What does ABA pay in Maryland? Coverage, rates, place of service, and profitability

Is ABA covered by Maryland Medicaid

Yes. The Maryland Department of Health covers medically necessary ABA for Medical Assistance participants under 21 with an autism diagnosis under the federal EPSDT authority, with Carelon Behavioral Health administering the program as the administrative services organization (Maryland Department of Health; COMAR 10.09.28; EPSDT under 42 U.S.C. 1396d(r)). Providers enroll in Maryland Medicaid through the ePREP portal and then work through Carelon for authorization and clinical review. Covered codes span assessment, direct treatment, supervision, and family guidance.

Who is eligible: age, diagnosis, and EPSDT

Medicaid ABA in Maryland is a children's benefit, running birth through age 20, requiring Maryland Medical Assistance enrollment, an autism diagnosis confirmed through a comprehensive diagnostic evaluation, and medical necessity, grounded in EPSDT (EPSDT, 42 U.S.C. 1396d(r)). As with EPSDT generally, the Medicaid benefit is built around the under-21 population, while the commercial mandate, discussed below, reaches individuals under 19.

The reimbursement rates and setting tiers

Rates current as of June 2026 review. Maryland is distinctive in this guide for paying the direct-therapy code at different rates by setting, and for making telehealth the highest tier rather than the lowest. The direct-therapy code 97153 pays $18.61 per 15-minute unit in the clinic, $20.30 for home-based delivery, and $23.70 via telehealth (Maryland ABA fee schedule). Because the setting drives the rate, the place of service is part of the rate calculation, not a separate consideration. Code descriptions are paraphrased.

Because the setting drives the rate in Maryland, the rate cannot be read without reading the place of service alongside it, which is the subject of the next section.

Place of service: clinic, home, school, and telehealth

Maryland is a clear illustration of why place of service is a rate variable, not a logistical detail. ABA may be delivered in the clinic, the home, the school, or the community, subject to the approved plan, and the setting changes both the rate and the rules.

• Clinic (center-based). The clinic is the baseline setting at $18.61 per unit, and it is where facility-licensure and physical-plant questions arise, which is why this setting connects to the facility-licensure topic below.
• Home. Home-based delivery pays a higher tier at $20.30 per unit. Maryland's Electronic Visit Verification requirement, under the federal Cures Act, applies to personal care and home health services rather than to ABA specifically, so home-based ABA is governed by the treatment plan and documentation. Confirm current scope, since EVV requirements can expand.
• School and community. Medically necessary ABA can be delivered at a school, but only as a behavioral-health service meeting Carelon's clinical criteria, and it is distinct from the educational services a district provides under an individualized education program (IDEA). A behavior technician is not a one-to-one educational aide, and ABA cannot substitute for the school's own obligations. Keep the medical and educational lanes separate and document the clinical basis for school-delivered ABA.
• Telehealth. Maryland reimburses synchronous telehealth for ABA and, notably, pays it at the highest tier of $23.70 per unit, reflecting a deliberate telehealth-friendly posture (MD Medicaid Provider Transmittal 90-25, June 27, 2025; HB 869/SB 372, 2025). Telehealth is commonly used for family guidance, supervision, and consultation as part of the treatment plan, with synchronous-delivery and treatment-plan documentation requirements. Confirm which services your plan approves for telehealth.

One Maryland-specific billing rule ties directly to place of service: Carelon limits the use of place-of-service codes on ABA claims for the same rendering provider on the same day, so a single provider generally bills one setting per day (Carelon Maryland ABA provider guidance). The operational takeaway is that the setting can raise the rate, decides whether facility-licensure and EVV questions arise, and carries its own claim rules, so capture the correct place of service on every claim and plan your setting mix deliberately.

The profit engine: the direct-therapy code

As everywhere, the economic engine is code 97153, the technician-delivered one-to-one direct therapy that fills most authorized hours, and the spread over a loaded technician wage drives margin at scale. Maryland's wrinkle is favorable: the per-unit rate is solid at $18.61 and rises with home and telehealth delivery, so a setting mix weighted toward home and appropriate telehealth can lift blended margin above the clinic base. Read the engine with your setting mix in mind, and confirm the current tier amounts.

The CDE gate and prior authorization

Access to Maryland's ABA benefit is gated by a comprehensive diagnostic evaluation (CDE) confirming autism, and services are then authorized by Carelon, with authorization periods commonly running about 180 days (Maryland ABA Provider Manual; Carelon). The CDE, the treatment plan, and the authorization define the covered scope, and reauthorization on cycle is required to continue services. Build your intake to produce a compliant CDE and to manage the authorization calendar so coverage does not lapse.

The delivery system: Carelon as the ASO

Maryland delivers its ABA benefit through Carelon Behavioral Health acting as the administrative services organization, which handles authorization, provider assistance, and clinical review, while the Maryland Department of Health sets policy and manages enrollment through ePREP (Maryland Department of Health; Carelon). Because a single administrative organization administers the program statewide, the authorization and documentation expectations are relatively uniform, but operational details (including the payment processor) change, so track Carelon's provider alerts.

The commercial mandate: hour floors, not caps

Medicaid is one payer, and Maryland's commercial mandate takes an unusual and provider-favorable shape. Rather than imposing a dollar cap, it sets minimum weekly-hour floors that state-regulated plans must cover for habilitative ABA: for example, minimum weekly hours that step down by age band, covering individuals under 19 (Md. Insurance Code § 15-835). Because the mandate is expressed as a floor rather than a ceiling, it functions to guarantee access rather than to cap it, and federal mental-health parity reinforces that posture. As always, the mandate reaches state-regulated plans, not self-funded employer (ERISA) plans, and commercial rates are negotiated. Confirm current terms with the Maryland Insurance Administration.

Reading Maryland profitability

Putting the pieces together, Maryland is a solid ABA market with a favorable rate structure.

On the favorable side, the direct-therapy rate is among the better published rates in this guide and rises with home and telehealth delivery, so setting mix is a real margin lever; ABA is firmly covered under Medicaid; the commercial mandate uses hour floors rather than dollar caps; and a single statewide administrator makes expectations relatively uniform. On the constraining side, access is gated by the comprehensive diagnostic evaluation and 180-day authorizations, the place-of-service same-day billing rule constrains scheduling, and operational details shift, so track Carelon guidance. The practical read is solid economics where profitability turns on setting mix, technician productivity, clean authorizations, and a CDE-ready intake. None of this is a projection of any practice's results, and it is not financial advice; it is the reimbursement structure you would model against.

How this connects to the rest of your compliance stack

Reimbursement is where the rest of the structure turns into revenue, and place of service is the bridge to several of the other topics:

• Facility licensure and HIPAA. The clinic setting is where facility-licensure and physical-plant questions arise, while home, school, and telehealth delivery often avoid them; the setting mix you choose drives that question. See facility licensure and HIPAA.
• Licensing and credentialing. You must be licensed, enrolled through ePREP, and set up with Carelon before rates apply. See the Maryland licensing and credentialing page.
• Entity and ownership. The billing entity and its ownership are disclosed at enrollment. See the Maryland entity page and the Maryland ownership page.
• Practice sale and expansion. A favorable rate structure and setting flexibility support valuation. See practice expansion and sale.

Getting set up to bill Maryland Medicaid: the sequence

1. License and enroll. License the team and enroll in Maryland Medicaid through ePREP, then set up access with Carelon.
2. Secure the comprehensive diagnostic evaluation. Obtain the CDE confirming autism, the gate to the benefit.
3. Build the treatment plan and authorize. Develop the plan of care and secure Carelon authorization, tracking the roughly 180-day cycle.
4. Bill by place of service. Apply the correct setting so 97153 pays at the right tier, observing the one-setting-per-provider-per-day rule, and use telehealth where approved.
5. Reauthorize on cycle. Manage the authorization calendar so coverage does not lapse.
6. Layer in commercial payers. Contract with state-regulated plans under the hour-floor mandate (§ 15-835).

Maryland reimbursement variables at a glance

Frequently asked questions