---
title: "Cigna / Evernorth ABA coverage in Texas: the intake guide."
url: "https://carelu.com/payers/cigna-texas"
markdown_url: "https://carelu.com/payers/cigna-texas.md"
state: TX (Texas)
payer: Cigna / Evernorth in Texas
kind: Commercial insurance
description: "How Cigna / Evernorth covers ABA for Texas families — the national EN0499 policy (which applies in Texas with no carve-out), prior authorization, the Tex. Ins. Code § 1355.015 mandate, Texas behavior-analyst licensure, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Cigna / Evernorth ABA coverage in Texas: the intake guide.

_Payer Guide · Cigna · Texas · Last updated September 2026 · 7 primary sources_

> EN0499 (no TX carve-out) + the Tex. Ins. Code § 1355.015 mandate layer; no TX Medicaid plan.

For an intake team in Texas, a Cigna 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.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: Cigna/Evernorth's precertification list via CignaforHCP. EN0499 (read in full 9/17/2026) sets medical-necessity criteria but states no prior-authorization requirement for any ABA code, so the PA answer cannot be sourced to it. [1]
- **Prior auth for treatment:** Not published / unverified. Verify via: Cigna/Evernorth's precertification list via CignaforHCP. EN0499 (read in full 9/17/2026) sets medical-necessity criteria but states no prior-authorization requirement for any ABA code, so the PA answer cannot be sourced to it. [1]
- **Autism diagnosis required?**: Yes — ASD only; Rett syndrome (F84.2) excluded under EN0499 [1]

## At a glance

- **Covers ABA?:** Yes — for ASD, per the national Cigna policy
- **State mandate:** Tex. Ins. Code § 1355.015 (HB 1919, 2007, as amended)
- **Mandate age:** From diagnosis — but the ASD dx must predate the 10th birthday; coverage continues once eligible
- **Mandate caps:** No cap under 10; $36,000/yr ABA cap at age 10+ (parity-limited)
- **Exempt from mandate:** ERS and UT/A&M system plans; self-funded ERISA; limited policies
- **Licensure:** TX Licensed Behavior Analyst — TDLR (Occupations Code Ch. 506)

## The national policy, applied in Texas

Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. And unlike some states, Texas has no carve-out: we verified the current EN0499 contains no Texas-specific exception, so the national policy applies to Texas business, with the state mandate below as the legal floor for state-regulated group plans. Plan funding type is still the first fact to establish on every benefits check. The full national policy breakdown lives in our Cigna / Evernorth guide; this page covers what changes in Texas. [1][2]

## The Texas mandate: the age-10 gate and the $36K cap

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]

## No Cigna Medicaid in Texas

Unlike Aetna and UnitedHealthcare, Cigna has no Texas Medicaid plan to cross-wire with: its Texas Medicaid (STAR+PLUS) contracts were sold to Molina Healthcare in 2021, and its 2025 sale to HCSC covered Medicare businesses only. A "Cigna Medicaid" mention in Texas today means Molina — route those families to the Molina guide. Every genuine Cigna card in Texas is commercial (or marketplace) business under this page's rules. [7]

## Licensure & rates in Texas

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: Cigna 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]

## Intake gates

The questions that decide whether a family can start with Cigna / Evernorth in Texas, and what they have to bring.

- **Age limit**: EN0499 sets no age limit — its gate is a confirmed ASD diagnosis, not an age. In Texas the legal floor is the mandate: Tex. Ins. Code § 1355.015 runs coverage from the date of diagnosis provided the ASD diagnosis predates the 10th birthday, with no upper age cutoff once eligible — and self-funded ERISA, ERS and UT/A&M system plans sit outside it. [1][3]
- **Diagnosis recency**: EN0499 sets no recency window on the ASD diagnosis itself, but it does require the date on which the diagnosis was most recently made to be supplied, and it requires the standardized ABA assessment instrument to have been administered within the 60 days before treatment starts. [1]
- **Who may diagnose**: A confirmed ASD diagnosis (ICD-10-CM F84.0-F84.9, excluding F84.2 Rett syndrome) made against DSM-5-TR criteria by a health care professional who is licensed to practise independently and whose licensure board considers diagnostics within their scope of practice. The name, credentials and type of licensure of the diagnosing clinician, and the date the diagnosis was most recently made, must both be provided. [1]
- **Diagnostic tools required**: A reliable, valid and standardized assessment instrument measuring the DSM-5-TR ASD domains — social communication and social interaction, and restricted, repetitive patterns of behavior. EN0499 does not name a fixed list but sets conditions: completed in its entirety and as designed, reliability and validity established for the population tested, administered by someone trained to administer and interpret it, the most current version (Vineland-3, not Vineland-II), and reported with the date of administration, the respondent, and the form type. [1]
- **Referral required?**: EN0499 imposes no referral or physician order. The gate is the confirmed independent-licensure diagnosis plus a full ABA assessment performed by a BCBA, LBA, or independently licensed mental health clinician with documented ABA training. Where the assessment was performed by someone other than the requesting provider, documented collaboration with that professional and confirmation that the results reflect current functioning are required. [1]
- **Telehealth**: EN0499 treats ABA as deliverable in person, by telehealth, or as a hybrid, with the modality chosen on individual characteristics, the treatment plan, caregiver participation, environment, evidence of efficacy and safety, and technological requirements. The line-of-sight and close-proximity requirement it places on direct treatment expressly does not apply to telehealth services. [1]
- **Other insurance (who pays first)**: Evernorth follows the NAIC order-of-benefit rules "subject to applicable law and the terms of the benefit plan": a dependent child of married parents living together follows the "birthday rule" — "The plan of the parent whose birthday falls earlier in the calendar year is primary" (only month and day count; same birthday, the longer-running plan wins). Divorced or separated parents follow the custodial rule: a court decree first, otherwise custodial parent, custodial parent's spouse, noncustodial parent, noncustodial parent's spouse. When Cigna is secondary, bill the primary first, then submit to Cigna with the primary's explanation of payment (electronic COB content replaces the paper copy); the 90-day filing limit runs from the primary payer's processing date. Cigna pays ahead of Medicaid (payer of last resort — and get the Medicaid PA even when it is secondary), TRICARE (secondary to other health insurance by law) and CHAMPVA (pays after other health insurance). [8][13][14][15][16][17]
- **Prior-auth decision time** _(plan-dependent)_: Cigna/Evernorth publishes no clock of its own — "We (or our designees) make coverage determinations in accordance with the time frames required under applicable law" — so it turns on funding. Fully insured Texas HMO/PPO: a determination "not later than the third calendar day after the date the request is received" (Tex. Ins. Code §§ 843.348, 1301.135), and the plan must accept a renewal request "at least 60 days before the date the preauthorization expires" (28 TAC § 19.1718(l)). Self-funded ERISA plans: up to 15 days for a pre-service decision, extendable once by 15 days; 72 hours for urgent care. What Cigna does publish on timing is encouragement, not a rule: its autism resource guide says "we encourage providers to request authorizations up to 30 days in advance of or two weeks after the start date of service. A delay in request may result in a retrospective review and could delay the determination for up to 30 days." EN0499 (eff. 5/15/2026) sets the actual retrospective trigger: "A retrospective authorization request for ABA is any request made when more than 90 days have passed since the start date of the requested authorization, or any time after the patient has discharged." [8][1][2][9][10][11][12]
  - Ask the plan: Benefits verification: fully insured (Texas timelines) or self-funded/ASO (ERISA timelines)? Then confirm the reauthorization window with the Cigna Autism Care Coordinator team (877-279-7603).

## Delivery and billing rules

Coverage decides whether Cigna / Evernorth in Texas pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Case supervision is performed by a BCBA, LBA, or a mental health professional licensed to practise independently with documented ABA training. Direct case supervision (the BCBA face-to-face with the individual and the RBT or BCaBA delivering treatment) plus indirect case supervision runs at the accepted standard of one to two hours per ten hours of direct treatment; where direct treatment is 10 hours a week or less, a minimum of one to two hours a week of direct case supervision is provided. The name and credentials of the supervisor must be documented. [1]
- **Concurrent billing (97153 + 97155)**: EN0499 does not bless a 97153-plus-97155 same-clock-time pairing explicitly — it defines concurrent billing as multiple providers billing for the same patient at the same time, regardless of funding source, and it flatly excludes ABA delivered to the same individual at the same time as any other treatment modality (ABA and speech therapy, or ABA and occupational therapy). ABA delivered by multiple provider organizations in the same authorization period is not medically necessary unless additional documented conditions are met. [1]
- **Daily limits / MUEs**: No per-day or per-week unit ceiling is published. EN0499 defines treatment intensity as the number of direct ABA treatment hours per week (excluding case supervision and caregiver training), individually determined from assessment data, and expressly says the recommended intensity must be set on medical necessity independent of the individual's outside schedule or previous utilization. The Texas 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. [1][3]
- **Session-note signature**: Each session record must carry the start date and time, the end date and time, the location of service delivery, the focus of service, a detailed description of the intervention conducted, the individuals present, the specific service delivered (direct service, supervision, stakeholder training), and the name, credential where applicable, and signature of the ABA provider who rendered the service. [1]
- **Place of service**: Goals must be defined across every setting where treatment will occur — home, clinic, school, community — and EN0499 names residential facilities, childcare facilities, homes, schools, transportation, community settings, clinics, vocational or educational classes, and recreational and social environments as sites where ABA may be delivered when medically necessary. The hard boundary is purpose: services primarily educational or vocational in nature, or related to academic or work performance, are not covered, and ABA may not replace or replicate activities that are the responsibility of the setting — classroom aide, 1:1 teacher, tutor, vocational coach, respite. [1]
- **Bill as provider** _(plan-dependent)_: EN0499 governs who may render and supervise — BCBA, LBA, or independently licensed mental health clinician with documented ABA training for QHP-level codes, technicians for technician-level codes — but publishes no rendering-versus-supervising NPI rule. Claim-level attribution is a reimbursement-policy and contract question. [1]
  - Ask the plan: Cigna/Evernorth provider services and the participating-provider agreement — EN0499 is a coverage policy and carries no claim-attribution rule.

## What intake should collect for Cigna / Evernorth in Texas

- **Plan funding type:** Fully insured (mandate applies) vs. self-funded ERISA (exempt) — it decides which rulebook governs. Ask for the employer and check the card.
- **Diagnosis date vs. age 10:** The mandate's eligibility gate: was the ASD diagnosis made before the 10th birthday? Capture the exact dx date.
- **Member ID + card photo:** Enough to run a live benefits verification — the only reliable answer on limits and cost-sharing.
- **Diagnosis report:** DSM-5 ASD diagnosis, diagnosing provider and credentials, evaluation date.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Cigna / Evernorth in Texas ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00004
- **Payer ID (Availity):** 62308
- **Payer ID (Change Healthcare / Optum):** 62308
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** Evernorth Behavioral Health
- **BH administrator payer ID:** 62308
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### How the 271 reports ABA benefits

- **ABA benefit bucket (service type code):** MH
- **Deductible applies to ABA:** yes — Base deductible for MH-flavored codes is returned per the companion guide's own worked example, but REMAINING deductible/benefit amounts are explicitly withheld for Mental Health, Pharmacy, and Vision plans (§7.2.2-7.2.3) — a real 271 for an ABA member may show the base figure but not how much has been used.
- **Cost-share type:** plan-dependent — Both copay (EB*C) and coinsurance (EB*A) segments are structurally supported per plan; which applies to a given member is plan-document-specific.
- **271 response quality for ABA:** high

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes — for ASD, per national policy EN0499 (no Texas carve-out — confirmed no TX-specific exception in the current edition) | — | — | — | — | — |
| 97152 | Yes — for ASD, per national policy EN0499 (no Texas carve-out — confirmed no TX-specific exception in the current edition) | — | — | — | — | — |
| 97153 | Yes — for ASD, per national policy EN0499 (no Texas carve-out — confirmed no TX-specific exception in the current edition) | — | — | — | — | — |
| 97154 | Yes — for ASD, per national policy EN0499 (no Texas carve-out — confirmed no TX-specific exception in the current edition) | — | — | — | — | — |
| 97155 | Yes — for ASD, per national policy EN0499 (no Texas carve-out — confirmed no TX-specific exception in the current edition) | — | — | — | — | — |
| 97156 | Yes — for ASD, per national policy EN0499 (no Texas carve-out — confirmed no TX-specific exception in the current edition) | — | — | — | — | — |
| 97157 | Yes — for ASD, per national policy EN0499 (no Texas carve-out — confirmed no TX-specific exception in the current edition) | — | — | — | — | — |
| 97158 | Yes — for ASD, per national policy EN0499 (no Texas carve-out — confirmed no TX-specific exception in the current edition) | — | — | — | — | — |
| 99366 | Not confirmed (see code notes) | — | — | — | — | — |
| 0362T | Yes — for ASD, per national policy EN0499 (no Texas carve-out — confirmed no TX-specific exception in the current edition) | — | — | — | — | — |
| 0373T | Yes — for ASD, per national policy EN0499 (no Texas carve-out — confirmed no TX-specific exception in the current edition) | — | — | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 99366, 0362T, 0373T:** Verify via: Cigna/Evernorth provider services — EN0499 is a medical-necessity policy only; no coding/reimbursement mechanics (unit caps, POS, telehealth modifiers) or per-code PA requirements are published in it.

### Contacts

- **Provider services phone:** 1-800-926-2273
- **Phone menu path:** Select prompt #5 for providers, then: #1 Claims, #2 Eligibility and benefits, #3 Authorization (IOP/PHP/Inpatient), #4 Online services, #5 Personal updates.
- **Portal:** [Cigna for Health Care Professionals (CignaforHCP)](https://cignaforhcp.cigna.com)

Questions to ask on a verification call:

- Does Evernorth/Cigna require prior authorization on ABA assessment codes (97151/97152/0362T) separately from treatment codes (97153–97158), since EN0499 doesn't state a per-code PA distinction?
- Is CPT 99366 (interdisciplinary team meeting) covered and billable under this member's ABA benefit?
- Is the ABA copay or coinsurance charged per visit or per day?
- Does the plan's out-of-pocket maximum apply to ABA services?
- What are the daily/session unit caps for 97151–97158, 0362T, and 0373T under this member's plan?
- What POS settings and modifiers (telehealth 95/GT, licensure tiers) does Cigna/Evernorth require for ABA billing?
- Does Cigna support real-time (vs. batch) 270/271 eligibility for payer ID 00004?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23)
- https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf (accessed 2026-07-23)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://www.cigna.com/static/www-cigna-com/docs/5010-270-271-companion-guide.pdf (accessed 2026-07-23)
- https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/en_mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf (accessed 2026-07-23)
- https://static.evernorth.com/assets/evernorth/provider/resourceLibrary/behavioralResources/doingBusinessWithUs/cbhProviderServiceCenter.html (accessed 2026-07-23)

## Common questions

### Does Cigna cover ABA therapy in Texas?

Yes — under national policy EN0499 (which has no Texas carve-out), 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.

### What does the Texas autism mandate require?

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.

### Is there a Cigna Medicaid plan in Texas?

No — Cigna sold its Texas Medicaid (STAR+PLUS) business to Molina in 2021. A Texas family mentioning "Cigna Medicaid" is on Molina today.

### What does Cigna pay for ABA in Texas?

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.

## Primary sources

1. [Evernorth EN0499 — Intensive Behavioral Interventions](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/en_mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf)
2. [Cigna autism resource guide](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf)
3. [Tex. Ins. Code § 1355.015 (full text + history)](https://texas.public.law/statutes/tex._ins._code_section_1355.015)
4. [Tex. Ins. Code § 1355.002 (applicability)](https://texas.public.law/statutes/tex._ins._code_section_1355.002)
5. [Tex. Ins. Code § 1355.003 (exceptions)](https://texas.public.law/statutes/tex._ins._code_section_1355.003)
6. [TDLR — Behavior Analysts program (Occupations Code Ch. 506)](https://www.tdlr.texas.gov/bhv/)
7. [Molina — Cigna Transition Provider Notice (TX Medicaid sale)](https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/tx/medicaid/comm/Cigna-Transition-Provider-Notice-Final.pdf)
8. [Evernorth Behavioral Health Administrative Guidelines (March 2026) (PDF)](https://static.evernorth.com/assets/evernorth/provider/pdf/resourceLibrary/behavioral/ebh-provider-admin-guide.pdf)
9. [Tex. Ins. Code § 843.348 — HMO preauthorization](https://texas.public.law/statutes/tex._ins._code_section_843.348)
10. [Tex. Ins. Code § 1301.135 — PPO preauthorization](https://texas.public.law/statutes/tex._ins._code_section_1301.135)
11. [28 Tex. Admin. Code § 19.1718 — Preauthorization for HMOs and PPOs (incl. renewal requests)](https://www.law.cornell.edu/regulations/texas/28-Tex-Admin-Code-SS-19-1718)
12. [29 CFR § 2560.503-1(f)(2) — ERISA group health plan claim decision deadlines](https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XXV/subchapter-F/part-2560/section-2560.503-1)
13. [28 Tex. Admin. Code § 3.3507 — COB order of benefits](https://www.law.cornell.edu/regulations/texas/28-Tex-Admin-Code-SS-3-3507)
14. [TMPPM Vol. 1, Section 8: Third Party Liability (TPL)](https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/1_08_Third_Party_Liability/1_08_Third_Party_Liability.htm)
15. [TMPPM Vol. 1, Section 5: Prior Authorization, § 5.1.4 (clients with private insurance)](https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/1_05_Prior_Authorization/1_05_Prior_Authorization.htm)
16. [32 CFR § 199.8 — TRICARE double coverage](https://www.ecfr.gov/current/title-32/subtitle-A/chapter-VII/part-199/section-199.8)
17. [VA — CHAMPVA Guidebook (updated Jan. 1, 2025) (PDF)](https://www.va.gov/files/2025-12/CHAMPVA-Guidebook.pdf)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.