Texas Probes Blue Cross Over Alleged Care Delays. The Announcement Doesn’t Mention ABA.

AUSTIN, TEXAS – Texas Attorney General Ken Paxton announced an investigation Sept. 28 into Blue Cross and Blue Shield of Texas (BCBSTX), a division of Health Care Service Corporation (HCSC), over alleged denials and delays of urgent care. The one patient example his office gave involved a newborn. It said administrative denials and “potentially improper” review procedures delayed approval of the baby’s transfer to a facility that could provide needed treatment, though the plan allegedly covered the procedure.

The announcement does not mention autism, ABA, or behavioral health. Paxton, the Republican nominee for U.S. Senate, is not seeking another term as attorney general. Separately, BCBSTX changed how providers request ABA approval this year. Since April, it has directed providers on its commercial plans to start ABA requests by phone; under its notice, a clinician then calls back to review the case.

BCBSTX told Becker’s Payer Issues on Sept. 29 that it does not comment on investigations. In the American Medical Association’s 2025 study, which used 2024 enrollment data, HCSC had the largest share of commercial enrollment in each of the 26 Texas metro areas examined, from 37% in the Austin area to 74% in Abilene, according to a Texas Medical Association summary.

How BCBSTX Changed ABA Requests

BCBSTX announced the change in a Jan. 15 notice to providers. Effective April 2026, the notice directs providers to start ABA requests for patients on BCBSTX’s commercial plans by calling the number on the patient’s ID card; a representative takes the intake, and a clinician follows up with a telephone review. The notice advises first confirming benefits, any authorization requirement, and the review vendor that handles the request. “Forms will no longer be the primary method to process these requests,” it said. The insurer said the change is intended to “streamline request intakes and support consistent and timely processing.”

HCSC, which says it serves 27 million people nationwide, posted the same notice for its plans in Illinois, New Mexico, and Oklahoma.

The criteria had changed earlier. The update history in BCBSTX’s ABA payment policy records a move to MCG criteria effective Jan. 1. MCG, part of the Hearst Health network, says a majority of U.S. health plans license its products. BCBSTX lists MCG’s guidelines as its criteria for mental health conditions on commercial plans; providers can open them in the Availity Essentials portal, and members and providers may call to request a copy.

The State’s Decision Deadline

Texas law sets a deadline for these decisions. For routine requests from in-network providers, state-regulated commercial HMO, PPO, and EPO plans generally must issue a decision by the third calendar day after receiving the request. If a request arrives outside a plan’s required staffing hours, the clock starts when staffing resumes. Patients already in the hospital, or needing post-stabilization or life-threatening care, get shorter deadlines. In-network providers may make the request by telephone.

The deadline has limits: the Texas Department of Insurance says self-funded employer plans are generally regulated by the federal Labor Department rather than the state, even when an insurer administers them. That means the Texas deadline does not cover every plan BCBSTX handles.

What Is Public So Far

The office said its investigation will focus on what BCBSTX has said about how it approves and denies medically necessary claims. The BCBSTX inquiry followed Paxton’s Sept. 1 investigation of TriWest, the West Region contractor for TRICARE, the military’s health program, over alleged wrongful claim denials. It preceded his Oct. 5 investigation of UnitedHealth Group over alleged denials of medically necessary care. Each announcement cites the state’s Deceptive Trade Practices Act.

“I will wage a relentless legal battle against any insurance company that fails to protect the health and safety of Texans.” – Ken Paxton, Texas Attorney General (2026)

The office issued civil investigative demands, formal requests for records and information, in all three probes. It did not post them with any of the announcements; in some earlier investigations, including those involving Oncor in 2021 and Goldman Sachs in 2022, it posted its demands online. State law generally bars the office from disclosing records a company produces in response, though it may use them to enforce the law, including in court.

Voters choose Paxton’s successor Nov. 3. The major-party nominees are Republican state Sen. Mayes Middleton and Democratic state Sen. Nathan Johnson. The next attorney general’s term begins Jan. 1, 2027. If the investigation is still open then, the new attorney general would inherit it.

AT A GLANCE

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