Medicaid ABA Coverage in Delaware
Delaware Medicaid covers ABA for kids under 21. Here's how to get it.
What Delaware Medicaid Covers
Delaware Medicaid, sometimes called Diamond State Health Plan, covers medically necessary Applied Behavior Analysis (ABA) for enrollees under 21. This coverage comes through the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which requires states to cover all medically necessary services for children.
There is no fixed dollar cap, age cap, visit cap, or hour limit for ABA under Delaware's autism mandate. Limits vary by your specific Medicaid plan, and they can change. The exact question to ask your plan is: "What are my plan's specific ABA coverage limits, including sessions per week and total hours per year?"
Who Qualifies
Your child must be under 21 and enrolled in Delaware Medicaid. You also need a formal autism diagnosis, usually from a developmental pediatrician, child psychiatrist, or psychologist.
Your child's doctor or a qualified professional must develop a treatment plan that shows ABA is medically necessary. The plan should include specific goals, the number of hours recommended, and how progress will be measured.
How Prior Authorization Works
Before ABA can start, your Medicaid plan must approve it. This is called prior authorization. Your ABA provider will typically submit the request, including the diagnosis and treatment plan, to your managed care plan.
Your managed care plan's name is on your child's Medicaid member card. If you are not sure which plan you have, call the number on the card.
The approval process can take a few weeks. Ask your provider for a timeline and check in with your plan if you have not heard back within two weeks.
Finding an ABA Provider
There are ABA agencies across Delaware's three counties. The largest concentrations are New Castle County, Kent County, and Sussex County.
When you contact an agency, ask two things: "Do you accept my Medicaid plan?" and "Is your Medicaid panel currently open?" If the panel is closed, you may need to wait or look elsewhere.
What to Do When a Panel Is Closed
If an agency's Medicaid panel is closed, ask to be put on a waitlist. Also ask if they can recommend another provider that might have openings.
Contact your Medicaid plan's member services. They can give you a list of in-network ABA providers and may know which ones have openings.
You can also call the Delaware Department of Health and Social Services (DHSS) for help. They can direct you to resources and may be able to assist with network adequacy issues.
Important Insurance Notes
Delaware has an autism insurance mandate, but it only applies to fully insured employer plans. If your employer's plan is self-funded, it is governed by ERISA and is not required to follow state mandates, though many self-funded plans cover ABA anyway.
Medicaid is different. If your child is on Delaware Medicaid, EPSDT requires coverage of medically necessary ABA, regardless of whether the plan is fully insured or self-funded. Your child's eligibility is based on Medicaid rules, not employer plan rules.
If you have private insurance through an employer, check your plan documents or call the number on your insurance card to ask: "Is my plan fully insured or self-funded? Does it cover ABA therapy?"
Delaware listings right now
49 ABA agencies across 3 Delaware counties.