Does Cook Children's Health Plan Cover ABA Therapy?
Yes, through its Medicaid plans. Cook Children's Health Plan covers ABA therapy for children 20 and younger with autism in STAR and STAR Kids when it's medically necessary, but its CHIP plan doesn't include ABA. Alpaca Health accepts Cook Children's Health Plan, checks your benefits for free, and handles the approval paperwork with your BCBA.
How Cook Children's Health Plan covers ABA therapy
ABA comes through the plan's two Medicaid programs, for members 20 and younger.
- Programs that include ABA: The plan's STAR program serves children and pregnant women, and STAR Kids serves those 20 and younger with disabilities or complex health needs.
- Six counties: The plan serves Denton, Hood, Johnson, Parker, Tarrant, and Wise counties, which the state calls the Tarrant service area.
- Same rules as Texas Medicaid: The plan's ABA checklist follows the state's ABA rules, which every Texas Medicaid health plan has to follow.
- Part of Texas Health Steps: ABA falls under Texas Health Steps, the state's name for EPSDT (the federal rule that Medicaid pays for the care children need through age 20).
- CHIP doesn't include ABA: The state's Medicaid and CHIP guide says Texas Health Steps isn't a benefit for children in CHIP, and the plan's CHIP handbook doesn't list it.
- Not sure which program you have: We check your child's coverage during your free benefits review.
What your child needs to qualify
1. STAR or STAR Kids at age 20 or younger
Your child needs active coverage in one of these Medicaid programs. The ABA benefit ends on the 21st birthday.
2. An autism diagnosis
A licensed psychologist, developmental pediatrician, or other specialist makes the diagnosis with a standard test like the ADOS-2 (a play-based autism test). It must be from the past 3 years and state how severe the symptoms are.
3. A referral from your child's doctor
Most behavioral health care with this plan needs no referral, but ABA does. Your child's regular doctor can sign it for the first assessment, and a doctor or nurse practitioner signs again before therapy starts.
4. An assessment that shows medical necessity
A licensed behavior analyst (LBA) watches your child, interviews you, tests everyday skills, and writes a treatment plan. A diagnosis alone isn't enough, so the assessment must show medical necessity, which means ABA is needed to treat your child's condition.
5. A behavior analyst enrolled in Medicaid
Only LBAs enrolled in Texas Medicaid can bill for ABA, so a BCBA also needs a Texas license. Licensed assistants and certified technicians can run some sessions under the LBA.
How prior authorization works with Cook Children's Health Plan
This step means the plan has to approve ABA before it pays. The plan reviews these requests itself. Your child's LBA sends each one with the assessment, the treatment plan, and the signed referral.
- Every ABA service: The plan's approval list includes each ABA code, from the first assessment to weekly therapy.
- How fast the plan decides: The plan answers routine requests within 3 business days and urgent ones within 1 business day.
- First approval: Treatment is approved for 90 days, and one more 90 days can follow if attendance logs and a progress summary support it.
- Renewals every 180 days: After that, each reauthorization (a renewed approval) can cover up to 180 days and needs a new assessment.
- Attendance counts: You and your child are expected to attend at least 85% of planned sessions, or the LBA has to explain why the same hours are still needed.
- Step 1DiagnosisA specialist confirms autism with a standard test, within the past 3 years.
- Step 2Referral and assessmentYour child's doctor signs a referral, and Cook Children's Health Plan approves the LBA's assessment (CPT 97151).
- Step 3Treatment planThe LBA sets measurable goals for your child and for parent training.
- Step 4Therapy approvalCook Children's Health Plan approves the first 90 days of therapy.
- Step 5Progress reviewsAttendance logs and a progress summary go to the plan before each renewal.
What Cook Children's Health Plan covers for ABA therapy
The approval list names each ABA billing code (CPT code). Your child's LBA asks the plan for hours under each one.
- Assessments (97151): The LBA gets up to 6 hours to test your child's skills and write the plan, and repeats the assessment 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 the plan.
- 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. Texas Medicaid guidelines run from 2 to 4 hours a week to maintain skills to more than 20 for intensive programs, and a physician reviews requests above the guideline that fits your child.
What families pay with Cook Children's Health Plan
Covered ABA costs nothing in STAR or STAR Kids. The plan's member handbook says providers can't charge copays, the set fees many plans charge per visit, or any other amount for covered services.
- No bills for covered care: The plan's provider manual bars network providers from billing you for the rest of a covered service or for a missed appointment.
- Other insurance pays first: If your child also has private insurance, it's billed before the plan, and a provider can't charge you that insurance's copay.
- Stay in the network: Most care from providers outside the plan's network needs approval first, so check before ABA starts.
- When you could owe money: A provider can bill you for care the plan doesn't cover, such as ABA aimed at academic goals, only if you ask for it and sign a statement first.
Where Alpaca Health accepts Cook Children's Health Plan
Cook Children's Health Plan only covers families in Denton, Hood, Johnson, Parker, Tarrant, and Wise counties, so Alpaca Health accepts it there.
How Alpaca Health handles your Cook Children's Health Plan benefits
You don't have to call the plan yourself. After you fill out our short intake form, our team checks your child's coverage and program. 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 assessment and treatment plan that Cook Children's Health Plan reviews, and we handle the submission.
- A BCBA who takes your plan: We look for an independent BCBA near you who accepts Cook Children's Health Plan.
Is Cook Children's Health Plan Medicaid?
Yes for STAR and STAR Kids, which are Medicaid programs, but not for CHIP. CHIP is a separate low-cost program for children 18 and under who can't get Medicaid. ABA comes only through the Medicaid programs, so it matters which one your child has.
Does Cook Children's Health Plan CHIP cover ABA therapy?
No, ABA isn't a CHIP benefit. CHIP does cover speech, physical, and occupational therapy, plus developmental assessments. Children with disabilities may be able to get Medicaid through the Medicaid Buy-In for Children, which can carry a monthly premium. We can check whether your child has CHIP or Medicaid during your free benefits review.
What can I do if Cook Children's Health Plan denies ABA therapy?
You can appeal within 60 days of getting the denial letter, and the plan decides within 30 days. To keep current ABA going during the appeal, file within 10 days of the notice. Next, you have 120 days to ask for an outside medical review or a State Fair Hearing, and a provider can represent you. For a medical necessity denial, your child's provider can also ask to speak with the plan's medical director.
Does Cook Children's Health Plan cover autism testing?
Yes, for STAR and STAR Kids members. Texas Health Steps checkups include autism screening at 18 and 24 months, and Medicaid also pays for testing that leads to a diagnosis. A screening checklist can't replace that testing. If your child doesn't have a diagnosis yet, Alpaca Health offers an autism evaluation and checks your coverage first.
Can my child get ABA at home with Cook Children's Health Plan?
Yes, in-home ABA sessions can be covered, and the state's ABA flyer also lists clinics and community settings. A behavior technician working as a school shadow or aide isn't covered. The LBA can hold the assessment, parent training, and team meetings by live video, while technician sessions stay in person.
Check your Cook Children's Health Plan coverage
Tell us about your child and their plan. We'll confirm your Cook Children's Health Plan benefits, handle the approval paperwork, and look for a BCBA near you who takes your plan.