For an intake team in Texas, an Aetna card means three layers at once: the carrier's national clinical policy, Texas's autism insurance mandate (Tex. Ins. Code § 1355.015), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order.
Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is national — what changes in Texas is the legal floor underneath it: the state mandate below governs what state-regulated group plans must cover, while self-funded employer plans answer to ERISA and federal parity instead. Plan funding type is therefore the first fact to establish on every benefits check. The full national policy breakdown lives in our Aetna guide; this page covers what changes in Texas.[1][2]
Texas's mandate — Tex. Ins. Code § 1355.015, enacted by HB 1919 in 2007 and expanded several times since — applies to group health benefit plans (group policies, HMOs, group hospital service contracts, and TRS school-employee plans), and it has a structure intake teams must internalize: coverage runs from the date of diagnosis, but only if the ASD diagnosis was in place before the child's 10th birthday. Once eligible, coverage continues — the statute sets no upper age cutoff on continuing benefits. Covered services are broad ("all generally recognized services": evaluation, ABA, behavior training, speech/OT/PT, medications). The statute also requires autism screening at 18 and 24 months.[3][4][5]
The dollar terms split at the same birthday: under age 10 there is no dollar cap, and at age 10 and older the plan isn't required to cover ABA beyond $36,000 per year (§ 1355.015(c-1)). That cap should be framed carefully: ASD is generally treated as a mental health condition, and an annual dollar limit on MH benefits sits in tension with federal parity law for parity-covered large-group plans — the standard industry reading is that many fully-insured large-group plans don't enforce it, though we found no TDI or federal guidance document confirming that, so treat the parity argument as analysis, not settled rule. Exemptions: the state-employee (ERS) and UT/A&M system plans are carved out, self-funded ERISA plans are exempt by federal preemption, and small-group applicability has a genuine statutory ambiguity — § 1355.015 has no small-employer subsection, so confirm small-group cases with TDI rather than assuming either way.[3][4][5]
A family saying "we have Aetna" in Texas may actually be on the carrier's Medicaid plan — Aetna Better Health of Texas (STAR, STAR Kids, and CHIP in the Bexar and Tarrant service areas) — which follows the state Medicaid rules, not this commercial policy. Verify which line of business the card belongs to, and use the dedicated guide for the Medicaid plan. Note also that we found no Texas-specific Aetna commercial ABA policy or form in public sources (Aetna's document servers restrict automated retrieval, so treat that absence as high-confidence but worth a portal check): the national policy plus the state mandate is the working picture.
Texas has required licensure to practice ABA since 2018: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LaBA) credentials under the Behavior Analyst Licensing Act (Occupations Code Chapter 506), administered by the Texas Department of Licensing and Regulation (TDLR) with BACB certification as the backbone — family members implementing plans and technicians working under an LBA/LaBA's authority are statutorily exempt. On rates: Aetna does not publish commercial ABA fee schedules for Texas (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. The Texas Medicaid fee schedule (97153 at $14.50/unit as of 9/1/2025) is the public benchmark to negotiate against.[6]
The questions that decide whether a family can start with Aetna in Texas, and what they have to bring. Each maps onto something intake should ask on the first call.
CPB 0648 requires the evaluation to be performed by the appropriate certified or licensed health care professional and names board certified behavior analyst, developmental pediatrician, neurologist, occupational therapist, physical therapist, primary care provider, psychiatrist, psychologist, and speech-language pathologist/audiologist. It does not say whether one provider may diagnose alone or whether a multidisciplinary assessment is required.[2]
CPB 0648 names the instruments it considers medically necessary components of testing for the diagnosis of pervasive developmental disorders: the ADI-R, the ADOS-2, the CARS-2 and the Asperger Syndrome Diagnostic Scale. The policy does not state whether all four or only a subset are required.[2]
Aetna coordinates "as allowed by state or federal law following the National Associations of Insurance Commissioners (NAIC) guidelines," and names the birthday rule among the order-of-benefit rules it applies: for a child whose parents are married or living together, the plan of the parent whose birthday falls earlier in the calendar year is primary (same birthday: the plan that has covered the parent longer). For separated or divorced parents a court order decides; without one it runs custodial parent, custodial parent's spouse, noncustodial parent, noncustodial parent's spouse (28 TAC § 3.3507 for Texas-regulated plans). "If there is no applicable law, then we coordinate according to the member's plan" — and many self-funded plans pay secondary on a maintenance-of-benefits basis, which can leave nothing after a rich primary. Against government coverage Aetna pays first: Medicaid is payer of last resort (bill Aetna, send its EOB to Medicaid, and get the Medicaid PA too), TRICARE is by law secondary to other health insurance, and CHAMPVA pays after other health insurance.[12][13][14][15][16][17]
No age limit in Aetna's own policy. What binds in Texas is the mandate: Tex. Ins. Code § 1355.015 runs coverage from the date of diagnosis but only if the ASD diagnosis was in place before the child's 10th birthday, with no upper age cutoff once eligible — and no dollar cap under 10, with a $36,000/year ABA cap at 10 and over that federal parity arguably limits for large-group plans. Self-funded ERISA plans, ERS and the UT/A&M system plans sit outside the statute.[3][1]
Ask the plan: A live benefits verification — market segment and plan funding type decide whether the mandate applies at all.
Neither CPB 0554 nor CPB 0648 states a recency window on the ASD diagnosis, and the Texas mandate sets none — it gates on the diagnosis having been made before the 10th birthday, not on how old it is. Reauthorization cadence, commonly about 6 months, is where currency is actually tested.[1][2][3]
Ask the plan: Aetna precertification (form GR-69017-4) via Availity, and the plan document for any plan-specific evaluation-currency rule.
Aetna's policies do not impose a referral or physician-order requirement of their own; what they require is precertification on form GR-69017-4 for both assessment and treatment. The Texas mandate adds no order requirement either. Referral requirements, where they exist, come from the plan's own network rules (for example HMO products).[1][3]
Ask the plan: The member's plan document and a live benefits verification — HMO products may carry their own referral rules.
Depends on how the plan is funded. Fully insured Texas HMO/PPO: Aetna's Texas supplement commits to an approval notice within "3 calendar days from receipt of a complete request, or 2 working days of receipt of all necessary information to decide," adverse preauthorization notices within 3 working days, and no more than 1 hour for post-stabilization or life-threatening care — tracking Tex. Ins. Code §§ 843.348 and 1301.135 ("not later than the third calendar day after the date the request is received"). Texas also requires state-regulated plans to let a provider request renewal of an existing preauthorization "at least 60 days before the date the preauthorization expires" (28 TAC § 19.1718(l)) — file the ABA reauth early. Self-funded employer (ERISA) plans sit outside Texas law: the federal claims rule allows up to 15 days for a pre-service decision, extendable once by 15 days, and 72 hours for urgent care. Aetna's national provider manual publishes no ABA-specific clock of its own.[7][8][9][10][11][12]
Ask the plan: Benefits verification: ask whether the plan is fully insured (Texas timelines apply) or self-funded/ASO (ERISA timelines), then confirm the reauthorization submission window with Aetna precertification (Availity or the number on the card).
Coverage decides whether Aetna in Texas pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
No per-day unit ceiling is published. CPB 0554 sets none, and Texas's mandate caps dollars rather than units — no cap under age 10, $36,000/year for ABA at 10 and over on plans the statute reaches, with self-funded ERISA, ERS and UT/A&M plans outside it.[1][3]
Ask the plan: A live benefits verification — annual maximums and any plan-level visit or hour limits are plan-specific.
CPB 0554 describes ABA as evaluating observable behavior within relevant settings including the home, school and community, but sets no place-of-service restriction. CPB 0648 notes many Aetna plans exclude coverage of educational services and may exclude developmental or intelligence testing in educational settings — so the school boundary is a benefit-exclusion question, not a clinical one.[1][2]
Ask the plan: A live benefits verification — the educational-services exclusion is written into the plan document, not the clinical policy.
CPB 0554 does not set supervision ratios for behavior technicians. In Texas the binding floor is licensure: the LBA and LaBA credentials under Occupations Code Chapter 506 (TDLR), with technicians working under an LBA or LaBA's authority and direction and statutorily exempt from licensure themselves.[1][6]
Ask the plan: Aetna provider relations and the participating-provider agreement — CPB 0554 carries no supervision standard.
Not addressed in CPB 0554 or CPB 0648. Concurrent-billing edits for Aetna commercial claims live in its reimbursement and code-editing policies rather than the clinical bulletins.[1]
Blocked on: Aetna's commercial reimbursement/code-editing policies via Availity, or provider relations.
Not addressed in CPB 0554 or CPB 0648.[1][2]
Ask the plan: Aetna provider relations or the participating-provider agreement — the clinical bulletins carry no documentation or signature standard.
Not addressed in Aetna's clinical bulletins. In Texas the licensure structure is the constraint: only Licensed Behavior Analysts and Licensed Assistant Behavior Analysts may practise (Occupations Code Ch. 506, TDLR), with technicians exempt while working under an LBA or LaBA's authority and direction.[6][1]
Ask the plan: Aetna provider relations and the participating-provider agreement — rendering-versus-supervising NPI rules are contractual, not in CPB 0554.
Yes — under the carrier's national policy for ASD, layered on Texas's mandate (Tex. Ins. Code § 1355.015) for state-regulated group plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.
For covered group plans: treatment coverage from the date of diagnosis, provided the ASD diagnosis was made before the child's 10th birthday (coverage continues once eligible), with no dollar cap under 10 and a $36,000/year ABA cap at 10+ that federal parity arguably limits for large-group plans. Screening is covered at 18 and 24 months.
The Texas mandate doesn't apply, but that isn't the end: Aetna's national policy covers ABA for ASD on its own terms, and federal parity governs group plans. Run the benefits verification before turning any family away.
Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the Texas Medicaid fee schedule (97153 at $14.50 per 15-minute unit effective 9/1/2025), and treat rate-setting as part of contracting.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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