For an intake team in Delaware, a Cigna card means three layers. First is Evernorth’s national ABA policy EN0499 with the Cigna autism resource guide. Second is Delaware’s autism mandate. Third is the plan’s funding type, which decides whether the mandate applies. Evernorth also attaches a Delaware Regulatory Addendum to its provider agreements, setting a claim deadline and a state arbitration route.
Cigna, through Evernorth Behavioral Health, covers ABA under EN0499 (effective May 15, 2026). Per the autism resource guide, "Prior authorization is no longer required for assessment … codes 97151, 97152, or 0362T with a diagnosis of autism, as long as the provider is independently licensed or a Board Certified Behavior Analyst" and the plan covers ABA. Treatment needs the completed assessment and treatment plan on the ABA Prior Authorization Form. "All ABA CPT codes are covered telehealth services." Neither document mentions Delaware, so the national criteria apply, with the state mandate on top for fully insured plans.[1][2]
Evernorth’s Administrative Guidelines (September 2026) attach a Delaware addendum to provider agreements, which does not apply to self-funded plans. It requires claims "within one hundred eighty (180) days of the date the Covered Service was rendered." When Evernorth’s final reimbursement decision does not pay a claim in full, the provider may petition the Delaware Department of Insurance for arbitration "no later than sixty (60) days after the date of mailing" of that decision, after trying to resolve it informally first. The fee is $50 for claims of $1,000 or less and $100 otherwise. Evernorth must respond within 20 days, and the arbitrator decides within 45 days of the petition.[3]
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.[4][5][6]
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).[11][12][8][13][14][16]
Cigna publishes no ABA rate table. Evernorth’s Administrative Guidelines say the Provider Agreement’s terms "include the reimbursement rates applicable to covered services," and refer ABA providers to "Exhibit A in your Provider Agreement" for the fee schedule and the list of reimbursable autism services. Virtual services carry modifier 95, which Evernorth says "will not change the reimbursement." Fee questions go to Provider Services, 800.926.2273. For a public benchmark, Delaware Medicaid pays 97153 at $15.68 per 15 minutes without a modifier.[3][16]
Evernorth’s guidelines also set the secondary and resubmission clocks: for a secondary claim the 90 days run from "the primary payer’s processing date as stated on an explanation of benefits [EOB] or explanation of payment [EOP]," Medicaid-primary claims get three years, and a timely claim returned for more information gets a new 90 days from the date of the request. No check-run or weekly cut-off schedule is published.[3]
Evernorth’s EN0499 sets what a continued-treatment request must show: "current data" collected "within no more than 60 days prior to the start date of the continued treatment request, as well as collected within no more than 60 days prior to the date the authorization request is received," with collection dates, for every behavior and skill targeted; data showing "ongoing and sustained progress toward mastering the treatment goals"; measurable improvement on "a reliable, valid, and standardized assessment instrument completed no more than one year prior to the start date of the continued treatment request"; an account of barriers and plan changes where progress is not shown; and dated stakeholder (caregiver) training data. EN0499 does not require the data to be graphed.[1]
The questions that decide whether a family can start with Cigna / Evernorth in Delaware, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis, but the request needs the date it was most recently made. The clocks run on data: the standardized instrument and baseline data within 60 days before treatment, and current data within 60 days of a continued-treatment request.[1]
A healthcare professional licensed to practice independently whose board considers diagnosis within scope, applying DSM-5-TR criteria.[1]
No single instrument is mandated, but it must be standardized and valid, completed in full, and the current edition ("must be the Vineland-3 vs. Vineland-II").[1]
EN0499 requires no referral. Assessments need no PA with an autism diagnosis from an independently licensed provider or BCBA; treatment needs the PA form. 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.[2][1][5]
"All ABA CPT codes are covered telehealth services," and EN0499 allows in-person, telehealth or hybrid delivery chosen on clinical factors; the line-of-sight requirement does not apply to telehealth. Bill modifier 95. 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.[2][1][3][5]
EN0499 sets no age cap and says focused intervention "should not be restricted by age." 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][4][5][6]
Ask the plan: Live benefits verification: establish fully insured vs. self-funded ERISA first.
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. Cigna/Evernorth publishes no Delaware-specific ABA turnaround.[7][5][15]
Ask the plan: At benefits verification ask whether the plan is fully insured (Delaware-regulated) or self-funded (ERISA).
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).[9][17][18][19]
Ask the plan: Ask Cigna/Evernorth at benefits verification for the coordination-of-benefits order (and whether a self-funded plan uses the birthday rule).
Coverage decides whether Cigna / Evernorth 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.
EN0499: case supervision by a BCBA, Licensed Behavior Analyst or independently licensed clinician with ABA training, at one to two hours of direct plus indirect supervision per ten hours of direct treatment; at 10 hours a week or less, at least one to two hours a week. For fully insured Delaware plans the DHSS floor also applies: not less than 1.5 hours of BCBA supervision per 10 hours a week (16 Del. Admin. Code 2102).[1][8]
Only one provider may bill a unit of time, except 97153, 97154 and 97155 during direct supervision, when the BCBA or QHP directs the technician and both are face-to-face with the patient. Other therapies are a separate rule: EN0499 (eff. 5/15/2026) says “Provision of ABA treatment is not covered or reimbursable when delivered to the same individual, at the same time as any other treatment modality (e.g., ABA and speech therapy, or ABA and occupational therapy).”[2][1]
No per-day cap. All ABA bills in 15-minute units on 97151–97158, 0362T and 0373T only. 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.[2][5][6]
Each service needs its own record with start and end time, location, focus, intervention, who was present, service type, and the name, credential and signature of the provider who rendered it.[1]
EN0499 has goals and data reported per setting (home, clinic, school, community); primarily educational or vocational services are not covered. Delaware’s mandate bars visit limits "regardless of the locations in which services are provided."[1][5]
Non-credentialed staff are billed under the supervising provider. On a CMS-1500 the rendering provider prints their name in box 31 and only a BCBA or other licensed provider goes in box 33; electronic claims use payer ID 62308.[2]
No. Evernorth’s EN0499 requires dated data collected within 60 days before both the requested start date and the request’s receipt, sustained progress, and a standardized assessment from the past year, but it does not require graphs.
90 days from the date of service unless your provider agreement or a longer state limit applies; secondary claims get 90 days from the primary payer’s EOB/EOP date, and a claim returned for more information gets a new 90 days. No check-run schedule is published.
Yes, under EN0499 for ASD, with Delaware’s mandate layered on for fully insured plans. Self-funded employer plans follow their own documents.
No, for 97151, 97152 and 0362T with an autism diagnosis when the provider is independently licensed or a BCBA. PA starts at treatment.
Evernorth’s Delaware addendum requires claims within 180 days of the date of service (it does not apply to self-funded plans).
After trying to resolve it informally, petition the Delaware Department of Insurance for arbitration within 60 days of Evernorth’s final reimbursement decision. The fee is $50 for claims of $1,000 or less, $100 otherwise, and the decision comes within 45 days.
Cigna publishes no ABA rates; your fee schedule is Exhibit A of your Evernorth Provider Agreement (Provider Services 800.926.2273). Delaware Medicaid’s 97153 base rate ($15.68 per 15 minutes) is the public benchmark.
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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