The state plan states that services are provided "pursuant to 42 C.F.R. § 440.130(c)" as preventive services recommended by a physician or other licensed practitioner of the healing arts, and every page of the amendment prints "Approval Date: January 12, 2017" and "Effective Date October 1, 2016" (CMS-hosted SPA 16-010). The state's adopting order was final effective October 11, 2016 (20 DE Reg 291). The fee schedule host printed in the amendment returned an empty reply, so no rate is stated.
The adopting order and state plan amendment date to 2016 and 2017, and the manuals searched contain no ABA text, so the Register order and the state plan are the governing documents. Whether the managed care plans administer ASD services, and who reviews prior authorization, was not verified. Confirm both with the Division of Medicaid and Medical Assistance.
The reimbursement criteria at a glance
- Is ABA covered by Delaware Medicaid
- Who is eligible: age and the medical evaluation
- Who may provide ASD services
- How Delaware pays: the method, not the rates
- Place of service
- Hours, reassessment, and prior authorization
- The commercial mandate
- Practices with in-house diagnostics versus ABA-only practices
- How this connects to the rest of your compliance stack
- Getting set up to bill Delaware Medicaid: the sequence
- What this guide could not verify
- Delaware reimbursement variables at a glance
- Frequently asked questions
- Where professional advice is essential
Is ABA covered by Delaware Medicaid
Yes. The state plan describes "Behavioral Services to Treat Autism Spectrum Disorder (ASD) Pursuant to Act, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services," and states that "Delaware Medicaid Covers and reimburses all preventative services assigned a grade of A or B by the United States Preventive Services Task Force (USPSTF), all approved vaccines and their administration, recommended by the Advisory Committee on Immunization Practices (ACIP), and behavioral interventions to treat Autism Spectrum Disorder (ASD) without cost-sharing" (SPA 16-010). The state rule adopting the benefit is titled "Medical Care and Other Types of Remedial Care - Behavioral Interventions to Treat Autism Spectrum Disorder" (20 DE Reg 291, final effective October 11, 2016).
Who is eligible: age and the medical evaluation
"Behavioral assessments and services to treat Autism Spectrum Disorder (ASD) pursuant to EPSDT are provided only to Medicaid beneficiaries under age twenty-one." Before an assessment or treatment, "the child must receive a medical / physical evaluation that indicates that ASD Assessment or ASD Treatment services are medically necessary and recognized as therapeutically appropriate." CMS's approval letter describes coverage for "Medicaid recipients up to twenty-one (21) years of age who have a diagnosis of Autism Spectrum Disorder" (SPA 16-010).
Who may provide ASD services
The state rule requires that "Unlicensed Professionals must be certified by the Behavior Analyst Certification Board (BACB)" as a BCBA, a BCaBA working under the supervision of a BCBA, or a Registered Behavior Technician working under the supervision of a BCaBA or BCBA. Licensed practitioners "may provide ASD services without any other certification": licensed clinical social workers, licensed professional counselors of mental health, advanced practice nurses, medical doctors and doctors of osteopathy, physician assistants, psychiatrists, and psychologists or their assistants (20 DE Reg 291). In the state plan, every listed practitioner type "with the exception of the Registered Behavior Technician" is qualified to provide ASD assessments and the Behavioral Plan of Care (SPA 16-010). Medicaid provider type, specialty, and enrollment steps for BCBAs or ABA agencies were not found on any official page.
How Delaware pays: the method, not the rates
"As available, rates are developed using the Resource Based Relative Value Scale (RBRVS) methodology," and where no relative value unit exists the agency examines "the CMS-approved Medicaid fee-for-service rate schedules of other states for similar services." The plan states that "the agency's fee schedule rate was set as of October 1, 2016 and is effective for services provided on or after that date" and is published on the Delaware Medical Assistance Program website (SPA 16-010, Attachment 4.19-B). The URL printed in the amendment returned an empty reply, so no per-unit rate is stated.
Place of service
"These services are designed to be delivered primarily in the home or in other community settings," and the plan of care must include a "specific description of the recommended amount, type, frequency, setting and duration of ASD treatment services" (SPA 16-010). No school or telehealth rule for ASD services was found in the amendment, and the practitioner manuals searched carry no ABA text.
Hours, reassessment, and prior authorization
"Total ASD treatment services covered under this section and recommended as part of the Behavior Support Plan or ABA Treatment Plan may only be the amount medically necessary for each child. Plans that recommend more than 40 hours per week require prior authorization." The behavioral assessment "should be reviewed no less frequently than every six months or as behaviors or the circumstances of the child change" (SPA 16-010, limitations). Whether ASD services are carved into the Diamond State Health Plan managed care organizations, and who reviews prior authorization, was not verified.
The commercial mandate
18 Del. C. § 3366 (individual plans) and § 3570A (group and blanket plans) require coverage of autism spectrum disorder treatment for individuals less than 21 years of age. "Coverage for applied behavior analysis services under this section by an insurer shall be subject to a maximum benefit of $36,000 per 12-month period per person," and the Insurance Commissioner must publish an adjustment by April 1 of each calendar year (Delaware Code Online, Title 18, edition including acts enacted as of October 1, 2026). The adjusted figure for 2026 was not retrieved. The Delaware Licensing page covers who may deliver the services the mandate pays for.
Practices with in-house diagnostics versus ABA-only practices
The fork is written into the Medicaid rule. A practice with a psychologist or physician on staff has a licensed route that needs no BACB certification, and those practitioner types can complete the ASD assessments and the plan of care. An ABA-only practice staffs entirely under the BACB categories, and its RBTs cannot perform the assessments or the plan of care. Both need the medical evaluation before services start.
How this connects to the rest of your compliance stack
The credentials the rule relies on are covered on the Delaware Licensing page, and the entity analysis is on the Delaware entity page.
Getting set up to bill Delaware Medicaid: the sequence
- Choose the credential route. BACB-certified staff as BCBA, BCaBA, or RBT, or a listed licensed practitioner.
- Obtain the medical evaluation first. It must show the services are medically necessary.
- Write the plan of care with the setting and hours. Plans above 40 hours a week need prior authorization.
- Confirm enrollment and managed care handling. Provider type, specialty, and plan involvement were not found on official pages.
- Review the assessment at least every six months. Also when behaviors or circumstances change.
What this guide could not verify
- Per-unit rates for 97151 to 97158 or any state-specific code. The fee schedule host printed in the state plan returned an empty reply.
- School and telehealth rules for ASD services.
- Whether managed care plans cover ASD services and who reviews prior authorization.
- Medicaid provider type, specialty, and enrollment steps for BCBAs or ABA agencies.
- The Insurance Commissioner's published CPI-adjusted maximum benefit for 2026.
Delaware reimbursement variables at a glance
| Variable | Delaware value |
|---|---|
| ABA covered by Medicaid? | Yes, as an EPSDT preventive service (SPA 16-010, effective October 1, 2016) |
| Age | Under 21 |
| Evaluation | Medical or physical evaluation first, showing medical necessity |
| Providers | BACB-certified BCBA, BCaBA, RBT; listed licensed practitioners |
| Rates | Not verified; method is RBRVS or other states' rates |
| Place of service | Primarily home or community |
| Prior authorization | Plans over 40 hours per week; reassessment at least every six months |
| Commercial mandate | 18 Del. C. § 3366 and § 3570A; under 21; $36,000 per 12 months with annual adjustment |
Frequently asked questions
Does Delaware Medicaid cover ABA?
When is prior authorization required?
Can an RBT do the assessment?
What is the commercial cap?
Where professional advice is essential, not optional
Delaware's Medicaid framework is old and compact, and the rates were not readable for this guide. Bring in a billing specialist to work from the Division of Medicaid and Medical Assistance's current fee schedule and to confirm managed care handling.
The governing authorities to know are State Plan Amendment 16-010, 20 DE Reg 291, and 18 Del. C. § 3366 and § 3570A.
This page describes rules read from the CMS-hosted state plan amendment, the Delaware Register, and the Delaware Code Online. The Delaware Medical Assistance Program's fee schedule could not be read. The Division of Medicaid and Medical Assistance, the state insurance regulator, and each payor provide current requirements. Do not rely on this page or any secondary source in place of direct verification.