Does Aetna Better Health of Texas Cover ABA Therapy?
Yes, through its STAR and STAR Kids Medicaid plans. Aetna Better Health of Texas covers ABA therapy for members 20 and younger with autism when it's medically necessary, but its CHIP plan doesn't include ABA. Alpaca Health accepts Aetna Better Health of Texas, checks your benefits for free, and handles the approval paperwork with your BCBA.
How Aetna Better Health of Texas covers ABA therapy
ABA is a Medicaid benefit with this plan, for members 20 and younger who have autism and meet Texas Medicaid's rules.
- Plans that include ABA: The plan's ABA notice names STAR, for kids and some families, and STAR Kids, for children and young adults with disabilities.
- Where each plan runs: STAR serves the Bexar and Tarrant service areas, around San Antonio and Fort Worth, and STAR Kids serves the Tarrant and Dallas service areas.
- Same rules as Texas Medicaid: Members have to meet the Texas Medicaid criteria for ABA and get care from the plan's network of Medicaid ABA providers.
- Part of Texas Health Steps: ABA falls under Texas Health Steps, the state's name for EPSDT (the federal rule that Medicaid covers the care children need through age 20).
- CHIP doesn't include ABA: The notice leaves out CHIP members, and the plan's CHIP code list marks every ABA code as not covered.
- Not the same as private Aetna: This plan follows Medicaid rules, while Aetna employer plans have their own ABA policy and costs.
What your child needs to qualify
1. STAR or STAR Kids coverage at 20 or younger
Your child needs active coverage in one of these two plans. The ABA benefit ends on the 21st birthday.
2. An autism diagnosis
A specialist, such as a developmental pediatrician or licensed psychologist, makes the diagnosis with a standard test like the ADOS-2 (a play-based autism test). The diagnosis must be from the past 3 years.
3. A referral from your child's doctor
Texas Medicaid's ABA rules call for a signed referral. Your child's regular doctor can sign it, once for the first evaluation and again before therapy starts.
4. An evaluation that shows medical necessity
A licensed behavior analyst (LBA) tests your child's skills and writes a treatment plan. A diagnosis alone isn't enough, so the evaluation has to show medical necessity, which means your child needs ABA to treat their condition.
5. An LBA in the plan's network
Members get ABA through the plan's network of Medicaid providers. Only LBAs enrolled in Texas Medicaid can bill for ABA, so a BCBA also needs a Texas license.
How prior authorization works with Aetna Better Health of Texas
This step means the plan has to approve ABA before it pays. Your child's LBA sends each request. The plan's STAR code list and STAR Kids code list show that the evaluation and every therapy code need approval.
- What the LBA sends: The evaluation, the treatment plan, and the signed referral go to Aetna Better Health.
- How fast the plan decides: Its approval rules give it 3 business days to decide a Medicaid request, and missing records can add time.
- First approval: Under the state's ABA rules, treatment is first approved for 90 days, and attendance logs and a progress summary can support 90 more.
- Renewals every 180 days: After that, each reauthorization (a renewed approval) can cover up to 180 days and needs a new evaluation.
- Attendance counts: You and your child are expected to attend at least 85% of planned sessions to keep the same hours.
- Step 1DiagnosisA specialist confirms autism with a standard test, within the past 3 years.
- Step 2Referral and evaluationYour child's doctor signs a referral, and Aetna Better Health approves the LBA's evaluation (CPT 97151).
- Step 3Treatment planThe LBA sets measurable goals for your child and for parent training.
- Step 4Therapy approvalAetna Better Health approves the first 90 days of therapy.
- Step 5Progress reviewsAttendance logs and progress summaries go to Aetna Better Health before each renewal.
What Aetna Better Health of Texas covers for ABA therapy
Your child's LBA asks the plan for hours under each billing code (CPT code) below. Sessions can happen at home, in a clinic, or out in the community.
- Evaluations (97151): The LBA gets up to 6 hours to test your child's skills and write the treatment plan, and repeats the evaluation every 180 days.
- One-to-one therapy (97153, 97155): A behavior technician works with your child, and the LBA joins some sessions to supervise and adjust therapy.
- Group sessions (97154, 97158): Your child can join a group of 2 to 8 children when the treatment plan calls for it.
- Caregiver training (97156): The LBA leads parent training, with or without your child in the room.
- Team meetings (99366): You can meet with the LBA and at least 2 other licensed professionals up to 2 times a year.
Your child's LBA recommends the weekly ABA hours for the plan to approve. Texas Medicaid's guidelines list 2 to 4 hours a week to keep skills up and more than 20 for intensive programs. Direct therapy is capped at 8 hours a day.
What families pay with Aetna Better Health of Texas
Covered ABA costs your family nothing. The plan's STAR handbook says doctors and others can't charge you copays (fixed fees at a visit) or other amounts for covered services. The STAR Kids handbook says the same.
- No bills for covered care: Network providers can't bill you for covered services, even if they miss an approval step or a filing deadline.
- Check the network first: A provider who isn't enrolled in Texas Medicaid or signed up with the plan may not get paid, and you could get the bill.
- Other insurance pays first: If your child also has private insurance, providers bill it before the plan, since Medicaid pays last.
- Care Medicaid doesn't cover: A provider can bill you for services outside the benefit, such as ABA aimed at academic goals, only if you agree in writing first.
Where Alpaca Health accepts Aetna Better Health of Texas
This plan only serves certain Texas counties around San Antonio, Fort Worth, and Dallas. We'll tell you if a BCBA who takes this plan is available near you.
How Alpaca Health handles your Aetna Better Health of Texas benefits
You don't have to call the plan yourself. After you fill out our short intake form, our team checks your child's Medicaid coverage and Aetna Better Health plan. We follow up within one business day with what's covered and what comes next.
- Coverage check: We confirm your child's coverage is active and whether they're in STAR, STAR Kids, or CHIP.
- Approval paperwork: Your BCBA writes the evaluation and treatment plan Aetna Better Health reviews, and we handle the submission.
- A BCBA who takes your plan: We look for an independent BCBA near you who accepts Aetna Better Health of Texas.
Is Aetna Better Health of Texas the same as Aetna?
They're separate plans. Aetna Better Health of Texas offers Medicaid and CHIP, so state rules set what's covered, and private Aetna plans follow their own policy. If your child has STAR or STAR Kids, you'll have a Your Texas Benefits Medicaid card as well as the plan's ID card. Our insurance page lists the plans we accept, and we check yours during your free benefits review.
Does Aetna Better Health of Texas CHIP cover ABA therapy?
This plan's CHIP coverage doesn't include ABA, since the benefit is only for STAR and STAR Kids members. CHIP is for families who earn too much for Medicaid. It does cover physical, speech, and occupational therapy with prior approval and a doctor's prescription. We can check whether your child has CHIP or Medicaid during your free benefits review.
Which Texas counties does Aetna Better Health of Texas serve?
STAR and CHIP run in the Bexar area: Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina, and Wilson counties. STAR, STAR Kids, and CHIP run in the Tarrant area: Denton, Hood, Johnson, Parker, Tarrant, and Wise counties. Only STAR Kids runs in the Dallas area: Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, and Rockwall counties. If you live somewhere else, this plan isn't offered there, but you can still look for ABA that takes Medicaid.
What can I do if Aetna Better Health of Texas denies ABA therapy?
You can appeal within 60 days of the denial notice, and the plan usually answers within 30 days. To keep current ABA going during the appeal, file within 10 days, but you may have to pay for it if you lose. After that, you have 120 days to ask for an outside medical review or a state fair hearing. For a medical necessity denial, you or your child's doctor can send more records that show the need.
Does Aetna Better Health of Texas cover autism testing?
Yes, for STAR and STAR Kids members. Texas Health Steps checkups include autism screening at 18 and 24 months. The plan's code lists show that psychological testing needs no prior approval for up to 8 hours a year. If your child doesn't have a diagnosis yet, Alpaca Health offers an autism evaluation and checks your coverage first.
Check your Aetna Better Health of Texas coverage
Tell us about your child and their Aetna Better Health plan. We'll confirm your child's benefits, handle the approval paperwork, and look for a BCBA near you who takes your plan.