For an intake team in Delaware, an Aetna card means three layers. First is Aetna’s national ABA medical necessity guide. Second is Delaware’s autism mandate in 18 Del. C. §§ 3366 and 3570A. Third is the plan’s funding type, which decides whether the mandate applies at all. Aetna runs no Delaware Medicaid plan; DHSS’s three MCOs are AmeriHealth Caritas, Delaware First Health and Highmark Health Options.
Aetna’s ABA medical necessity guide (©2026) requires a DSM-5 ASD diagnosis "obtained by an appropriate provider," functional impairment "on a standardized scale of functioning in the past 12 months" at least one standard deviation below the mean (or a significant risk of harm), and a treatment plan with measurable targets. It lets the impairment level set the hours, with QHP direction at "1 to 2 hours per 10 hours of treatment by protocol," and re-evaluates progress every six months. Its only state exhibit is Maryland, so Delaware members get the national criteria plus the Delaware mandate. All ten ABA codes are on Aetna’s behavioral health precertification list.[1][3][20]
Delaware’s autism mandate is two parallel sections: 18 Del. C. § 3366 for individual plans and § 3570A for group and blanket plans. Each requires coverage "for the screening and diagnosis of autism spectrum disorders and the treatment of autism spectrum disorders in individuals less than 21 years of age," for plans delivered, issued or renewed in Delaware after December 11, 2012, and says coverage "shall not be denied on the basis that the treatment is habilitative or nonrestorative in nature." ABA is subject to "a maximum benefit of $36,000 per 12-month period per person," adjusted each April 1 by CPI-U, "but shall not be subject to any limits on the number of visits an individual may make to an autism services provider … regardless of the locations in which services are provided." The Insurance Commissioner’s 2026 notice sets that maximum at $38,601.65 per person from April 1, 2026 to March 31, 2027; payments for non-ABA autism treatment do not count toward it. Treatment must be "prescribed or ordered" by "a licensed physician or licensed psychologist who determines the care to be medically necessary." Except for inpatient care, the insurer may review ongoing treatment "not more than once every 12 months" unless it and the physician or psychologist agree to more, at the insurer’s cost. Payment is only required to autism services providers who meet DHSS’s certification standards, and a BCBA is deemed to meet them. The mandate does not change school or early-intervention obligations under an IEP, IFSP or 504 plan. It reaches fully insured plans; self-funded employer plans answer to ERISA and federal parity instead.[6][7][8]
Delaware does not license behavior analysts: the BACB’s state licensure table (2026) lists no Delaware law or board. The Board of Mental Health and Chemical Dependency Professionals (24 Del. C. ch. 30) licenses counselors, chemical dependency professionals, marriage and family therapists and art therapists, with no behavior-analyst subchapter. The credential rules that do exist come from the insurance mandate. Under 16 Del. Admin. Code 2102, a provider "currently certified as a BCBA or BCBA-D" is deemed qualified to provide ABA, and "Only people certified as a BCBA or BCBA-D or behavioral technicians who work under the supervision of a BCBA or BCBA-D" qualify. A BCaBA works under supervision. Technicians need a high school diploma or GED, background and abuse-registry checks, annual CPR, an ASD course, an ABA-principles course, competency-based training verified by the supervising BCBA (a current BCaBA meets this), and at least 10 hours of observed training before working one-on-one. BCBA supervision "shall not be less than 1.5:10 per week," with at least 1 hour a week when fewer than 10 hours of ABA are delivered. One open question: Delaware’s psychology act defines the practice of psychology to include "behavior analysis and therapy" (24 Del. C. § 3502), and § 3531(b) exempts "a qualified member of other recognized professions" who does not use a psychologist title. The statute does not name BCBAs, so ask the Division of Professional Regulation if this matters to you. On rates: commercial ABA rates are negotiated and mostly unpublished. The public benchmark is Delaware Medicaid’s ABA schedule (97153 $15.68 per 15 minutes base, $21.34–$31.82 with a modifier).[13][14][10][15][16][18]
Aetna publishes no ABA rate table. Its provider manual (6/26) treats payment as a contract term: the "rates and compensation under your agreement are subject to the Aetna coding/claim edit policies," and with both an intermediary contract and a direct agreement, "your direct Aetna rates will apply unless we specifically notify you otherwise." A member whose benefits are exhausted cannot be charged "more than the contracted rate." For a public benchmark, Delaware Medicaid pays 97153 at $15.68 per 15 minutes without a modifier.[5][18]
Two Delaware rules govern commercial claims. 18 Del. C. § 3571V says a carrier "shall permit a provider a minimum of 180 days from the date a covered service is rendered to submit a claim," whether or not the provider is in network (a contract may allow longer). Under 18 Del. Admin. Code 1310, "No more than 30 days after receipt of a clean claim" the carrier must pay it, pay part and explain the rest, deny it in writing, or make one written request for specific information; once that information arrives it has 15 days to act. The Commissioner can order interest on late payments. Both reach state-regulated plans and their administrators, not self-funded ERISA plans.[7][12][5]
Aetna’s Health Care Professional Toolkit (6/26) publishes no claim filing deadline: the limit for initial, corrected and secondary claims is the one in your Aetna participation agreement, and claim disputes "Must be submitted within contractual timeframes." The toolkit defines a clean claim as one "received in a timely manner" with all required data, and says a clean claim "Doesn’t involve coordination of benefits," so secondary claims sit outside the clean-claim clock. It publishes no check-run or weekly cut-off schedule.[7][12][5]
Aetna’s ABA medical necessity guide (©2026) sets what a renewal must show: the plan records baseline levels of each target behavior by "frequency, rate, symptom intensity or duration, or other objective measures," with "quantifiable criteria for progress"; where target behaviors have improved, documentation of that improvement is included, and where they have not, documentation of "modification of the treatment, additional assessments that have been conducted, and/or there has been appropriate consultations from other staff or experts." "A member’s progress is to be evaluated every six months," and the guide relies on "Repeated measurement with standardized measures to assess progress." It does not require graphs and sets no data-recency window.[1]
The questions that decide whether a family can start with Aetna in Delaware, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis itself, but medical necessity requires functional impairment on a standardized scale administered in the past 12 months (at least one standard deviation below the mean) or a significant risk of harm.[1]
A DSM-5 ASD diagnosis by "an appropriate provider (i.e. licensed psychologist/psychiatrist, physician or other health care professional qualified to diagnose mental health conditions within their scope of practice)."[1]
The guide requires a standardized functional measure from the past 12 months (Vineland-3, ABAS, VB-MAPP or ABLLS as examples). CPB 0648 covers the ASD diagnostic evaluation.[1][2]
Aetna’s guide requires no physician referral; it requires precertification of all ten ABA codes. For a fully insured Delaware plan, the mandate covers treatment "prescribed or ordered" by a licensed physician or licensed psychologist who determines it is medically necessary, so keep that order on file. Self-funded ERISA plans sit outside the statute.[3][1][7]
Aetna’s guide sets no age cap; its age ranges are typical, not limiting. For fully insured Delaware plans, 18 Del. C. §§ 3366 and 3570A require autism coverage "in individuals less than 21 years of age," and ABA may be capped at a CPI-adjusted maximum ($38,601.65 per person from April 1, 2026), with no visit limits. Self-funded ERISA plans are outside the statute.[1][6][7][8]
Ask the plan: Live benefits verification: establish fully insured vs. self-funded ERISA, then the plan’s own age terms.
Aetna’s provider manual (6/26) says Aetna Behavioral Health "offers telehealth services to all commercial fully insured members and to all commercial self-insured plan sponsors, unless those self-insured plan sponsors opt out," and providers must "ensure that they have the proper licensure based on state requirements." Aetna’s current ABA telehealth code list is not public. For a fully insured Delaware plan, 18 Del. C. § 3571R requires coverage for services delivered by telemedicine, bars excluding a service "solely because the service is provided through telemedicine," and requires reimbursement "on the same basis and at least at the rate" paid in person. The originating site is the patient’s Delaware location, and insurers and providers "may agree to alternative siting arrangements." Self-funded employer plans are outside the statute.[5][7]
Ask the plan: Availity or the precertification line: ask whether the plan is fully insured in Delaware or a self-funded plan that opted out, and which ABA codes, POS and modifier Aetna pays by telehealth.
Depends on how the plan is funded. Delaware’s pre-authorization statute (18 Del. C. §§ 3581–3587, as amended by 85 Del. Laws c. 176) applies to state-regulated plans. A utilization review entity must decide a clean health-care-service request within 5 business days, or 3 business days if submitted electronically, and an urgent one within 48 hours (24 hours electronically). An approval "shall be valid for a period of time that is reasonable and customary for the specific service, but no less than 90 days," and a carrier "may not require more than 1 pre-authorization for an episode of care." It may not revoke an approval on medical-necessity grounds after the provider receives it. Members get at least 30 days to appeal, and the appeal is decided within 15 days. Read with the autism mandate, ongoing ABA may be reviewed "not more than once every 12 months" unless the insurer and the physician or psychologist agree otherwise. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1 instead: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension, urgent care within 72 hours. Aetna publishes no Delaware-specific ABA turnaround.[9][7][17]
Ask the plan: At benefits verification ask whether the plan is fully insured (Delaware-regulated) or self-funded (ERISA), and whether you are submitting electronically.
For a child on two group plans, Delaware follows the birthday rule: "The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later" (18 Del. Admin. Code 1307, 5.2.1); "birthday" means month and day only, and a tie goes to the plan that covered the parent longer. For separated or divorced parents, a court decree that makes one parent responsible controls; otherwise the custodial parent’s plan pays first, then the custodial parent’s spouse’s plan, then the non-custodial parent’s plan. That rule binds state-regulated group plans; a self-funded plan sets its own order. If the child also has Delaware Medicaid, this plan pays first: Medicaid is payer of last resort and pays "the lesser of patient responsibility or DMAP allowed amount minus TPL paid amount." TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[11][19][21][22]
Ask the plan: Ask Aetna at benefits verification for the member’s coordination-of-benefits order (and whether a self-funded plan uses the birthday rule).
Coverage decides whether Aetna in Delaware pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Aetna’s Network Participation Criteria (5/26) require ABA to be "provided directly or supervised by individuals licensed by the state or certified by the Behavior Analyst Certification Board," with "A minimum of one hour of face-to-face supervision" of an unlicensed or noncertified paraprofessional "for each 10 hours of applied behavior analysis," and the supervisor "onsite with the child at least one hour a month." All staff "must meet state requirements." For fully insured Delaware plans the DHSS standard is higher: at least 1.5 hours of BCBA supervision per 10 hours a week (16 Del. Admin. Code 2102).[4][10]
No per-day cap. Hours follow the guide’s severity table, with typical intensities of 10–25 hours a week for comprehensive and 1–20 for focused programs (typical, not caps). Fully insured Delaware plans may apply the mandate’s ABA dollar maximum ($38,601.65 per person from April 1, 2026) but no visit limits.[1][7][8]
Outpatient ABA is setting-neutral in Aetna’s guide; inpatient, residential or partial-hospitalization settings use that level of care’s criteria, and the guide expects coordination with the school. Delaware’s mandate bars visit limits "regardless of the locations in which services are provided" and leaves IEP obligations untouched.[1][7]
Services must be "provided directly or billed by" a licensed behavior analyst (in licensing states), a BCBA, or a licensed psychologist where in scope, unless mandates, plan documents or contracts say otherwise. Delaware has no behavior-analyst license, so the BCBA is the billing credential.[1][13]
Not addressed in Aetna’s published ABA criteria.[1]
Ask the plan: Aetna provider services, the participating-provider agreement, or a written coding determination from Aetna Behavioral Health.
Not addressed. Aetna sets treatment-plan content, not who signs a session note or by when.[1]
Ask the plan: The participating-provider agreement and Aetna Behavioral Health documentation standards.
No. Aetna’s ABA medical necessity guide asks for objective baseline measures, quantifiable progress criteria, standardized re-measurement and a six-monthly progress evaluation, with treatment changes documented where there is no improvement, but it does not require graphs or set a data-recency window.
Aetna’s provider toolkit publishes no filing limit; the participation agreement sets it for initial, corrected and secondary claims, and a claim involving coordination of benefits is not a "clean claim." No check-run schedule is published.
Yes, under its national ABA guide for ASD, with Delaware’s mandate layered on for fully insured plans. Self-funded employer plans follow their own documents.
Delaware’s mandate covers individuals under 21 and lets fully insured plans cap ABA at a CPI-adjusted maximum: $38,601.65 per person from April 1, 2026 to March 31, 2027. Visits cannot be limited.
Aetna publishes no ABA rates; payment follows your participation agreement. Delaware Medicaid’s 97153 base rate ($15.68 per 15 minutes) is the public benchmark.
Delaware issues no behavior-analyst license, so BACB certification is the credential, and DHSS’s standard deems a BCBA qualified. Aetna still requires its own credentialing and says telehealth providers must hold the licensure their state requires.
Delaware law guarantees at least 180 days from the date of service on state-regulated plans; your Aetna agreement may allow longer.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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