How to start an eating disorder IOP or PHP in Texas

1. Which Texas license applies

Texas licenses substance use programs under Health and Safety Code chapter 464 and 26 TAC chapter 564, and a client of a licensed chemical dependency treatment facility must meet DSM criteria for a substance use disorder (26 TAC 564.801). Anorexia, bulimia, binge eating disorder and ARFID aren't substance use disorders, so that license doesn't fit. How the rest works:

• Freestanding IOP or PHP run by licensed clinicians. Usually treated like a mental health clinic, with every clinician practicing under their own license. Confirm it for your model: send HHSC the questions in our mental health IOP licensing guide, and add two that matter for eating disorders: "We will take vital signs, weights and blood draws on site and serve supervised meals. Does that change the answer?" and "Does serving adolescents change it?"
• Hospital-based program. A PHP run as a hospital department works under the hospital's license and rules. That route also opens Medicare (section 8).
• Co-occurring substance use. If you'll treat substance use disorders as a program, not just screen and refer, you're in CDTF territory and 26 TAC 564 applies to that treatment. See running a dual diagnosis program.
• Who owns it. A program that employs physicians raises Texas corporate-practice-of-medicine questions. Settle ownership and how the medical director is paid with a health-care attorney before you sign anyone.
• Teens. Many eating disorder clients are minors. Who can consent, what you share with parents and how you coordinate with school are in our adolescent IOP guide.

The city still decides zoning, the certificate of occupancy and the fire inspection. Because you'll serve food, also ask the city or county health department whether catered or prepared meals need a food permit at your site.

2. Levels of care

Eating disorder care runs from outpatient to inpatient. No single body defines the hours, so programs and payers set their own. The ranges below are what treatment centers and one major insurer publish; your contract and the plan's criteria decide what counts.

Level	Typical schedule	Meals in program	Who it's for
Outpatient	Weekly therapy, dietitian and medical visits	None	Medically stable, eating with enough support at home
IOP	About 3 to 4 hours a day, 3 to 5 days a week (Cigna, UC San Diego)	Usually one supported meal or snack a day	Medically stable, needs structure around eating that weekly visits can't give
PHP (day treatment)	About 6 hours or more a day, 5 to 7 days a week (Cigna; UC San Diego lists 6 to 10 hours, 5 to 6 days)	Commonly at least two supervised meals a day	Medically stable but unable to eat or stop compensatory behaviors without daily supervision
Residential	24 hours, in a licensed facility	All meals	Medically stable, needs 24-hour structure
Inpatient (medical or psychiatric)	Hospital	All, with medical refeeding	Medically unstable, or acutely suicidal

Most new programs open with an IOP, prove their outcomes and staffing, then add a PHP. Our guide to starting a PHP covers what a PHP adds in hours, physician involvement and payer review, and IOP vs. PHP vs. outpatient compares the levels for any diagnosis.

3. Medical stability criteria

An IOP or PHP is for people who are medically stable. Your admission criteria, your step-up rule and your daily checks all rest on that line, so write it down with your medical director before the first referral.

The reference is the American Psychiatric Association's Practice Guideline for the Treatment of Patients With Eating Disorders, fourth edition, published in 2023 (summary in the American Journal of Psychiatry). Its table of factors that support medical hospitalization lists, for adults:

Measure	Adult value that supports hospitalization
Resting heart rate	Under 50 beats a minute
Orthostatic heart rate	A sustained rise of more than 30 beats a minute on standing
Blood pressure	Under 90/60 mmHg, or a drop of more than 20 mmHg systolic on standing
Temperature	Under 36 °C (96.8 °F)
Weight	BMI under 15, or loss of more than 10% of body weight in 6 months or 20% in a year
Electrolytes	Low potassium, sodium, phosphate or magnesium, judged against the lab's reference range

Adolescent values differ (the guideline gives separate ones, and orthostatic thresholds are higher for teens). For clients under 21, also read the Society for Adolescent Health and Medicine's 2022 position paper on medical management of restrictive eating disorders in adolescents and young adults. These are factors a clinician weighs, not a scoring sheet; check the published table before you copy any number into a policy.

Turn that into four written rules:

1. Admission: the vitals, labs (and an ECG when the medical director wants one) required before the first program day, how recent they must be, and who reviews them.
2. Monitoring: how often weights and vitals are taken at each level (for example, vitals every program day in PHP), and how weights are taken and shared with the client.
3. Step-up: the values that send a client to the emergency department or to a higher level the same day, who makes the call, and how the family is told.
4. Refeeding risk: who screens for refeeding syndrome when intake increases, and which labs are repeated during the first weeks.

A program that can't show these rules, and the daily data behind them, will struggle at accreditation and at every concurrent review.

4. The clinical program

The 2023 APA guideline recommends treatment by a team with medical, psychiatric, psychological and nutritional expertise, and names the therapies by diagnosis:

• Anorexia nervosa: eating-disorder-focused psychotherapy for adults; a family-based approach with caregiver education for adolescents and emerging adults with an involved caregiver.
• Bulimia nervosa: eating-disorder-focused cognitive behavioral therapy for adults, with an SSRI such as fluoxetine when the client prefers it or psychotherapy alone isn't working by about 6 weeks; family-based treatment for adolescents with an involved caregiver.
• Binge eating disorder: eating-disorder-focused CBT or interpersonal therapy, individually or in a group; medication for adults who prefer it or don't respond.

So the program description payers and accreditors read should name: the therapies you deliver and who's trained in them, the family program (essential for teens; see building a family program), the meal support protocol, the nutrition education curriculum, the psychiatric evaluation and medication management schedule, and discharge planning to outpatient therapy, dietitian and medical follow-up. Write the weekly schedule and the group curriculum with meals and snacks as fixed blocks, not gaps between groups.

5. Staffing, including the dietitian

Role	Texas license or credential	What they do in the program
Medical director	Physician, Texas Medical Board (a psychiatrist, or a pediatrician or internist with eating disorder experience)	Signs the medical criteria, reviews admissions and step-ups, oversees prescribers. See hiring a medical director.
Medical provider	Physician, nurse practitioner (Texas Board of Nursing) or physician assistant	Medical evaluation, labs, ECG orders, weekly medical checks, refeeding monitoring
Psychiatric prescriber	Psychiatrist or psychiatric NP	Psychiatric evaluation, medications, co-occurring depression, anxiety and OCD. See psychiatric services in an IOP.
Nurse	RN or LVN, Texas Board of Nursing	Vitals and weights, medication administration if you do it, step-up escalation
Dietitian	Licensed Dietitian (LD) through TDLR, usually also a Registered Dietitian Nutritionist (RDN)	Nutrition assessment, meal plans, meal support, nutrition groups, family meal coaching
Therapists	LPC, LCSW, LMFT or psychologist, Behavioral Health Executive Council	Individual, group and family therapy in the models above
Program director	Usually a licensed clinician	Schedule, staffing, utilization review, quality

The dietitian, in Texas. The Licensed Dietitian Act (Occupations Code chapter 701) reserves the title "licensed dietitian" and the letters "LD" for people licensed through TDLR, and "RD" and "RDN" for people registered by the Commission on Dietetic Registration. TDLR notes that no license is needed to call yourself a "dietitian" or "nutritionist", so the license is your hiring standard, not something the title guarantees. Hire someone who holds both the LD and the RDN: payers that pay for nutrition counseling credential licensed, registered dietitians, and accreditors will check the license like any other. Verify it on TDLR's license search at hire and at every renewal.

Specialty credentials. The iaedp Foundation's Certified Eating Disorder Specialist (CEDS) credential is voluntary. Its 2026 checklist asks for 2,500 hours of eating-disorder-specific experience over at least 24 months after licensure, 24 hours of consultation with an approved consultant, the core courses and an exam. It's a good hiring signal and a good thing for a program description to mention; no Texas rule requires it.

Every clinician needs an NPI, and each one a plan bills under needs credentialing; see the staff credential file checklist.

6. The building and the program day

• A dining space and food. A table where staff eat with clients, a kitchen or a catering arrangement, and storage. Decide who plans menus (the dietitian) and how food allergies and religious diets are handled.
• Medical space. A private room with a calibrated scale, a blood pressure cuff with child and adult sizes, a thermometer and a gown; a lab arrangement for blood draws; and an ECG source. On-site tests may need a CLIA certificate; see the CLIA waiver guide.
• Bathrooms. A written post-meal bathroom policy (for example, a supervised wait after meals) that respects dignity and is applied the same way to everyone.
• Safety. A ligature and environmental risk review like any behavioral health site; see the outpatient ligature risk assessment.

A typical PHP day we'd draft: vitals and check-in, breakfast with meal support, two groups, lunch with meal support and a post-meal processing group, an afternoon snack, a skills group and individual or family sessions. An IOP day is shorter, usually built around one meal or snack in the evening so clients can work or attend school.

7. Accreditation

For a mental health program without a state facility license, accreditation does much of the work a license does: it's what many commercial plans and TRICARE look for before contracting an IOP or PHP. The two choices are the Joint Commission's Behavioral Health Care and Human Services program and CARF; compare them in Joint Commission vs. CARF and see accreditation for new programs. Both survey a program that's already serving clients, so you'll open, see clients, then be surveyed. Expect surveyors to trace a client from admission through the medical criteria, weights and vitals, meal plans and step-up decisions.

8. Payers and mental health parity

• Federal parity covers eating disorders. Section 13007 of the 21st Century Cures Act (2016) clarified that a group or individual plan that covers eating disorder benefits, including residential treatment, must cover them in line with the Mental Health Parity and Addiction Equity Act. The Departments' ACA FAQs Part 38 (2017) confirmed eating disorders are mental health conditions under MHPAEA.
• Ask for the criteria. Under the federal parity rules, a plan must make its medical necessity criteria for mental health benefits available on request (29 CFR 2590.712). Ask every plan which criteria set it uses for eating disorder IOP and PHP, and get a copy before you write your program description.
• The 2024 rule. The Departments said in May 2025 they won't enforce the parts of the 2024 parity rule that are new compared with the 2013 rule while they reconsider it; the statute and 2013 rule, including the comparative analyses of treatment limits, still apply (DOL mental health parity).
• Texas plans. For state-regulated plans, Texas added parity requirements in Insurance Code chapter 1355, subchapter F (HB 10, 2017), and the Texas Department of Insurance enforces them through 28 TAC chapter 21, subchapter P (TDI's parity rule). Self-funded employer plans follow the federal rules instead; your VOB should record which kind each client has.
• Medicare pays PHP and IOP only through hospitals, community mental health centers and a few other provider types, not freestanding clinics; see Medicare coverage of IOP and PHP. Medicare's medical nutrition therapy benefit covers diabetes and kidney disease, not eating disorders (Noridian MNT).
• Texas Medicaid pays adult mental health IOP and PHP mainly through managed care plans as in-lieu-of services, plan by plan; see Texas Medicaid for IOP and PHP.
• Carve-outs. Many plans hand behavioral health to another company, which then contracts, authorizes and pays you. See behavioral health carve-outs.

Facility contracts take months per plan; plan cash for that. Our credentialing services for programs file and follow up each one ($950 per plan), and single case agreements cover a client whose plan you're not in yet.

9. Codes and claims

Service	Common codes	Notes
IOP day	S9480 per diem; revenue code 0905 on a UB-04	Each plan's contract decides the code pair and claim form
PHP day	H0035 or S0201; revenue codes 0912/0913	Some plans pay by revenue code alone
Nutrition counseling	CPT 97802 (initial), 97803 (follow-up), 97804 (group)	Billed outside the per diem only if the contract allows it
Psychiatric evaluation, medication visits	90792; E/M 99202–99215	Often billed separately by the prescriber; check the contract
Family therapy	90846, 90847	Usually included in the per diem inside a program

Diagnosis codes changed in 2024. From October 1, 2024, ICD-10-CM split the eating disorder codes by type, severity and remission: anorexia restricting type is F50.010 to F50.019 (F50.01 alone is no longer valid), binge-purge type F50.020 to F50.029, bulimia F50.20 to F50.25, and binge eating disorder moved under F50.81, with severity tied to DSM-5-TR criteria (APA coding update). A claim with an old code denies. The full code reference is in IOP and PHP billing codes.

10. Authorizations and reviews

Expect prior authorization for both levels and short authorization periods with concurrent reviews, often weekly. Reviewers want to see why this level, why not a lower one, and that the client is improving. Have this ready for every review, from the chart, not from memory:

• Weight trend since admission and the target the treatment team set, with the dates weights were taken
• Vital signs and any abnormal labs, and what the medical provider did about them
• Meal and snack completion, and the frequency of bingeing, purging, restriction or compulsive exercise
• Attendance, participation and family involvement
• Suicide risk and co-occurring conditions
• What has to change before the client can step down, and the discharge plan

Assign one person to own the authorization log, track every end date and request the next review days before it. Our utilization review guide sets that up, prior authorization for behavioral health covers denials and peer-to-peers, and continued-stay documentation shows how to write the note a reviewer approves. Cima EHR for programs tracks each authorization's end date and builds the per diem claim from attended days.

11. Timeline

Our Texas roadmap for a mental health IOP or PHP, which an eating disorder program follows, with the license question settled before the lease:

Step	Typical timing
Kickoff and your dated roadmap	Week 1
Business formed with the Texas Secretary of State (you or your attorney file)	Week 4
Policy and procedure manual written	Weeks 5–10
Cima EHR Program plan set up	Weeks 13–15
Facility license question settled with HHSC and your attorney	Weeks 13–15
Site leased, after the city confirms zoning	Weeks 13–16
Individual NPI for each clinician	Weeks 15–16
Team hired and verified	Months 4–5
Soft opening, mock admission and fire drill	Months 6–7
Facility contracts with the insurance plans	Months 6–9
First admission	Month 7
Mock accreditation survey	Month 7
Accreditation survey	Months 7–8
Accreditation decision	Months 8–10
Each plan's effective date confirmed	Month 10
Billing each plan from its effective date	Month 10

From the kickoff, on the earliest path through our 109-step Texas roadmap. Agencies and insurance plans set their own pace, so treat these as typical, not promised.

Add time for the eating-disorder-specific pieces: recruiting a dietitian and medical provider with eating disorder experience, writing the medical criteria with your medical director, and fitting out the dining and medical rooms.

Already open? The program policy and procedure manual is $7,500 on its own, and a mock survey is $6,500. Or book a free 30-minute call and we'll walk through your model.

12. Opening checklist

1. Program model decided: diagnoses, ages, levels (IOP first, PHP later?), hours, meals.
2. HHSC's written answer on the facility license, with the eating-disorder questions above; attorney sign-off on ownership and the medical director arrangement.
3. Site with zoning confirmed, a dining area, a medical room, and a food permit answer from the health department.
4. Medical director, medical provider, dietitian (LD and RDN), therapists and nurse hired, licenses verified, NPIs on file.
5. Written medical criteria: admission, monitoring, step-up, refeeding.
6. Policy manual, including meal support, weighing, bathroom, family involvement and minors' consent.
7. Program description and schedule naming the therapies and the meal blocks.
8. Each target plan's criteria requested in writing; facility contracts filed.
9. EHR set up with the levels, per diem codes, authorization tracking and the new F50 codes.
10. Accreditation planned: gap assessment, mock survey, application.

The general opening steps are in the IOP and PHP opening checklist.

Questions

Do you need a license to open an eating disorder treatment center in Texas?

Each clinician needs their own license. A freestanding eating disorder IOP or PHP doesn't fit Texas's chemical dependency treatment facility license, and we know of no separate outpatient facility license for it, so ask HHSC in writing for your model. Residential care and hospital-based programs fall under other licenses.

Who can provide nutrition counseling in an eating disorder program in Texas?

Hire a dietitian licensed through TDLR (LD) who is also a Registered Dietitian Nutritionist. Texas law reserves the "licensed dietitian" and "LD" titles for licensees, and payers and accreditors expect the license.

When is someone too medically unstable for an eating disorder IOP or PHP?

The 2023 APA guideline lists factors that support hospitalization; for adults these include a resting heart rate under 50, blood pressure under 90/60, temperature under 36 °C, a BMI under 15 and electrolyte problems. Adolescent values differ. Your medical director turns these into the program's written step-up rule.

Does insurance have to cover eating disorder treatment?

Not every plan must cover it, but under the 21st Century Cures Act a plan that covers eating disorder benefits must follow federal mental health parity rules, and Texas has its own parity law for state-regulated plans. Coverage of IOP or PHP still depends on the plan and its medical necessity criteria.

Can a freestanding eating disorder PHP bill Medicare?

Generally no. Medicare pays partial hospitalization and intensive outpatient services through hospitals, community mental health centers and a few other provider types, not freestanding clinics.

What billing codes does an eating disorder IOP use?

Commonly S9480 (or revenue code 0905) for an IOP day and H0035 or S0201 (or revenue codes 0912/0913) for PHP, with the new F50 diagnosis codes. Nutrition counseling is 97802/97803 when the contract lets you bill it separately.

How long does it take to open an eating disorder IOP?

Our mental health program roadmap reaches a first admission in about six months, then facility contracts and accreditation take months more. Plan for that gap in cash.

Sources

All checked October 27, 2026. Rules and payer criteria change; open the current version before relying on any detail.

• American Psychiatric Association, Practice Guideline for the Treatment of Patients With Eating Disorders, 4th ed. (2023); Crone et al., Am J Psychiatry 2023;180(2):167–171.
• Golden et al., Medical Management of Restrictive Eating Disorders in Adolescents and Young Adults, Society for Adolescent Health and Medicine position paper, J Adolesc Health (2022).
• Texas Health and Safety Code chapter 464; 26 TAC 564.801.
• Texas Occupations Code chapter 701, Licensed Dietitian Act; TDLR Dietitians program.
• iaedp Foundation, CEDS requirements (2026 checklist).
• U.S. Departments of Labor, HHS and the Treasury, FAQs about ACA Implementation Part 38 (eating disorders and the Cures Act); 29 CFR 2590.712; DOL mental health parity.
• Texas Department of Insurance, mental health parity rules, 28 TAC chapter 21, subchapter P.
• Noridian (Medicare), Medical Nutrition Therapy.
• American Psychiatric Association, DSM-5-TR ICD-10-CM code updates, September 2024.
• Level-of-care descriptions: Cigna, treatment for eating disorders; UC San Diego Eating Disorders Center, levels of care.

Cima Consulting isn't a law firm and doesn't give legal or medical advice. HHSC, accreditors and insurance plans make their own decisions; we don't guarantee licenses, contracts, rates or dates.