How families actually pay for ABA therapy in Texas.

2026 plan-year edition · figures verified August 2026 · also available en español

1 · Start here: the decision order

The most expensive mistake a Texas family can make is starting with the marketplace. Before comparing a single plan, screen these three programmes in this order — each one, for the families who qualify, beats every marketplace option:

First: Children's Medicaid (STAR). Household income up to roughly 133% of the federal poverty level, ages 0–18. Covers ABA under the THSteps/EPSDT benefit with no dollar cap and no waiting list, and you can apply in any month — Medicaid has no open-enrolment window. If your household qualifies, this is the whole answer.

Second: CHIP. Income up to roughly 201% of the poverty level. Here is the trap almost nobody warns you about: a child who qualifies for CHIP cannot receive premium tax credits on a marketplace plan. You may enrol the child in your family marketplace plan anyway — but at full, unsubsidised price. The arithmetic almost always lands the same way: child on CHIP, parents on a subsidised marketplace plan. Texas charges a small annual CHIP enrolment fee.

Third — and most missed: Medicaid Buy-In for Children (MBIC). Texas covers children with disabilities up to age 19 with family income up to 300% of the federal poverty level — roughly $96,000 for a family of four in 2026 — for a monthly premium of at most about $230. It is full Medicaid: ABA with no annual cap, no age cliff, no network fight, and enrolment any month of the year. The gate is a disability determination to the Social Security standard — receiving SSI is not required, but a diagnosis alone does not automatically qualify. Most families earning a normal income have never heard MBIC exists. Ask us, or ask HHSC, about it by name.

Only then: the marketplace. If your child does not qualify for any of the above — or you want the parents covered too — the individual marketplace is the right tool, and the rest of this guide is about using it well.

2 · The out-of-pocket reality

At published 2026 rates, a comprehensive ABA programme — 30 to 40 hours a week of direct therapy plus supervision — bills roughly $112,000 to $190,000 a year. Read that number, then set it aside, because it is not what you pay.

Every marketplace plan carries a legal ceiling on what your family can pay in a year for in-network, covered care:

So for in-network, authorised ABA, a $150,000 therapy year costs your family at most the out-of-pocket maximum — and on a cost-sharing-reduction silver plan, dramatically less. Which means the real questions are never "what does ABA cost?" They are:

Is the clinic in the plan's network? Will the hours be authorised? Does a coverage cap apply? Those three questions are sections 4, 5 and 3 of this guide, and they are where plans genuinely differ.

One honest caveat on rates: what an insurer actually pays your clinic is set by private contract and is not public. The billed range above comes from the two published public schedules — Texas Medicaid's fee schedule at the low end and TRICARE's Houston-locality maximums at the high end. Anyone who quotes you one confident commercial number is guessing.

3 · What Texas law does and doesn't promise

You will hear — from clinics, from Facebook groups, sometimes from people selling insurance — that "Texas law requires health plans to cover ABA." Here is the precise truth, because the imprecise version costs families money:

Texas's autism mandate (Insurance Code §1355.015) applies to employer group plans. The statute's own applicability section limits it to group health benefit plans, and the Texas Department of Insurance's benefit chart says it plainly: autism spectrum disorder coverage — individual plans: no; small-group plans: yes. Self-funded employer plans (most large employers) are exempt from state mandates entirely under federal ERISA law.

On an individual marketplace plan, ABA coverage comes from two federal sources instead. First, the Essential Health Benefits rules: Texas's benchmark plan includes autism services under habilitative and behavioural-health benefits, and states that it imposes no age or dollar maximums on autism coverage. Second, the federal mental-health parity law, which requires that behavioural-health benefits be limited no more strictly than medical ones. This coverage is real — we place these policies every year — but it is a different legal foundation than the mandate, and it is enforced through plan documents and appeals, not through a statute you can quote at a call-centre agent.

Two age rules worth knowing from the group-plan mandate, because carriers sometimes import its language into individual policies: coverage under the mandate requires the autism diagnosis to have been in place before the 10th birthday, and from age 10 the mandate does not require ABA coverage above $36,000 per year. Whether an individual policy applies either rule is decided by that policy's own contract language — it has to be read, not assumed, and reading it is part of our free review.

4 · Network: the question that decides the year

Behavioural-health networks are the narrowest networks in the marketplace — narrower than primary care, narrower than any other specialty. Confirming your clinic's status is worth more than any premium comparison.

How to check properly. The federal Marketplace's own data answers "is this provider in this plan's network" — but carriers sometimes submit no provider data at all, and no data is not the same as no. A clinic that shows nothing may well be in network. The only reliable confirmation is the carrier's own directory plus a phone call to the clinic's billing office asking "are you in network for this exact plan name for 2026?" Plan names are precise; "we take Blue Cross" is not an answer.

Your rights when no clinic is in network. Texas law (Insurance Code §1301.005 and rule 28 TAC §3.3708) requires an insurer whose network cannot actually provide a covered service to pay an out-of-network provider at the in-network benefit level. In practice: if no in-network ABA provider is reasonably available near you, you can demand a network-gap referral, and the insurer must process it — for EPO plans, within five business days of your documentation. Ask for it by name: a network adequacy referral or single-case agreement.

The fine print that matters: in-network cost-sharing is fully protected only when you use the provider the insurer designates. If you insist on your own clinic, you get in-network benefit levels but remain exposed to balance billing — which is exactly why a negotiated single-case agreement, where the clinic agrees to accept the insurer's payment as payment in full, is the thing to ask the clinic and insurer to sign.

5 · The prior-authorisation file

Every carrier requires prior authorisation for ABA, and the family that walks in with the file complete gets authorised weeks faster. Have these ready:

• The diagnostic evaluation confirming an autism spectrum diagnosis, from a qualified provider (developmental paediatrician, psychiatrist, or licensed psychologist), with the report — not just a letter.
• Standardised assessment results (commonly VB-MAPP, ABLLS-R, or Vineland-3).
• The BCBA's written treatment plan: measurable goals, baseline data, requested hours per week broken out by CPT code, parent-training plan, and discharge criteria.
• The prescribing provider's order or referral for ABA, if the plan requires one.
• The clinic's NPI number and the supervising BCBA's licence details — your clinic's billing office has these.

The reauthorisation clock. Authorisations run out — typically every six months, sometimes quarterly. Progress data and an updated treatment plan are due each time, and clinics generally start the renewal six to eight weeks early. Put the renewal date on your own calendar too; a lapsed authorisation means unpaid weeks, and the family finds out last.

For reference, the CPT codes on an ABA bill — all billed in 15-minute units:

6 · The 2026 numbers that change decisions

The subsidy cliff is back. The expanded premium subsidies expired at the end of 2025. For 2026, above 400% of the federal poverty level — about $128,600 for a family of four — there is no premium tax credit at all, and premiums rose sharply this year. If your income sits near the line, the difference between 399% and 401% is thousands of dollars; income timing (retirement contributions, HSA contributions) genuinely matters, and is a conversation for a licensed advisor and your tax professional.

Repayment caps are gone. Starting with tax year 2026, if you underestimate your income and receive too much advance premium credit, you repay all of the excess at tax time — the old caps were eliminated. For a family with variable income, estimating conservatively is the safer direction.

Cost-sharing reductions are the quiet giant. Below 250% of the poverty level, silver plans come with reduced deductibles and out-of-pocket maximums — at or below 200% FPL, the family maximum falls to $7,000. For a family expecting a full year of ABA, a CSR silver plan is frequently worth more than any premium difference. And for high, predictable spend generally, gold plans — with lower deductibles and coinsurance — often beat cheaper bronze plans on the year's total.

7 · Questions to ask any carrier before you enrol

• "Is [clinic name] — NPI [number] — in network for [exact plan name] for 2026, at the location my child attends?"
• "Is ABA processed under behavioural-health outpatient benefits or under habilitative services, and does any visit limit apply to it?"
• "Does this plan apply any annual dollar maximum to ABA at any age? Where is that stated in the Evidence of Coverage?"
• "What does prior authorisation for ABA require, how long does it take, and how often is reauthorisation required?"
• "What are the deductible, the coinsurance for behavioural-health outpatient services, and the family out-of-pocket maximum?"
• "Are my child's prescriptions on the formulary, and at what tier?"
• "If no ABA provider in your network can take my child within a reasonable time and distance, what is your network-gap referral process?"

Get answers in writing where you can. A reference number for every call, the representative's name, and the date — it feels excessive until the week it wins an appeal.

8 · What to do next

If this guide did its job, you now know which programme order to check, what your real exposure number is, and what to verify before enrolling. The step this guide cannot do is the plan-by-plan answer for your exact clinic, doctors and prescriptions against the actual 2026 plans in your county. That review is free, it is done by a licensed advisor from our Houston office — the same practice 350+ Texas companies use — and it takes three minutes to request: start the coverage review, or call 281.493.6862. Se habla español.

Hipson Investments is an insurance agency in Houston, Texas, established 1996. This guide is educational. It is not a determination of eligibility for any programme, an offer of coverage, or legal, tax or medical advice. Figures are 2026 plan-year figures from public federal and Texas sources, verified August 2026; programme rules change, and the current rule controls. Securities and certain advisory services offered through Ameritas — see our privacy notice and site disclosures.