---
title: "Delaware Medicaid ABA coverage: the intake guide."
url: "https://carelu.com/payers/delaware-medicaid"
markdown_url: "https://carelu.com/payers/delaware-medicaid.md"
state: DE (Delaware)
payer: Delaware Medicaid (DMAP / Diamond State Health Plan)
kind: State Medicaid program
description: "How Delaware Medicaid covers ABA: an EPSDT benefit for children under 21 under SPA 16-010, delivered through three Diamond State Health Plan MCOs (AmeriHealth Caritas Delaware, Delaware First Health, Highmark Health Options), DMAP’s modifier-tiered ABA rates, telehealth rules, and no state behavior-analyst license."
last_reviewed: October 2026
---

# Delaware Medicaid ABA coverage: the intake guide.

_Payer Guide · Delaware Medicaid · Last updated October 2026 · 21 primary sources_

> ABA is an EPSDT benefit under 21 (SPA 16-010), delivered almost entirely through three MCOs; DMAP pays ABA by degree-level modifier.

Delaware Medicaid covers applied behavior analysis as an EPSDT benefit for members under 21. State Plan Amendment 16-010, approved by CMS on January 12, 2017 and effective October 1, 2016, added "Behavioral Services to Treat Autism Spectrum Disorder" to the plan, and says "All medically necessary services for children under the age of 21 will be furnished without limitation." Prior authorization is written into the state plan only for treatment plans over 40 hours a week.

In practice the managed care plan on the card decides how ABA is authorized and paid. DHSS says Medicaid benefits come "mainly through a managed care organization," and Delaware contracts with three: AmeriHealth Caritas Delaware, Delaware First Health and Highmark Health Options. All three cover ABA. Their documents differ on how ABA relates to the 30-unit cap on children’s outpatient behavioral health, which is the first thing to confirm with the plan.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment** _(plan-dependent)_: Depends on the plan. The state plan names no prior authorization for the assessment; it requires a medical/physical evaluation first. Nearly every member is in an MCO: Delaware First Health lists 97151 and 97152 as PA-required, and Highmark Health Options precertifies all outpatient behavioral health [1][2][10][8]
  - Ask the plan: The member’s MCO (AmeriHealth Caritas Delaware, Delaware First Health or Highmark Health Options); for a fee-for-service member, DMAP Provider Services through the Delaware Medical Assistance Portal.
- **Prior auth for treatment** _(plan-dependent)_: The state plan requires prior authorization when a treatment plan recommends more than 40 hours a week. Each MCO adds its own rules: Delaware First Health lists 97151–97158 as PA-required, Highmark Health Options precertifies all outpatient behavioral health, and AmeriHealth Caritas Delaware uses a behavioral health PA form [1][10][8][16]
  - Ask the plan: The member’s MCO utilization management line; for fee-for-service, DMAP Provider Services.
- **Autism diagnosis required?**: Yes. SPA 16-010 covers "treatment services for Medicaid recipients up to twenty-one (21) years of age who have a diagnosis of Autism Spectrum Disorder," and a medical/physical evaluation must show the services are medically necessary first [1]

## At a glance

- **Covers ABA?:** Yes, through EPSDT for members under 21 (SPA 16-010)
- **Structure:** Managed care: AmeriHealth Caritas Delaware, Delaware First Health, Highmark Health Options; fee-for-service for the few members outside an MCO
- **State-plan prior auth:** Required for treatment plans over 40 hours a week; MCOs set their own PA rules below that
- **DMAP rates (per 15 min):** 97151/97152 $43.76 · 97153 $15.68 base ($21.34 HN, $31.25 HO, $31.82 HP) · 97155 $17.66 base ($26.31/$35.19/$36.55) · 97156 $31.25
- **Who may deliver:** BCBA (independently); BCaBA under a BCBA; RBT under a BCaBA or BCBA; licensed LCSW, LPCMH, APN, MD/DO, PA, psychiatrist, psychologist
- **Licensure:** None: Delaware does not license behavior analysts; the state plan relies on BACB certification
- **Other insurance:** Medicaid pays last; bill the commercial plan first

## Where ABA sits: EPSDT under SPA 16-010

SPA 16-010 covers "Behavioral assessments and services to treat Autism Spectrum Disorder (ASD) pursuant to EPSDT … only to Medicaid beneficiaries under age twenty-one," as preventive services "recommended by a physician or other licensed practitioner of the healing arts." Before an ASD assessment or treatment, "the child must receive a medical / physical evaluation that indicates that ASD Assessment or ASD Treatment services are medically necessary." The behavioral assessment must use a validated instrument and be reviewed "no less frequently than every six months." The Behavioral Plan of Care must set measurable goals, the "amount, type, frequency, setting and duration" of treatment, and the caregiver’s role, though caregiver participation "is encouraged but not required." Services are "designed to be delivered primarily in the home or in other community settings." Aversive interventions, seclusion and restraints are prohibited. Total treatment "may only be the amount medically necessary," and "Plans that recommend more than 40 hours per week require prior authorization." Behavioral interventions for ASD carry no cost-sharing. [1][7]

## Managed care: three MCOs, and the 30-unit question

DHSS contracts with AmeriHealth Caritas Delaware, Delaware First Health and Highmark Health Options, and "The Medicaid MCO provides almost all of the care for Medicaid members who join their plan." Each MCO limits outpatient behavioral health for members under 18 to 30 units or visits a year, with the Department of Services for Children, Youth and Their Families (DSCYF) responsible above that. How ABA fits that cap is described differently: [2][8][9][14][15]

- **Highmark Health Options:** Its 2025 provider manual lists "Applied behavioral analysis (ABA)" among services it covers when medically necessary and "will not count … against the 30 units." [2][8][9][14][15]
- **Delaware First Health:** Its benefits list says behavioral services to treat ASD for members under 21 "are not subjected to the 30-visit limit." Its CHIP (Delaware Healthy Children Program) table lists ASD services for members under 18 with a 30-unit limit. [2][8][9][14][15]
- **AmeriHealth Caritas Delaware:** Its provider page says that after 30 units in a year, providers "should obtain a prior authorization and payment for future applied behavioral analysis (ABA) services from the Delaware Division of Developmental Disabilities Services (DDDS)." Its member page says it covers "the first 30 outpatient hours per year" of autism services, with hours above 30 through DSCYF. [2][8][9][14][15]

## What does Delaware Medicaid pay for ABA?

DMAP’s ABA Fee Schedule (effective November 1, 2022) prices ABA by modifier tier, per 15-minute unit. 97151 and 97152 pay $43.76 at HN, HO and HP alike. 97153 pays $15.68 without a modifier, $21.34 with HN, $31.25 with HO and $31.82 with HP. 97155 pays $17.66 without a modifier, $26.31 HN, $35.19 HO and $36.55 HP. 97156 pays $31.25 at every tier. 97154, 97157, 97158, 0362T and 0373T do not appear. The January 1, 2026 Physician Fee Schedule carries the same unmodified rates (97153 $15.68, 97155 $17.66, 97156 $31.25), so the 2022 rates are still current. The schedule does not say which credential bills which modifier; ask DMAP or the MCO before you bill. The state plan sets these rates from RBRVS where an RVU exists, and otherwise from comparable states’ Medicaid fees. MCOs pay contracted rates. [3][4][1]

## Staffing, licensure and out-of-state BCBAs

SPA 16-010 lists who may deliver ASD services. Licensed LCSWs, LPCMHs, advanced practice nurses, MDs and DOs, physician assistants, psychiatrists and psychologists need no other certification. A BCBA "is not required to work under the supervision of a licensed practitioner." A BCaBA "can only provide ASD services under the supervision of a BCBA," and a Registered Behavior Technician "under the supervision of a BCaBA® or BCBA®," with supervision requirements "specified by the Behavioral Analyst Certification Board." Everyone except the RBT may do the assessment and plan of care, and the plan author should normally be the clinician who did the assessment. Delaware has no behavior-analyst license (the BACB table lists none), so certification is the credential. A BCBA based in another state still has to enroll: DMAP’s telehealth rules require providers at both ends to be enrolled with DMAP, to "Act within their scope of practice," to have an NPI and taxonomy, and to be located in the continental United States. MCO members also need the plan’s credentialing. [1][17][6]

## Claims operations: filing limits, telehealth billing, appeals

Fee-for-service claims must reach DMAP "no later than twelve months from the date of service"; a claim already sent on time to Medicare or another primary carrier gets six months from that carrier’s decision. The MCOs are stricter: all three require first-time claims within 120 days of the date of service. AmeriHealth Caritas Delaware pays or denies 90% of clean claims within 30 days, and Delaware First Health 90% within 14 days. On telehealth, DMAP says "The same procedure codes and rates apply as for services delivered in person" and "Practitioners should use 02 Modifier as Place of Service for all telehealth charges"; MCO-credentialed providers follow the MCO’s billing rules. MCO members and providers have 60 days from a Notice of Adverse Benefit Determination to appeal (Delaware First Health and Highmark Health Options state this). No Delaware Medicaid document read says whether Electronic Visit Verification applies to ABA, or whose NPI goes on a technician’s claim. [5][13][12][8][6][11]

## Intake gates

The questions that decide whether a family can start with Delaware Medicaid (DMAP / Diamond State Health Plan), and what they have to bring.

- **Age limit**: Under 21. ASD services under SPA 16-010 "are provided only to Medicaid beneficiaries under age twenty-one." [1]
- **Diagnosis recency**: No diagnosis-recency rule appears in the state plan. The dated requirements are a medical/physical evaluation before services start, and a behavioral assessment reviewed "no less frequently than every six months." [1]
- **Referral required?**: Yes. Services must be "recommended by a physician or other licensed practitioner of the healing arts," and 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." [1]
- **Telehealth**: DMAP covers telehealth for any covered State Plan service "that would typically be provided … in an in-person setting by an enrolled practitioner," and "Telehealth is not limited based on the diagnosed medical condition." The member’s place of residence is an approved originating site but gets no originating-site fee. "The same procedure codes and rates apply as for services delivered in person," billed with "02 Modifier as Place of Service." Telehealth needs no separate prior authorization beyond what the service already needs. Providers at both ends must be enrolled with DMAP, and the distant practitioner must be in the continental United States. MCO-credentialed providers follow the MCO’s billing procedures. The manual does not list ABA codes specifically. [6]
- **Prior-auth decision time**: The state publishes no ABA decision timeframe. For fee-for-service, the federal floor applies: a standard request decided "in no case later than 7 calendar days after receiving the request," an expedited one within 72 hours. MCO members follow their plan’s clock: 42 CFR 438.210(d) caps standard decisions at 7 calendar days for rating periods starting on or after January 1, 2026. [19][18]
- **Other insurance (who pays first)**: Medicaid pays last: DMAP "can only pay after all other available insurance coverage has been billed first," and pays "the lesser of patient responsibility or DMAP allowed amount minus TPL paid amount." A claim sent on time to the primary carrier gets six months from that carrier’s decision even past the 12-month limit. The MCOs restate it: AmeriHealth Caritas Delaware wants the primary’s EOB within 60 days, and Highmark Health Options wants COB claims within 60 days of the primary’s adjudication. [5][20][13][8]

## Delivery and billing rules

Coverage decides whether Delaware Medicaid (DMAP / Diamond State Health Plan) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: SPA 16-010: a BCBA may work without a licensed supervisor; a BCaBA "can only provide ASD services under the supervision of a BCBA®"; an RBT "can only provide ASD services under the supervision of a BCaBA® or BCBA®," with supervision requirements "specified by the Behavioral Analyst Certification Board." Unlicensed practitioners may work under a licensed practitioner who "regularly reviews the work performed," documented in writing. The state plan sets no numeric ratio. [1]
- **Daily limits / MUEs**: No unit cap. The state plan covers "the amount medically necessary for each child," says medically necessary services under 21 "will be furnished without limitation," and requires prior authorization for plans that recommend more than 40 hours a week. [1]
- **Place of service**: ASD treatment is "designed to be delivered primarily in the home or in other community settings." By telehealth, the member’s residence is an approved originating site (no originating-site fee), billed with "02 Modifier as Place of Service." [1][6]
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: DMAP Provider Services (Delaware Medical Assistance Portal) or the member’s MCO. [3]

## What intake should collect for Delaware Medicaid (DMAP / Diamond State Health Plan)

- **Which Medicaid plan:** AmeriHealth Caritas Delaware, Delaware First Health, Highmark Health Options, or fee-for-service. The MCO runs authorization, credentialing and payment.
- **ASD diagnosis:** SPA 16-010 covers children under 21 with an ASD diagnosis.
- **Medical/physical evaluation:** Required before an ASD assessment or treatment, showing the services are medically necessary.
- **Planned weekly hours:** More than 40 hours a week needs prior authorization under the state plan; MCOs authorize below that too.
- **Other insurance:** Commercial coverage is billed first; Medicaid pays only what is left.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Does Delaware Medicaid cover ABA therapy?

Yes, for members under 21 with an ASD diagnosis, as an EPSDT benefit under State Plan Amendment 16-010. Most children get it through their MCO: AmeriHealth Caritas Delaware, Delaware First Health or Highmark Health Options.

### Does the 30-visit children’s behavioral health limit apply to ABA?

The plans describe it differently. Highmark Health Options says ABA is not counted against the 30 units, and Delaware First Health says ASD services under 21 are not subject to the 30-visit limit. AmeriHealth Caritas Delaware’s provider page says ABA after 30 units is authorized and paid by DDDS. Confirm with the plan before planning hours.

### What does Delaware Medicaid pay for ABA?

Per 15 minutes: 97151 and 97152 $43.76; 97153 $15.68 without a modifier, $21.34 HN, $31.25 HO, $31.82 HP; 97155 $17.66, $26.31, $35.19 or $36.55; 97156 $31.25. These rates date from November 1, 2022 and appear unchanged on the January 2026 physician schedule. MCOs pay contracted rates.

### Does a BCBA need a Delaware license?

No. Delaware does not license behavior analysts. Medicaid recognizes BACB-certified BCBAs, BCaBAs and RBTs. You still need DMAP enrollment and, for MCO members, the plan’s credentialing.

### Can a BCBA in another state treat a Delaware Medicaid child by telehealth?

Delaware issues no BCBA license, so there is none to get. DMAP telehealth requires providers at both ends to be enrolled with DMAP, to act within their scope of practice, to have an NPI and taxonomy, and to be in the continental United States. MCO members also need the plan’s network credentialing. Bill with the in-person code and POS 02.

### What is the timely filing limit for Delaware Medicaid ABA claims?

Twelve months from the date of service for fee-for-service DMAP. All three MCOs require claims within 120 days of the date of service.

## Primary sources

1. [Delaware State Plan Amendment 16-010 — Behavioral Services to Treat Autism Spectrum Disorder pursuant to EPSDT (approved Jan. 12, 2017; eff. Oct. 1, 2016)](https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/DE/DE-16-010.pdf)
2. [Delaware DHSS / DMMA — Diamond State Health Plan (three contracted MCOs)](https://dhss.delaware.gov/dmma/home/medicaid/diamond-state-health-plan/)
3. [DMAP — ABA Fee Schedule Effective November 1, 2022 (with HN/HO/HP modifier rates)](https://medicaidpublications.dhss.delaware.gov/docs/DesktopModules/Bring2mind/DMX/API/Entries/Download?Command=Core_Download&EntryId=1424&language=en-US&PortalId=0&TabId=94)
4. [DMAP — Physician Fee Schedule Effective January 1, 2026](https://medicaidpublications.dhss.delaware.gov/docs/DesktopModules/Bring2mind/DMX/API/Entries/Download?Command=Core_Download&EntryId=2015&language=en-US&PortalId=0&TabId=94)
5. [DMAP — General Policy Manual (claims timeliness 1.19; coordination of benefits / TPL 4.0)](https://medicaidpublications.dhss.delaware.gov/docs/DesktopModules/Bring2mind/DMX/API/Entries/Download?Command=Core_Download&EntryId=1797&language=en-US&PortalId=0&TabId=94)
6. [DMAP — Practitioner Provider Specific Policy Manual (rev. 03/17/2026; section 16.0 Telehealth)](https://medicaidpublications.dhss.delaware.gov/docs/DesktopModules/Bring2mind/DMX/API/Entries/Download?Command=Core_Download&EntryId=2112&language=en-US&PortalId=0&TabId=94)
7. [DMAP — Member FAQs (Rev. 08/2024): copay exemptions](https://medicaidpublications.dhss.delaware.gov/docs/DesktopModules/Bring2mind/DMX/API/Entries/Download?Command=Core_Download&EntryId=1077&language=en-US&PortalId=0&TabId=94)
8. [Highmark Health Options — 2025 Provider Manual (Delaware Medicaid)](https://www.highmarkhealthoptions.com/content/dam/digital-marketing/en/highmark/highmarkhealthoptions/providers/provider-resources/hho-2025-de-provider-manual.pdf)
9. [Delaware First Health — Medicaid Benefits List (DSHP and DHCP tables)](https://www.delawarefirsthealth.com/members/medicaid/benefits-services/benefits-overview/benefits-list.html)
10. [Delaware First Health — Medicaid/CHIP Prior Authorization Requirements, CMS-0057-F (eff. 12/31/2025)](https://www.delawarefirsthealth.com/content/dam/centene/medicaid/pdfs/provider/prior-authorization-requirements-metrics/DE_DEFirstHealth_DE_Medicaid_PriorAuthReq__CHP.pdf)
11. [Delaware First Health — 2025 Provider Manual (v11.2, 08/30/2026)](https://www.delawarefirsthealth.com/content/dam/centene/delaware/provider-manuals/2025%20DE%20First%20Health%20Provider%20Manual%20v11.2_08302026_FINAL.pdf)
12. [Delaware First Health — 2025 Provider Billing Manual](https://www.delawarefirsthealth.com/content/dam/centene/delaware/provider-manuals/2025%20DE%20First%20Health%20Billing%20Manual_R.pdf)
13. [AmeriHealth Caritas Delaware — Provider Manual 2026](https://www.amerihealthcaritasde.com/content/dam/amerihealth-caritas/acde/pdf/provider/provider-manual.pdf.coredownload.inline.pdf)
14. [AmeriHealth Caritas Delaware — Provider: Behavioral Health (30-unit limit; ABA after 30 units via DDDS)](https://www.amerihealthcaritasde.com/provider/behavioral-health/index.aspx)
15. [AmeriHealth Caritas Delaware — Member: Behavioral health benefits (autism services; first 30 outpatient hours, then DSCYF)](https://www.amerihealthcaritasde.com/member/eng/benefits/behavioral.aspx)
16. [AmeriHealth Caritas Delaware — Behavioral Health Prior Authorization Request Form (NaviNet or fax 877-234-4273)](https://www.amerihealthcaritasde.com/content/dam/amerihealth-caritas/acde/pdf/provider/provider-behavioral-health-prior-authorization-request-form.pdf.coredownload.inline.pdf)
17. [BACB — U.S. Licensure of Behavior Analysts (Delaware not listed)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
18. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
19. [42 CFR 440.230(e) — State Medicaid agency prior-authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-440/subpart-B/section-440.230)
20. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
21. [Delaware DMAP — Provider Bulletins folder (Medicaid publications library, quarterly DMAP Provider Bulletins)](https://medicaidpublications.dhss.delaware.gov/docs/Search?EntryId=16)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.