Navigating autism support shouldn’t feel like a second full-time job.

1Your current situation

• Your child is 7, in 2nd grade, and has an IEP.
• The child’s treating provider requested additional ABA hours, and the insurer denied that request.
• Your child isn’t on any Texas waiver interest lists yet.
• Speech services were reduced at the last ARD meeting.

2What we found

• Employer plans can be “self-funded” or “fully insured.” The Texas Department of Insurance doesn’t regulate self-funded employer plans, so the plan type affects which rules and help lines apply. It’s the first thing to confirm. [2]
• Texas waiver interest lists can involve many years of waiting. A child can be on the interest lists for several waivers at once. Being on a list doesn’t confirm eligibility or guarantee a spot: eligibility is reviewed when your child reaches the top. [3, 8]
• In certain Texas waiver programs, parents’ income is not counted toward the child’s eligibility. Each program has its own financial and functional rules, so check the rules for each waiver before assuming your family qualifies. [3, 9]
• In Texas, the IEP team meeting is called an ARD meeting. You can ask for a new one at any time; you don’t have to wait for the annual review. [5]

3Programs and resources to explore

• Texas waiver interest lists Explore nowCLASS, HCS, and others. A place on a list is not eligibility. [3]
• Medicaid Buy-In for Children Check eligibilityCan work as second coverage alongside employer insurance. Income limits apply. Whether you pay a monthly premium depends on your income and coverage: families with job-based insurance who can’t get HIPP don’t make a monthly payment. [4]
• Partners Resource Network Explore nowTexas’s network of free Parent Training and Information Centers. Help with IEPs and ARD meetings. [6]
• SSI Check eligibilityFinancial and disability rules apply. For a child under 18, SSA may count some of the parents’ income and resources under its parental deeming rules. Eligibility depends on the family’s circumstances. We would need more information before prioritizing this option. [7]

4What may apply now

• An internal appeal of the insurer’s denial
• Joining Texas waiver interest lists
• A new ARD meeting about speech services

5Suggested timing and deadlines to verify

Suggested timing (our recommendation)

• This weekAsk to add your child to Texas waiver interest lists.
• Next 2 weeksAsk the school, in writing, for an ARD meeting about speech services.

Deadlines to verify in your documents

• Denial letterCheck the deadline and instructions in your denial letter. Employer health plans subject to federal claims-procedure rules generally must allow at least 180 days to request an initial internal appeal. [1]

If a deadline is approaching, contact the relevant organization or a qualified professional directly. Do not wait for your Navela plan before taking time-sensitive action.

6Documents to gather

• Denial letter and Explanation of Benefits (EOB)
• Summary Plan Description (from HR)
• The treating provider’s request and supporting records
• Diagnostic evaluation report
• Current IEP and latest progress report

7Who to contact

• HR or benefits office: ask for the Summary Plan Description and whether the plan is self-funded or fully insured.
• Insurance member services: ask for the criteria used in the denial and a copy of your claim file.
• Texas HHS (CLASS) and your Local Intellectual and Developmental Disability Authority (HCS): ask how to add your child to each interest list. [3]
• School case manager: request an ARD meeting in writing.

8Questions to ask

• “Is our plan self-funded or fully insured?”
• “Which criteria did you use to deny the request?”
• “Can I have a copy of my full claim file?”
• “What data supported reducing speech minutes?”