---
title: FirstCare Health Plans ABA coverage (Texas Medicaid MCO).
url: "https://carelu.com/payers/firstcare-health-plans"
markdown_url: "https://carelu.com/payers/firstcare-health-plans.md"
state: TX (Texas)
payer: FirstCare Health Plans
kind: Medicaid managed care plan (MCO)
parent_program: Texas Medicaid (THSteps-CCP)
description: "How FirstCare Health Plans administers Texas Medicaid ABA in Lubbock and MRSA West — its Medicaid PA code list, submission mechanics via the myFirstCare portal, and the confirmed August 2026 plan wind-down."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# FirstCare Health Plans ABA coverage (Texas Medicaid MCO).

_Payer Guide · FirstCare Health Plans · Last updated September 2026 · 7 primary sources_

> Lubbock + MRSA West STAR/CHIP; PA confirmed on 97151-99366; plans wind down 8/31/2026 (pending approval).

FirstCare Health Plans — SHA LLC dba FirstCare, owned by Baylor Scott & White Health Plan, serving STAR in the Lubbock service area and the large Medicaid Rural Service Area (MRSA) West, plus CHIP in Lubbock only — administers ABA on the statewide TMPPM baseline with no dedicated Autism Services provider-manual section of its own; the plan's Behavioral Health section covers mental health and substance-use benefits in detail but never mentions autism or ABA. **The fact that matters most before building any workflow around FirstCare: the plan's own site states "Our plans end on Aug. 31, 2026, subject to regulatory approval"** — confirm current enrollment and transition guidance with FirstCare and HHSC before treating this as a stable long-term payer relationship.

This plan administers the **Texas Medicaid (THSteps-CCP)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Texas Medicaid (THSteps-CCP) guide](https://carelu.com/payers/texas-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — per FirstCare's own PA code list; submit via the Texas Standard PA form, myFirstCare portal, or fax [1]
- **Prior auth for treatment**: Required — 97151, 97153, 97154, 97155, 97156, 97158, 99366 all confirmed on FirstCare's Medicaid PA list [1]
- **Autism diagnosis required?**: Yes — ASD per the statewide TMPPM criteria; FirstCare's Medicaid PA defers to the TMPPM, not its commercial autism policy [5]

## At a glance

- **Plan status:** Winding down — FirstCare's own site states plans end 8/31/2026, subject to regulatory approval
- **Plan type:** Texas Medicaid MCO (Baylor Scott & White Health Plan) — STAR (Lubbock + MRSA West), CHIP (Lubbock only)
- **Clinical rules:** TMPPM Autism Services criteria; FirstCare's Medicaid PA list defers to it, not its commercial Autism policy #206
- **Prior auth:** Confirmed required on 97151, 97153, 97154, 97155, 97156, 97158, 99366 (Medicaid PA code list, eff. 7/1/2026)
- **Submission:** myFirstCare provider portal, or the Texas Standard PA form by fax to the Health Services Dept.
- **Rates:** Not published — contract-specific

## What FirstCare's Medicaid PA list confirms — and doesn't

FirstCare's STAR & CHIP Notification/Prior Authorization Codes list (effective 7/1/2026) lists 97151, 97153, 97154, 97155, 97156, 97158, and 99366 as requiring authorization, filed under "Therapy services" rather than behavioral health. Notably absent from that Medicaid-specific list: 97152, 97157, 0362T, and 0373T — those four codes appear only in FirstCare's separate commercial-oriented Medical Coverage Policy #206 ("Autism Spectrum Disorder"), which explicitly defers Medicaid decisions to the TMPPM: "For Medicaid plans, please confirm coverage as outlined in the Texas Medicaid Provider Procedures Manual." That same commercial policy confirms the Texas mandate's $36,000/year ABA cap for members 10+ "do not apply to self-funded/ERISA plans, Medicaid, or Medicare" — consistent with the statewide Medicaid baseline having no dollar cap. Treat 97152/97157/0362T/0373T PA status for FirstCare Medicaid as unconfirmed rather than assuming either way. [1][2]

## Submission mechanics, and the wind-down to plan for

Requests submit through the myFirstCare Self-Service Portal (my.firstcare.com/Web) or by fax using the Texas Standard Prior Authorization Request Form — FirstCare uses the statewide form, not a proprietary one. General turnaround is 3 working days from receipt of complete clinical information, and the plan asks providers to submit at least 5 days before the anticipated service date. One routing ambiguity we could not resolve: FirstCare's own contact tables list a separate Medical PA line (1-800-884-4905, fax 1-800-248-1852) and a Behavioral Health PA line (1-855-395-9652, fax 1-844-436-8779) — since ABA codes are filed under "Therapy services" rather than "Behavioral health" on the code list, confirm which line actually processes ABA requests before your first submission. And plan around the closure date directly: FirstCare's STAR page states its plans end August 31, 2026 pending regulatory approval — verify current transition guidance for any active caseload well before that date. [3][4]

## Intake gates

The questions that decide whether a family can start with FirstCare Health Plans, and what they have to bring.

- **Age limit**: Follows the Texas Medicaid (TMPPM) rule: birth through 20 years of age on the date of service, with eligibility ending the day of the 21st birthday. CHIP members are excluded from the ABA benefit. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate. [5][1][2]
- **Diagnosis recency**: Follows the Texas Medicaid (TMPPM) rule: the ASD diagnosis must be made or reconfirmed within 3 years of initiation or recertification; past 3 years a comprehensive re-evaluation of ASD symptom severity levels per DSM criteria is required first. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate. [5][1][2]
- **Who may diagnose**: Follows the Texas Medicaid (TMPPM) rule: a developmental pediatrician, neurologist, psychiatrist, licensed psychologist, or an interdisciplinary diagnostic team (a physician, PA or NP in consultation with qualified child specialists with autism expertise). FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate. [5][1][2]
- **Diagnostic tools required**: Follows the Texas Medicaid (TMPPM) rule: a reliable, valid, standardized diagnostic assessment tool or combination of tools — the manual names the ADOS, ADI-R and CARS as examples. Screening instruments alone (STAT, M-CHAT-R) do not substitute. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate. [5][1][2]
- **Referral required?**: Follows the Texas Medicaid (TMPPM) rule: a signed, dated prescriber referral for the evaluation, signed within 60 calendar days before or on the anticipated evaluation date; and for treatment a signed, dated referral from a physician or allowed practitioner (MD/DO, PA, NP, or CNS with delegated authority) stating frequency and duration, signed on or before the service start date and no more than 3 months old. Since 4/1/2025 the prescriber signature is no longer required on the CCP PA form for the 90-day extension. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate. [5][1][2][7]
- **Telehealth**: Follows the Texas Medicaid (TMPPM) rule: synchronous audio-visual only, modifier 95, on 97151, 97155, 97156, 97158 and 99366. One-on-one direct treatment delivered to the child by a behavior technician or LaBA must be in person — telehealth is prohibited for BT/LaBA-delivered direct service. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate. [5][1][2]
- **Prior-auth decision time**: FirstCare processes authorizations "in the order received and within 3 working days of receipt of the necessary clinical information," and sends an adverse determination "Within 3 working days in writing to the provider of record and the member if the member is not hospitalized." It asks for lead time without mandating it: "we encourage providers to submit requests a minimum of five days prior to the anticipated service date" (elective admissions and procedures: at least 2 working days). The manual has no ABA-specific timing or reauthorization lead time; an incomplete request follows the state process in 1 TAC § 353.425. [3][8][9]
- **Other insurance (who pays first)**: "Coverage under Medicaid and CHIP is secondary to all other insurance coverage, unless an exception applies under federal law. Coverage provided under Medicaid will pay benefits for Covered Services that remain unpaid after all other insurance coverage has been paid." File with FirstCare "within 95 days of the date on the primary payor's Explanation of Benefits (EOB) or Remittance Advice (RA)"; any overpayment made because FirstCare was not primary "must be refunded in full." The manual does not say whether FirstCare's ABA PA is still needed when it pays second — request it. [3][10]

## Delivery and billing rules

Coverage decides whether FirstCare Health Plans 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**: Follows the Texas Medicaid (TMPPM) rule: the manual sets no numeric ratio of its own, requiring LBAs to directly supervise LaBAs and behavior technicians in accordance with Texas licensure and deferring to the certifying body's minimums — for RBT-credentialed staff the BACB floor of supervision on at least 5% of service hours each month with two face-to-face contacts. Only direct supervision, where the LBA observes the LaBA or BT with the child, is reimbursable (under 97155); indirect supervision is unpaid. [5][1][2][6]
- **Concurrent billing (97153 + 97155)**: Follows the Texas Medicaid (TMPPM) rule: concurrent billing is prohibited — Texas Medicaid will not reimburse multiple ABA providers during one session with the child when more than one provider is present. The single exception is when the family and the child receive separate services and the child is not present in the family session. Total authorized hours may be requested under either 97153 or 97155 and billed as the code matching the service actually delivered — not both for the same clock time with the child present. [5][1][2]
- **Daily limits / MUEs**: Follows the Texas Medicaid (TMPPM) rule: direct treatment is capped at 8 hours (32 units) per day combined across 97153, 97154, 97155 and 97158; 97151 is capped at 6 hours (24 units) per evaluation and per re-evaluation; group treatment runs 2 to 8 children. Authorization periods are two consecutive 90-day terms then recertifications of up to 180 days. [5][1][2]
- **Session-note signature**: Follows the Texas Medicaid (TMPPM) rule: rendering ABA providers must sign each entry with full signature and credentials, with additional supervisory signatures per state licensure. Treatment notes carry the child's name, date of service, start and stop times, goals addressed, progress and a summary of interventions; 97155/97158 notes add protocol-modification decision points. The 97151 evaluation and the 90-day progress summary each need a dated signature from the LBA and from the parent or caregiver. [5][1][2]
- **Place of service**: Follows the Texas Medicaid (TMPPM) rule: home, clinic, office and community settings are payable. In schools, services delivered by a behavior technician as a shadow, an aide, or as general support are excluded; school personnel participating to coordinate care are not counted as duplicate providers, and interdisciplinary team meetings bill under 99366 against an ABA PA. BT and LaBA direct treatment must be in person in every setting. [5][1][2]
- **Bill as provider**: Follows the Texas Medicaid (TMPPM) rule: only the LBA enrolls in Texas Medicaid and bills. LaBAs and behavior technicians may not enroll — their services go out under the supervising LBA's NPI with the credential modifier identifying who rendered (HO = LBA, HN = LaBA, HM = behavior technician; 97151 takes HO only, 97155/97156/97158 take HO or HN). The LBA must directly employ or contract with every LaBA and BT on the team. [5][1][2]

## What intake should collect for FirstCare Health Plans

- **Plan continuity check:** FirstCare's own site states plans end 8/31/2026 (pending approval) — confirm current status and any HHSC-directed member transition plan before onboarding new cases.
- **STAR vs. CHIP:** STAR covers Lubbock + MRSA West; CHIP is Lubbock service area only.
- **ASD dx + recency:** State baseline: qualified diagnoser, DSM severity, within 3 years.
- **PA routing confirmation:** Confirm whether Medical PA or Behavioral Health PA processes ABA requests — FirstCare's own documents don't make this unambiguous.

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

## Verification of benefits (VOB) data

How FirstCare Health Plans ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 01105 (generic "FirstCare" — no Medicaid/STAR/CHIP-specific split found) — pVerify's payer-list page shows a single generic 01105 "FirstCare" entry (Eligibility: Yes) with no Medicaid-specific split — confirmed via repeated matching queries, not an independent raw-HTML grep. IMPORTANT: TMHP and Texas HHS both confirmed (7/17/2026 and 7/21/2026 respectively) that Baylor Scott & White/FirstCare is exiting Texas Medicaid managed care effective 9/1/2026 — TMHP will not accept claims with dates of service after 8/31/2026. Treat this MCO's Medicaid line as expiring, not a stable long-term payer, regardless of any payer ID confirmed here.
- **Payer ID (Availity):** 94998 (FirstCare Medicaid; distinct from 94999, FirstCare general/commercial) — Availity's master payer list independently confirms two distinct codes: 94998 "FIRSTCARE - MEDICAID" and 94999 "FIRSTCARE" (general/commercial) — use 94998 for Medicaid members. FirstCare's own public provider pages do not independently state either code.
- **Supports 270/271 eligibility:** Yes — Confirmed via Availity's master payer list; also rides the centralized TMHP 270/271 feed as every other MCO in this file — through 8/31/2026, per the confirmed Medicaid exit above.
- **Behavioral health administrator:** none — FirstCare's Medicaid PA code list files ABA under "Therapy services," not "Behavioral health," and no external BH vendor is named for ABA specifically — but FirstCare's own contact tables list separate Medical PA (1-800-884-4905) and Behavioral Health PA (1-855-395-9652) lines, and which one actually processes ABA requests is not resolved in FirstCare's own documents. Shipped 'none' (no third-party vendor) as inferred rather than verified, given that internal-routing ambiguity.
- **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:** no
- **Cost-share type:** plan-dependent
- **271 response quality for ABA:** high

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes — ABA Initial Evaluation / Re-evaluation, by the LBA | Required — CCP PA form + signed prescriber referral; not reimbursable unless the evaluation was submitted for authorization of payment; must be billed within 30 calendar days of the first date of service | 24 units (6 hours) per evaluation or re-evaluation event per per evaluation event; re-evaluations authorized no more than once every 180 days | office, home, clinic, community | Yes — 95 modifier, synchronous audio-visual only, delivered by the LBA (LaBAs and BTs/RBTs may not deliver any service remotely) | HO (required — LBA only) |
| 97152 | Not confirmed (see code notes) | — | — | — | — | — |
| 97153 | Yes — direct 1:1 ABA treatment (BT-complexity level), delivered per treatment-plan protocol | Required — covered under the treatment authorization (90-day initial + 90-day extension, then 180-day recertifications; no prescriber signature on the 90-day extension since 4/1/2025) | Shares the 8-hour (32-unit) combined daily direct-treatment cap, shared with 97153, 97154, 97155, and 97158 (TMPPM §2.3.12). per day | office, home, clinic, community | No — 1:1 direct treatment must be delivered in person | No modifier required (HO/HN/HM may be reported for information only) |
| 97154 | Yes — direct group ABA treatment (BT-complexity level; group is 2–8 children/youth) | Required — covered under the treatment authorization (90-day initial + 90-day extension, then 180-day recertifications) | Shares the 8-hour (32-unit) combined daily direct-treatment cap, shared with 97153, 97154, 97155, and 97158 (TMPPM §2.3.12). per day | office, home, clinic, community | No — group direct treatment must be delivered in person | No modifier required (HO/HN/HM may be reported for information only) |
| 97155 | Yes — protocol modification / direct 1:1 time by the LBA (or delegated LaBA) | Required — covered under the treatment authorization (90-day initial + 90-day extension, then 180-day recertifications) | Shares the 8-hour (32-unit) combined daily direct-treatment cap, shared with 97153, 97154, 97155, and 97158 (TMPPM §2.3.12). per day | office, home, clinic, community | Yes — 95 modifier, synchronous audio-visual, delivered by the LBA only | HO or HN (one required) |
| 97156 | Yes — parent/caregiver education & training, by the LBA (or delegated LaBA) | Required — covered under the treatment authorization | — | office, home, clinic, community | Yes — 95 modifier, synchronous audio-visual, delivered by the LBA (LaBAs may not deliver this — or any — service via telehealth, even by delegation) | HO or HN (one required) |
| 97157 | Not confirmed (see code notes) | — | — | — | — | — |
| 97158 | Yes — group protocol modification, by the LBA (or delegated LaBA) | Required — covered under the treatment authorization | Shares the 8-hour (32-unit) combined daily direct-treatment cap, shared with 97153, 97154, 97155, and 97158 (TMPPM §2.3.12). per day | office, home, clinic, community | Yes — 95 modifier, synchronous audio-visual, delivered by the LBA only | HO or HN (one required) |
| 99366 | Yes — interdisciplinary team meeting, attended by qualified nonphysician health-care providers | Not separately authorized — reimbursable when a PA for ABA evaluation, re-evaluation, or treatment is already on file; reimbursement limited to primary diagnosis F84 | — | office, home, clinic, community, remote participation for team members (95 modifier) | Yes — 95 modifier for remote participation by team members | No modifier required (95 for remote participation) |
| 0362T | Not confirmed (see code notes) | — | — | — | — | — |
| 0373T | Not confirmed (see code notes) | — | — | — | — | — |

Code notes:

- **97151:** FirstCare's Medicaid/CHIP PA code list (eff. 7/1/2026) confirms 97151 requires authorization, filed under "Therapy services" rather than "Behavioral health." Submit via the myFirstCare Self-Service Portal (my.firstcare.com/Web) or fax using the Texas Standard PA form. CONFIRMED (not just plan-stated): TMHP (7/17/2026) and Texas HHS (7/21/2026) both announced Baylor Scott & White/FirstCare is exiting Texas Medicaid managed care effective 9/1/2026 — TMHP will not accept claims with dates of service after 8/31/2026. Treat this MCO's Medicaid line as expiring within weeks of this dataset's access date, not a stable long-term payer relationship.
- **97152:** 97152 does not appear anywhere in the TMPPM Children's Services Handbook §2.3 Autism Services or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — cross-checked against both independently. Texas's actual THSteps-CCP Autism Services billable code set appears to be limited to 97151, 97153, 97154, 97155, 97156, 97158, and 99366. Verify via: TMHP provider relations / Online Fee Lookup — confirm whether this code is billable under Texas Medicaid THSteps-CCP Autism Services at all, under a different program, or not covered.
- **97153:** Either 97153 or 97155 may be billed for direct individual treatment hours — bill the code matching who delivered the session.
- **97154:** Either 97154 or 97158 may be billed for direct group treatment hours.
- **97155:** Also the code used to bill the required progress summary submitted after the first 90 days of treatment. Only DIRECT supervision (LBA observing the LaBA/BT with the client) is reimbursable under this code — indirect supervision (caseload review, data discussion) is not billable.
- **97156:** Continued treatment authorization considers caregiver attendance at ≥85% of planned sessions.
- **97157:** 97157 does not appear anywhere in the TMPPM Children's Services Handbook §2.3 Autism Services or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — cross-checked against both independently. Texas's actual THSteps-CCP Autism Services billable code set appears to be limited to 97151, 97153, 97154, 97155, 97156, 97158, and 99366. Verify via: TMHP provider relations / Online Fee Lookup — confirm whether this code is billable under Texas Medicaid THSteps-CCP Autism Services at all, under a different program, or not covered.
- **99366:** School-district personnel may participate and count toward the 3-participant licensed-professional minimum but are not separately reimbursable.
- **0362T:** 0362T does not appear anywhere in the TMPPM Children's Services Handbook §2.3 Autism Services or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — cross-checked against both independently. Texas's actual THSteps-CCP Autism Services billable code set appears to be limited to 97151, 97153, 97154, 97155, 97156, 97158, and 99366. Verify via: TMHP provider relations / Online Fee Lookup — confirm whether this code is billable under Texas Medicaid THSteps-CCP Autism Services at all, under a different program, or not covered.
- **0373T:** 0373T does not appear anywhere in the TMPPM Children's Services Handbook §2.3 Autism Services or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — cross-checked against both independently. Texas's actual THSteps-CCP Autism Services billable code set appears to be limited to 97151, 97153, 97154, 97155, 97156, 97158, and 99366. Verify via: TMHP provider relations / Online Fee Lookup — confirm whether this code is billable under Texas Medicaid THSteps-CCP Autism Services at all, under a different program, or not covered.

### Contacts

- **Provider services phone:** 800.431.STAR (7798) — STAR Medicaid customer service
- **Hours:** Utilization Management: Mon-Fri 6:00am-6:00pm CT, weekends/holidays 9:00am-12:00pm CT; online submissions accepted 24/7
- **Portal:** [myFirstCare Self-Service Portal](https://my.firstcare.com/Web)

Questions to ask on a verification call:

- CONFIRMED: Baylor Scott & White/FirstCare is exiting Texas Medicaid managed care effective 9/1/2026 (TMHP 7/17/2026, Texas HHS 7/21/2026) — confirm this family's post-exit MCO reassignment status before building a long-term authorization plan around FirstCare.
- Confirm the correct Availity payer ID (94998 FirstCare Medicaid, distinct from 94999 general/commercial) is being used for this member's 270/271 eligibility check.
- Is the ABA copay or coinsurance charged per visit or per day, and does the plan's out-of-pocket maximum apply?
- Since FirstCare files ABA under "Therapy services" rather than "Behavioral health," confirm whether ABA PA routes through the Medical PA line or the Behavioral Health PA line (1-855-395-9652).
- Are CPT codes 97152, 97157, 0362T, and 0373T billable under FirstCare's Medicaid Autism Services benefit, or only under its separate commercial Medical Coverage Policy #206?

### VOB data sources

- https://www.firstcare.com/-/media/project/bsw/sites/firstcare/documents/STAR/PA-List.pdf (accessed 2026-07-23)
- https://wadcdnstorageprod.blob.core.windows.net/bswhp/Medical-Policies/206.pdf (accessed 2026-07-23)
- https://www.firstcare.com/-/media/project/bsw/sites/firstcare/documents/STAR-CHIP-Provider-Manual.pdf (accessed 2026-07-23)
- https://www.firstcare.com/en/Individuals-and-Families/STAR-CHIP/STAR-Medicaid (accessed 2026-07-23)
- https://pverify.com/payer-list/ (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23)
- https://www.optum.com/content/dam/o4-dam/resources/pdfs/guides/optuminsight-rt-eligibility-payer-list.pdf (accessed 2026-07-23)
- https://www.tmhp.com/news/2026-07-17-baylor-scott-white-and-firstcare-health-plans-will-end-participation-texas-medicaid (accessed 2026-07-23; source document older than 18 months)
- https://www.hhs.texas.gov/provider-news/2026/07/21/evv-impacts-baylor-scott-white-firstcare-mcos-end-participation-texas-medicaid-managed-care (accessed 2026-07-23; source document older than 18 months)
- https://www.tmhp.com/sites/default/files/file-library/edi/D00026_270_271_Medicaid_CHIP_Eligibility_Companion_Guide.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/2_04_Childrens_Services/2_04_Childrens_Services.htm (accessed 2026-07-23)
- https://public.tmhp.com/FeeSchedules/StaticFeeSchedule/FeeSchedules.aspx?fn=%5C%5Ctmhp.net%5CFeeSchedule%5CPROD%5CStatic%5CTexas_Medicaid_Fee_Schedule_PRCR615C.pdf (accessed 2026-07-23)
- https://www.firstcare.com/en/providers (accessed 2026-07-23)

## Common questions

### Does FirstCare Health Plans cover ABA?

Yes — the Texas Medicaid Autism Services benefit for STAR members in Lubbock and MRSA West, on TMPPM criteria. FirstCare's own Medicaid PA code list confirms PA is required on 97151, 97153-97156, 97158, and 99366.

### Is FirstCare still accepting new Texas Medicaid members?

FirstCare's own site states its plans end August 31, 2026, subject to regulatory approval — confirm current enrollment and transition status directly with FirstCare or HHSC before building a long-term care plan around this payer.

### Does the Texas mandate's $36,000 ABA cap apply to FirstCare Medicaid?

No — FirstCare's own commercial autism policy confirms the mandate's dollar cap applies to state-regulated commercial plans, not Medicaid, matching the no-cap statewide Medicaid baseline.

## Primary sources

1. [FirstCare — Texas Medicaid/CHIP Notification/Prior Authorization Codes (eff. 7/1/2026, PDF)](https://www.firstcare.com/-/media/project/bsw/sites/firstcare/documents/STAR/PA-List.pdf)
2. [FirstCare — Medical Coverage Policy #206: Autism Spectrum Disorder (PDF)](https://wadcdnstorageprod.blob.core.windows.net/bswhp/Medical-Policies/206.pdf)
3. [FirstCare — 2026 STAR and CHIP Provider Manual (PDF)](https://www.firstcare.com/-/media/project/bsw/sites/firstcare/documents/STAR-CHIP-Provider-Manual.pdf)
4. [FirstCare — STAR Medicaid (plan status)](https://www.firstcare.com/en/Individuals-and-Families/STAR-CHIP/STAR-Medicaid)
5. [TMPPM Children's Services Handbook, § 2.3 Autism Services](https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/2_04_Childrens_Services/2_04_Childrens_Services.htm)
6. [BACB RBT Handbook (updated 06/2026)](https://www.bacb.com/rbt-handbook)
7. [TMHP — Update to a PA Requirement for Autism Services (eff. 4/1/2025)](https://www.tmhp.com/news/2025-02-14-update-prior-authorization-requirement-autism-services-effective-april-1-2025)
8. [Tex. Gov't Code § 540.0303 — MCO PA determinations for nonhospitalized recipients (eff. 4/1/2025)](https://texas.public.law/statutes/tex._gov't_code_section_540.0303)
9. [1 Tex. Admin. Code § 353.425 — MCO processing of incomplete PA requests](https://www.law.cornell.edu/regulations/texas/1-Tex-Admin-Code-SS-353-425)
10. [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)

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.