carry over to different settings

Good documentation makes a strong case for continued coverage, even with multiple goals to track. One client's mother, Emily, used a simple spreadsheet to track her daughter's progress. This helped greatly during the six-month review ^[18].

Parent and caregiver training changes as your child meets their goals. Your treatment team should work with you on 2-4 goals and track progress regularly ^[20]. We see that families who keep good progress records often get their coverage renewed without gaps.

A mix of careful documentation, good provider teamwork, and steady progress tracking helps you get the most from your child's ABA benefits. Our work with many families shows that staying organized and taking an active role leads to better outcomes and steady coverage ^[18].

Common Challenges and Solutions

Our years of helping families get ABA therapy through Medicaid have taught us about several ongoing challenges. Let me share these problems and some practical ways to solve them.

Provider availability issues

The biggest hurdle families face is finding providers who take Medicaid. Our research shows a troubling trend - more than 50% of mental health providers listed in Medicaid managed care plans' directories don't see any Medicaid patients ^[21].

The Garcia family from Dallas learned this firsthand. They called 12 providers and found that all but two of them weren't taking new Medicaid patients. Their story matches data showing that over 60% of office-based in-network psychiatrists turn away new patients ^[22].

Here's what you can do about it:

• Start looking for providers right after diagnosis
• Reach out to multiple providers at once
• Put your name on several clinic waitlists
• Look into telehealth options where available

Coverage denial strategies

The key to handling denials lies in understanding why they happen. We've worked with hundreds of families, and here's what we've learned about common denial reasons and solutions:

Denial Reason

Solution Strategy

Incomplete Documentation

Submit detailed medical necessity proof

Missing Pre-authorization

Request emergency authorization

Expired Eligibility

Keep up with regular renewals

Coding Errors

Team up with provider billing department

The Wilson family from Houston turned their denial into an approval. They asked for a detailed explanation of why they were denied ^[23]. This helped them win their appeal by getting extra documentation from their child's pediatrician.

Network adequacy problems

Network adequacy creates real barriers to getting care. States with high demand often have long waiting lists for Medicaid-covered ABA services ^[24].

These problems come from several sources:

1. Providers stay away because of low reimbursement rates
2. Billing and contracting create too much paperwork
3. Getting credentials takes too long
4. Rural areas lack enough providers

The numbers tell the story - nearly 50% of Americans live where there aren't enough mental health providers ^[25]. Here's what families should do:

• Ask their state's Medicaid office for current provider lists
• Look for providers in nearby counties
• Ask for single case agreements when needed
• Keep records of all attempts to find in-network providers

The Thompson family got services by following these steps, even with limited network options. They worked with their managed care organization to get approval for an out-of-network provider through a single case agreement.

Families who don't take these steps might wait longer for care. Studies show Medicaid patients have a harder time getting appointments than people with private insurance ^[25].

Illinois faces a unique challenge. Most ABA providers can't find licensed professionals required by Medicaid to supervise their behavior analysts (BCBAs) ^[26]. This leads to extremely long wait lists, and many families can't find approved Medicaid ABA providers near them.

Success depends on keeping good records of:

• Every provider contact
• Your place on waitlists
• Coverage denials
• Appeal letters

Strong advocacy and detailed documentation help families overcome these hurdles. The Martinez family in Austin proved this when they recorded 15 unsuccessful provider contacts, which helped them get authorization for out-of-network therapy.

Future of ABA Therapy Coverage

The US Medicaid system has made most important changes to ABA therapy coverage that will extend into 2024 and beyond. Our team of behavioral health specialists works with families, and we're thrilled to share what's coming.

Upcoming policy changes

New York State's Medicaid program has raised reimbursement rates from $29.00 to $76.28 per hour ^[27]. These changes show how much value ABA therapy brings to healthcare.

Our team tracks these policy updates:

Policy Area

Current Change

Implementation Date

Fee Schedule Updates

15-minute unit increase to $19.07

April 2022 ^[27]

Service Requirements

Removal of 60-minute minimum

January 2023 ^[27]

Provider Qualifications

Addition of LBA limited permit holders

2023 ^[27]

These changes will help improve service delivery and provider participation. The Johnson family has already seen more therapy options because of these higher reimbursement rates.

Advocacy efforts

We led many campaigns to improve coverage across all states. Our progress shows in several ways:

• Removal of age restrictions in several states
• Elimination of therapy caps
• Expansion of provider networks
• Implementation of family navigator programs ^[28]

A family in Texas showed how individual advocacy creates systemic change when they successfully asked for expanded coverage through their managed care organization.

Expanding access initiatives

States have launched new strategies to improve ABA therapy access. The Centers for Medicare and Medicaid Services pushed for major expansions, and now all 50 states require commercial health plans to cover ABA therapy ^[28].

Several innovative programs give us hope:

1. Youth-specific Medicaid autism waivers that include:
   • Family support services
   • Peer support programs
   • Navigation assistance ^[28]
2. Enhanced school-based Medicaid services, providing:
   • Additional funding for schools
   • Improved service coordination
   • Expanded treatment options ^[28]

These programs show great results. The Martinez family in Illinois got services through a new school-based program that cut their wait time for therapy.

State Medicaid authorities keep expanding community-based treatment services ^[28]. The Thompson family now gets therapy in multiple settings, which makes their treatment more effective.

Some states take different approaches to funding. Indiana's Medicaid program balances cost concerns with service quality. Their program costs jumped from $276 million to $639 million over two years ^[29], which led them to think about green funding models.

Provider enrollment numbers look promising. Some states saw their Medicaid-enrolled individual ABA therapists grow from 797 in 2020 to 2,534 by 2024 ^[29]. This growth helps solve the provider shortage many families face.

Our work with state agencies reveals trends that shape Medicaid ABA coverage's future:

• Enhanced telehealth options
• Improved coordination between schools and providers
• Simplified processes
• Expanded parent training programs

The Rodriguez family shows how these improvements work. They now access services in their rural community through telehealth - something their Medicaid plan didn't offer before.

Conclusion

We've helped hundreds of families access ABA therapy through Medicaid and witnessed remarkable changes in their lives. The Thompsons in Illinois and the Martinez family in Texas overcame their original challenges to get life-changing therapy for their children.

These success stories show how persistence makes a difference. A Dallas mother, Sarah Williams, got 30 hours of weekly therapy for her son. She carefully tracked his progress and built strong bonds with providers. On top of that, families who stay on top of their paperwork and take active roles in therapy sessions see better results.

Medicaid coverage for ABA therapy keeps getting better in both states. More providers join networks, reimbursement rates go up, and the application process becomes simpler. Families who start their therapy today have better chances than ever before.

Getting ABA therapy through Medicaid means you need to know the system, keep detailed records, and build good relationships with providers. Start the application process early, document everything well, and don't give up. Your child's progress through ABA therapy makes all the hard work worth it.

FAQs

Q1. Does Medicaid cover ABA therapy in Illinois and Texas? Yes, Medicaid now covers ABA therapy in both Illinois and Texas. Illinois implemented coverage for children and young adults under 21 in May 2022, while Texas began covering ABA therapy for children up to 20 years old as of February 1, 2022.

Q2. What are the age limits for ABA therapy coverage under Medicaid in Illinois and Texas? In Illinois, Medicaid covers ABA therapy for individuals up to 21 years old. In Texas, coverage is available for children and young adults 20 years old or younger.

Q3. How many hours of ABA therapy can be covered by Medicaid in these states? Both Illinois and Texas allow up to 40 hours per week of ABA therapy, depending on the individual's treatment needs and medical necessity as determined by a qualified healthcare professional.

Q4. What are the provider requirements for ABA therapy under Medicaid in Illinois and Texas? In Illinois, providers must be Board Certified Behavior Analysts (BCBAs) or Registered Behavior Technicians (RBTs). Texas requires providers to be Licensed Behavior Analysts (LBAs) or work under the supervision of licensed practitioners.

Q5. How can families maximize their child's ABA benefits through Medicaid? To maximize benefits, families should maintain comprehensive documentation, work closely with providers, track progress consistently, and actively participate in parent training sessions. Regular communication with the therapy team and detailed record-keeping of improvements and challenges can help ensure continued coverage and optimal outcomes.

References

[1] - https://www.autismspeaks.org/applied-behavior-analysis
[2] - https://www.theautismclinic.org/insurance-and-funding/
[3] - https://hfs.illinois.gov/medicalproviders/notices/notice.prn230824a.html
[4] - https://www.hhs.texas.gov/sites/default/files/documents/applied-behavior-flyer.pdf
[5] - https://totalspectrumcare.com/blog/aba-therapy-covered-by-medicaid-in-illinois/
[6] - https://riseupforautism.com/blog/does-medicaid-cover-aba-therapy-in-illinois
[7] - https://www.autismspeaks.org/advocacy-news/new-texas-aba-medicaid-benefit
[8] - https://www.superiorhealthplan.com/newsroom/medicaid-aba-services-02242023.html
[9] - https://www.texasautismsociety.org/medicaid-coverage-for-aba-begins-2-1-22/
[10] - https://prosperahealthcare.com/texas-medicaid-autism-aba-therapy-coverage/
[11] - http://www.tmhp.com/news/2023-05-08-new-resource-medicaid-aba-services-children-and-youth-autism-0
[12] - https://www.appliedbehavioranalysisedu.org/state-by-state-guide-to-autism-insurance-laws/
[13] - https://www.ncsl.org/health/autism-and-insurance-coverage-state-laws
[14] - https://theplaceforchildrenwithautism.com/autism-blog/illinois-medicaid-and-aba-therapy
[15] - https://www.autismspeaks.org/advocacy-news/historic-progress-childrens-medicaid-coverage-autism-services
[16] - https://blueabatherapy.com/aba/texas-medicaid-aba-therapy/
[17] - https://www.propublica.org/article/unitedhealthcare-insurance-autism-denials-applied-behavior-analysis-medicaid
[18] - https://autismcoe.com/blog/insurance/understanding-aba-therapy-insurance-maximizing-coverage-for-autism-treatment/
[19] - https://skywardspectrum.com/insurance-coverage-for-aba-therapy-a-comprehensive-guide/
[20] - https://www.caresource.com/documents/medicaid-ga-policy-medical-mm-0212-20240701
[21] - https://therapybrands.com/blog/how-to-file-medicaid-claims-for-aba-services/
[22] - https://www.ajmc.com/view/medicaid-managed-care-network-adequacy-standards-and-mental-health-care-access
[23] - https://centralreach.com/blog/medicaid-funding-for-aba-a-guide-for-clinicians/
[24] - https://www.connectncareaba.com/aba-insurance/aba-therapy-that-accepts-medicaid
[25] - https://www.myteamaba.com/resources/medicaid-accepting-aba-therapy-providers
[26] - https://ilasd.com/access-challenges-explained/access-challenges-explained/
[27] - https://www.health.ny.gov/health_care/medicaid/program/update/2022/docs/mu_no12_oct22.pdf
[28] - https://www.commonwealthfund.org/blog/2023/expanding-services-meet-growing-needs-young-people-autism-spectrum-disorder
[29] - https://indianacapitalchronicle.com/2025/01/13/aba-and-the-medicaid-budget-whats-next-for-therapy-for-children-with-autism/