---
title: "District of Columbia Medicaid ABA coverage: the intake guide."
url: "https://carelu.com/payers/district-of-columbia-medicaid"
markdown_url: "https://carelu.com/payers/district-of-columbia-medicaid.md"
state: DC (District of Columbia)
payer: District of Columbia Medicaid
kind: State Medicaid program
description: "How District of Columbia Medicaid (DHCF) covers ABA: an EPSDT benefit for children under 21 under State Plan Amendment 23-0009, treatment plans approved every six months, who may diagnose and deliver ABA, the managed care plans (AmeriHealth Caritas DC, MedStar Family Choice DC, HSCSN), telehealth billing, and claims rules."
last_reviewed: October 2026
---

# District of Columbia Medicaid ABA coverage: the intake guide.

_Payer Guide · District of Columbia Medicaid · Last updated October 2026 · 18 primary sources_

> ABA is an EPSDT benefit under SPA 23-0009 (since 10/1/2023); most children are in AmeriHealth Caritas DC, MedStar Family Choice DC or HSCSN.

District of Columbia Medicaid has covered applied behavior analysis since October 1, 2023, when CMS approved State Plan Amendment 23-0009. The amendment added Autism Spectrum Disorder services to EPSDT for beneficiaries under 21: screening, a diagnostic evaluation, a treatment plan, and treatment services that include "Applied Behavior Analysis (ABA) Therapy." It also made BACB-certified staff (BCBAs, BCBA-Ds, BCaBAs and RBTs) eligible to deliver Medicaid ABA for the first time.

The card decides almost everything else. DHCF says more than 90% of the roughly 100,000 DC Medicaid beneficiaries under 21 are in managed care. DC Healthy Families children are in AmeriHealth Caritas DC or MedStar Family Choice DC; children in the SSI-linked CASSIP program are in Health Services for Children with Special Needs (HSCSN). Wellpoint DC (formerly Amerigroup DC) left the program on August 1, 2026, and its members were moved to AmeriHealth Caritas DC. Each plan runs its own ABA authorization, so the first intake question is which plan is on the card.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: DHCF Health Care Delivery Management Administration, (202) 442-5988, or the DC Medicaid provider portal (dc-medicaid.com): ask whether 97151 needs authorization for a fee-for-service child. For managed-care children, ask the child’s plan. [1][19][21]
- **Prior auth for treatment**: Yes. The ASD treatment plan must "Be submitted to DHCF every six (6) months for review and prior approval, along with the screening, diagnostic evaluation, and supporting clinical documentation" (SPA 23-0009). Managed-care children get authorization from their plan [1][5]
- **Autism diagnosis required?**: Yes. ASD services treat conditions "associated with ASD, as defined in the most recent edition" of the DSM, and the treatment plan is written "After an ASD diagnosis is determined through a diagnostic evaluation" (SPA 23-0009) [1]

## At a glance

- **Covers ABA?:** Yes, as an EPSDT ASD treatment service for beneficiaries under 21 (SPA 23-0009, effective 10/1/2023)
- **Structure:** Managed care for 90%+ of children: AmeriHealth Caritas DC, MedStar Family Choice DC (DC Healthy Families), HSCSN (CASSIP); fee-for-service for the rest
- **Prior approval (FFS):** Treatment plan to DHCF every 6 months with the screening and diagnostic evaluation
- **Who may deliver ABA:** Psychologist, LICSW, SLP/audiologist, BCBA, BCBA-D; BCaBA under a BCBA/BCBA-D; RBT under a BCBA, BCBA-D or BCaBA
- **Who may diagnose:** Physician, PA, psychologist, psychology associate, LPC, LICSW or APRN, using a validated tool
- **Telehealth billing:** GT (video) or 93 (audio-only); POS 10 home, 03 school, 02 other (DHCF guidance)
- **Licensure:** DC licenses behavior analysts under the Board of Psychology (D.C. Law 25-191, 2024); confirm with DC Health that licenses are being issued

## Where ABA sits: the ASD services benefit in the State Plan

SPA 23-0009 describes ASD services as "services necessary to screen, diagnose, and treat behavioral, social interaction, communication, and physical conditions associated with ASD," available "to Medicaid beneficiaries under the age of twenty-one (21)." They are covered as preventive services under 42 CFR 440.130(c), so they "must be recommended by a physician or other licensed practitioner of the healing arts within his or her scope of practice." The benefit has four steps: screening; a diagnostic evaluation, which "shall be completed using a validated assessment tool or instrument" and must say whether evidence-based ASD services are medically necessary; a treatment plan; and treatment services, which are ABA therapy and psychological services. DHCF’s public notice (Transmittal 23-35) also lists physical, occupational and speech therapy among ASD treatment services identified in a plan. [1][2][3][4]

The treatment plan is the gate. It must be reviewed every six months, be individualized, list measurable long-, intermediate- and short-term goals, name each service with "the recommended amount, frequency, and setting and duration," state outcome measures and how often progress is reported, identify the providers responsible, and "Be submitted to DHCF every six (6) months for review and prior approval, along with the screening, diagnostic evaluation, and supporting clinical documentation." DHCF also wrote companion regulations, 29 DCMR Chapter 110 ("Medicaid Reimbursable Autism Spectrum Disorder Services"); its June 2024 rule report says the final rule was headed to the Mayor’s office, but DCRegs shows the chapter with no codified sections, so the SPA is the document we could read. [1][2][3][4]

## Who may diagnose, write the plan and deliver ABA

Diagnostic evaluations may be completed by a physician (including a psychiatrist), a physician assistant under a physician’s supervision, a psychologist, a psychology associate under a psychologist’s supervision, a licensed professional counselor, an LICSW, or an APRN. The treatment plan can be written by that diagnosing provider or by the treating practitioner the child is referred to, with a multidisciplinary team where needed. [1][14]

ABA therapy may be delivered by a psychologist, an LICSW, a speech-language pathologist or audiologist, or a BACB-certified practitioner: a BCBA or BCBA-D, "who must also comply with the District’s Medicaid screening and enrollment requirements"; an RBT "working under the supervision of a BCBA, BCBA-D, or BCaBA"; or a BCaBA "working under the supervision of a BCBA or BCBA-D." The SPA sets no numeric supervision ratio. Every ASD practitioner must also meet "the District’s statutory and regulatory licensing and scope of practice requirements, or the applicable scope of practice or professional practices act within the jurisdiction where services are provided." [1][14]

## The managed care plans, and the 2026 Wellpoint transition

DHCF contracts with two plans for DC Healthy Families, AmeriHealth Caritas DC and MedStar Family Choice DC, and with HSCSN for CASSIP, the program for children and young adults who receive or qualify for SSI. The plans maintain networks, authorize and pay for covered services and run appeals, but DHCF reminds them that children under 21 are entitled to EPSDT, "which requires coverage of all medically necessary services available under federal Medicaid law." Each plan publishes its own ABA rules: AmeriHealth Caritas DC requires PA on 97151, 97153 and 97155; MedStar lists "ABA Services" as needing prior authorization; HSCSN lets families use 12 units of ABA evaluation a year without PA but authorizes treatment. [5][6][19][20][21]

Wellpoint DC enrollees were auto-assigned to AmeriHealth Caritas DC on August 1, 2026, and may switch to MedStar until January 31, 2027. Transmittal 26-19 (rev.) says referrals and prior authorizations issued before August 1, 2026 stay valid through October 31, 2026 "whether or not the provider is contracted with AmeriHealth or MedStar," and that District law requires carriers to honor a prior carrier’s authorizations for at least 60 days. If you served a former Wellpoint child, request a new authorization from the receiving plan before the transition period ends. [5][6][19][20][21]

## Claims, telehealth and EVV

The DC Healthy Families contract requires each plan to accept claims "no later than three hundred sixty-five (365) days from date of service," to pay or deny 90% of clean claims within 30 days under the District’s prompt pay law (with interest if not), and 99% within 90 days. Plans must have providers bill "using the same format and coding instructions as required for the Medicaid FFS programs." Members can appeal an adverse benefit determination within 60 calendar days of the notice. The contract also says a child’s IEP or IFSP is not treated as third-party coverage. [7][9][8][10]

D.C. Code § 31-3863 requires Medicaid to cover services "appropriately delivered through telehealth if the same services would be covered when delivered in person." DHCF’s telemedicine guidance applies to fee-for-service and managed care alike: bill as you would in person, add modifier GT for video or 93 for audio-only, and use POS 10 when the child is at home, 03 at a DC public or charter school, or 02 elsewhere (with the originating site’s NPI). Providers must be licensed where the service is rendered, and outside the District must meet the licensure rules "of the jurisdiction where the patient is physically located." No DHCF document we read lists which ABA codes may be delivered remotely. DHCF’s EVV page describes EVV for personal care and home health services; it does not mention ABA. [7][9][8][10]

## Intake gates

The questions that decide whether a family can start with District of Columbia Medicaid, and what they have to bring.

- **Age limit**: Under 21. "ASD services are available to Medicaid beneficiaries under the age of twenty-one (21)" (SPA 23-0009). [1]
- **Who may diagnose**: Physician (including psychiatrist), physician assistant under a physician, psychologist, psychology associate under a psychologist, licensed professional counselor, LICSW, or APRN (SPA 23-0009, the "diagnosing providers"). [1]
- **Diagnostic tools required**: No instrument is named. The diagnostic evaluation is "a comprehensive review of a child’s cognitive, speech language, behavioral, fine motor, adaptive, and social functioning" and "shall be completed using a validated assessment tool or instrument." Screening uses "a screening tool that is supported by clinical best practices or emerging best practices." [1]
- **Referral required?**: Yes. ASD services "must be recommended by a physician or other licensed practitioner of the healing arts within his or her scope of practice," and after screening "a referral may be made" by a qualified screener (physician, PA, psychologist, psychology associate, LPC, LICSW or APRN) for the diagnostic evaluation. [1]
- **Telehealth**: Covered on the same basis as in person (D.C. Code § 31-3863). DHCF’s guidance applies to fee-for-service and managed care: bill as in person with modifier GT (video) or 93 (audio-only) and POS 10 (home), 03 (school) or 02 (other); the provider must be licensed where the service is rendered, or where the patient is if outside the District. No DHCF source read lists which ABA codes may be delivered remotely. [9][8]
- **Prior-auth decision time**: DHCF publishes no ABA decision timeframe. The federal fee-for-service floor applies: since January 1, 2026 a state agency must decide a standard request "in no case later than 7 calendar days after receiving the request" (extendable 14 days) and an expedited one within 72 hours. Managed-care children follow their plan; federal law caps standard plan decisions at 7 calendar days for rating periods starting on or after January 1, 2026, though DC’s 2023 plan contract still prints 14. [11][12][7]
- **Other insurance (who pays first)**: Medicaid pays last (42 CFR 433.139). The DC Healthy Families contract makes each plan identify and collect from other coverage, and says plans "shall not consider an enrolled child with an Individualized Education Plan (IEP) or an Individualized Service Family Plan (IFSP) to be an Enrollee with third party liability." Bill the commercial plan first and follow its ABA authorization rules. [13][7]

## Delivery and billing rules

Coverage decides whether District of Columbia Medicaid 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**: No numeric ratio is published. SPA 23-0009 lets an RBT deliver ABA "under the supervision of a BCBA, BCBA-D, or BCaBA" and a BCaBA "under the supervision of a BCBA or BCBA-D." [1]
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: DHCF Health Care Delivery Management Administration, (202) 442-5988, or the DC Medicaid provider billing manual on dc-medicaid.com: ask whether 97153 and 97155 may be billed for the same time. [1][4]

## What intake should collect for District of Columbia Medicaid

- **Which Medicaid card:** AmeriHealth Caritas DC, MedStar Family Choice DC, HSCSN (CASSIP), or fee-for-service. A former Wellpoint DC card means the child moved to AmeriHealth on 8/1/2026.
- **Diagnostic evaluation:** ASD diagnosis by a physician, PA, psychologist, psychology associate, LPC, LICSW or APRN, completed with a validated tool.
- **Screening and recommendation:** The screening result and the physician or other licensed practitioner’s recommendation for ASD services; both go to DHCF with the plan.
- **Treatment plan:** Goals, service amount, frequency, setting and duration, outcome measures and responsible providers; renewed every six months.
- **Other insurance:** Commercial coverage is billed first; Medicaid and its plans pay last.
- **Age:** ASD services cover beneficiaries under 21 (HSCSN enrolls through age 25).

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

## Common questions

### Does DC Medicaid cover ABA therapy?

Yes. Since October 1, 2023, State Plan Amendment 23-0009 covers ABA as an ASD treatment service for beneficiaries under 21. Most children get it through AmeriHealth Caritas DC, MedStar Family Choice DC or HSCSN.

### Can an RBT or BCaBA deliver DC Medicaid ABA?

Yes. The SPA lists RBTs working under a BCBA, BCBA-D or BCaBA, and BCaBAs working under a BCBA or BCBA-D. BCBAs and BCBA-Ds must enroll with DC Medicaid.

### Who can diagnose autism for DC Medicaid ABA?

A physician, physician assistant, psychologist, psychology associate, licensed professional counselor, LICSW or APRN, using a validated assessment tool.

### Can a BCBA licensed in another state treat a DC Medicaid child, including by telehealth?

DHCF requires providers to be licensed for the jurisdiction where the service is rendered, and for services outside the District, the licensure rules where the patient is located. The District began licensing behavior analysts in 2024 under the Board of Psychology; check with DC Health whether a DC license is being issued and required, and enroll with DC Medicaid either way.

### What happened to Wellpoint DC (Amerigroup) members?

They were moved to AmeriHealth Caritas DC on August 1, 2026 (they can switch to MedStar until January 31, 2027). Wellpoint authorizations issued before August 1 are honored through October 31, 2026; request a new authorization from the new plan before then.

### What does DC Medicaid pay for ABA?

DHCF says ASD fees are published on the DC Medicaid portal (dc-medicaid.com). We could not open it, so get the current rates from the portal or DHCF. Managed care plans pay contracted rates.

## Primary sources

1. [DC State Plan Amendment 23-0009 — Autism Spectrum Disorder services under EPSDT (approved Aug. 25, 2023; effective Oct. 1, 2023)](https://www.medicaid.gov/medicaid/spa/downloads/DC-23-0009.pdf)
2. [DHCF Transmittal 23-35 — Public Notice of Submission of State Plan Amendment, Autism Spectrum Disorder (Aug. 18, 2023)](https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/Transmittal%2023-35%20-%20Public%20Notice%20of%20Submission%20of%20State%20Plan%20Amendment%20%E2%80%93%20Autism%20Spectrum%20Disorder%20%282%29.pdf)
3. [DHCF Medical Care Advisory Committee — SPA, Waiver and Rule Report (June 2024): 29 DCMR Chapter 110 ASD rulemaking status](https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/attachments/MCAC%20SPA%20Waiver%20Rule%20Report%20June24.pdf)
4. [DCRegs — 29 DCMR Chapter 110, Medicaid Reimbursable Autism Spectrum Disorder Services (chapter listing)](https://www.dcregs.dc.gov/Common/DCMR/RuleList.aspx?ChapterNum=29-110)
5. [DHCF — Medicaid Managed Care Plans (MCPs): AmeriHealth Caritas DC, MedStar Family Choice DC, HSCSN (CASSIP)](https://dhcf.dc.gov/page/medicaid-managed-care-plans-mcps)
6. [DHCF Transmittal 26-19 (rev.) — Managed Care Plan Transition: Wellpoint DC enrollees to AmeriHealth Caritas DC (Aug. 6, 2026)](https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/Transmittal%2026-19%20%28rev.%29%20-%20Managed%20Care%20Plan%20Transition.pdf)
7. [DHCF — DC Healthy Families Managed Care Contract CW99929 (public version, as of April 1, 2023)](https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/attachments/MCP%20Contract%20PUBLIC.pdf)
8. [DHCF — Telemedicine Provider Guidance (January 2023, Transmittal 23-11)](https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/attachments/Telemedicine%20Provider%20Guidance_January%202023%20-%20Transmittal%2023-11.pdf)
9. [D.C. Code § 31-3863 — Telehealth: Medicaid reimbursement](https://code.dccouncil.gov/us/dc/council/code/sections/31-3863)
10. [DHCF — Electronic Visit Verification (EVV)](https://dhcf.dc.gov/page/electronic-visit-verification-evv)
11. [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)
12. [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)
13. [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)
14. [D.C. Code § 3-1207.71 — Behavior analyst licensure: eligibility and education](https://code.dccouncil.gov/us/dc/council/code/sections/3-1207.71)
15. [D.C. Code § 3-1202.11 — Board of Psychology (regulates the practice of behavior analysis; D.C. Law 25-191)](https://code.dccouncil.gov/us/dc/council/code/sections/3-1202.11)
16. [BACB — U.S. Licensure of Behavior Analysts (District of Columbia: 2024, DC Board of Psychology)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
17. [DC Medicaid web portal — fee schedule inquiry (where SPA 23-0009 says ASD fees are published)](https://www.dc-medicaid.com/dcwebportal/nonsecure/feeScheduleInquiry)
18. [DC DHCF — Publications (Medicaid transmittals and provider notices, newest first)](https://dhcf.dc.gov/publications)
19. [AmeriHealth Caritas DC — Prior Authorization Lookup Tool (code results queried 10/7/2026)](https://www.amerihealthcaritasdc.com/provider/resources/prior-authorization-lookup-tool)
20. [MedStar Family Choice DC — Quick Authorization Guide, DC Healthy Families (effective 08/15/2026)](https://www.medstarfamilychoicedc.com/-/media/project/mho/mfcdc/preauth_um/quick-authorization-guide-dc-healthy-families-plan_8-15-2026_web_excludingdrugs.pdf)
21. [HSCSN — Provider Manual (updated January 2026)](https://hscsnhealthplan.org/sites/default/files/2026-01/hscsn-provider-manual-january-2026-508C.pdf)

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.