Highmark Blue Cross Blue Shield Delaware is the state’s Blue plan, and its Medicaid affiliate is Highmark Health Options. For commercial members, Highmark added all ten ABA codes to its prior authorization list on March 1, 2026. They are reviewed in-house by Highmark Behavioral Health, and the list applies to Delaware members.
Under that sits Delaware’s autism mandate for fully insured plans: coverage under 21, a CPI-adjusted ABA maximum, and no visit limits. Establish funding type on every benefits check, because self-funded employer plans administered by Highmark follow their own plan documents.
Highmark announced in November 2025 that it would add 19 behavioral health codes to its prior authorization list on March 1, 2026, ABA among them. The list effective 10/01/2026, headed "For PA, WV, DE & NY Members," carries 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157 and 97158, plus H0032 and H2019, under "Applied Behavioral Analysis," with UM program "Highmark Behavioral Health." None is marked Gold Card Eligible. The list adds: "Some authorization requirements vary by member plan." Check the number on the card, Availity eligibility and benefits, or BlueExchange for out-of-area members.[2][1]
Highmark’s commercial ABA rates are negotiated, with one published exception. On August 17, 2026 Highmark announced new reimbursement for CPT 97153 "across applicable Commercial products in Delaware (DE), Pennsylvania (PA), and West Virginia (WV)," effective October 16, 2026. For DE PPO the rate is $15.73 per 15-minute unit in and out of the office. Highmark says the update does not change eligibility, medical necessity criteria, authorization requirements, coverage policies or documentation expectations. Rates for other codes and other products are in your agreement. For comparison, Delaware Medicaid pays 97153 at $15.68 without a modifier.[3][17]
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.[5][6][7]
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).[12][13][9][14][15][17]
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.[6][11]
Highmark’s provider manual (Chapter 2, Unit 6) covers members of other Blue plans who travel to or live in Delaware, New York, Pennsylvania and West Virginia. "Highmark is your sole contact for claim submission, payment, adjustments, and issue resolution." For outpatient care, "your out-of-area Blue Plan patients are responsible for obtaining precertification/preauthorization from their Blue Plan when required for outpatient services. However, you may contact the member’s Blue Plan for authorization on behalf of the member." Highmark’s router takes the member’s prefix and returns the home plan’s medical policy and precertification information. Electronic Provider Access, BlueExchange and BlueCard Eligibility (800-676-BLUE) handle pre-service review.[21]
It works the other way too. Highmark’s outpatient prior-authorization requirements "include those services provided by out-of-area providers participating with their local Blue Plan," and "Claims for services on the prior authorization list received without authorization will be denied." So a Highmark member getting ABA from a provider in another state still needs Highmark’s authorization, requested through that provider’s local Blue plan portal. Where Highmark overlaps another Blue (the 21-county central Pennsylvania and Lehigh Valley region, the 5-county southeastern Pennsylvania region and 13-county northeastern New York), claims for Highmark members go to Highmark and claims for the other Blue plan’s members go to that plan, whichever plan you contract with.[21]
The questions that decide whether a family can start with Highmark Blue Cross Blue Shield Delaware, and what they have to bring. Each maps onto something intake should ask on the first call.
Highmark requires prior authorization of every ABA code through Highmark Behavioral Health, not a referral. 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.[1][6]
Highmark’s Delaware ABA policy could not be retrieved. 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.[5][6][7]
Ask the plan: Availity benefits check: establish fully insured vs. self-funded, then the plan’s own age terms.
Highmark’s Telemedicine and Telehealth policy RP-046 (version 2026.09.01) covers Delaware commercial plans. It pays "All medically appropriate telehealth services rendered by network providers … at parity with comparable in-person services, subject to the member’s benefit plan," applies Delaware’s telemedicine mandate, and pays no originating-site access fee for a non-medical site such as the member’s home. It does not list ABA codes specifically. 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.[4][6]
Ask the plan: Availity benefits check: confirm the plan covers ABA by telehealth and which POS (02 or 10) and modifier Highmark expects.
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. Highmark said in November 2025 that it had cut average turnaround for urgent and non-urgent requests "from approximately five days to one day."[8][6][16][2]
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).[10][18][19][20]
Ask the plan: Ask Highmark at benefits verification for the member’s coordination-of-benefits order (and whether a self-funded plan uses the birthday rule).
Not published in any Highmark Delaware source read.[1]
Blocked on: Highmark Behavioral Health: ask what diagnostic documentation and dates it expects with the first request.
Not published in any Highmark Delaware source read. The mandate covers treatment prescribed or ordered by a licensed physician or licensed psychologist.[6][1]
Blocked on: Highmark Medical Policy Search (Delaware commercial V-37) or Highmark Behavioral Health.
Not published in any Highmark Delaware source read.[1]
Blocked on: Highmark Medical Policy Search (Delaware commercial V-37) or Highmark Behavioral Health.
Coverage decides whether Highmark Blue Cross Blue Shield 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.
Highmark’s Delaware ABA policy could not be retrieved. For fully insured plans, the mandate’s DHSS standards apply: BCBA supervision of behavioral technicians "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 (16 Del. Admin. Code 2102).[9][6]
Blocked on: Highmark Medical Policy Search (Delaware commercial V-37) or Highmark Behavioral Health; self-funded plans per plan document.
No daily cap is published. On fully insured plans the mandate bars visit limits "regardless of the locations in which services are provided," but allows the ABA dollar maximum ($38,601.65 per person from April 1, 2026). Hours are set by authorization.[6][7][1]
Ask the plan: Availity benefits check: confirm funding type and any ABA dollar maximum used to date.
On fully insured plans the mandate covers ABA without visit limits "regardless of the locations in which services are provided," and does not affect school obligations under an IEP or 504 plan. Highmark pays telehealth with POS 02 or 10 under RP-046.[6][4]
Ask the plan: Highmark Behavioral Health or Availity: confirm the member’s plan covers ABA in the home, clinic, school or community setting.
Not addressed in any Highmark Delaware source read.[1]
Blocked on: Highmark Medical Policy Search (Delaware commercial V-37) or Highmark Provider Services.
Not addressed in any Highmark Delaware source read.[1]
Blocked on: Highmark Provider Manual (documentation standards) or your provider agreement.
Not addressed in any Highmark Delaware source read.[1]
Blocked on: Highmark Provider Services: ask whose NPI renders technician 97153 and whether the BCBA goes in box 24J or 31.
Yes. Since March 1, 2026 all ABA codes, 97151 through 97158 plus 0362T and 0373T, are on Highmark’s authorization list for Delaware members, reviewed by Highmark Behavioral Health. Requirements can vary by plan.
For Delaware PPO, $15.73 per 15 minutes in or out of the office, effective October 16, 2026. Other rates are in your contract.
Fully insured plans may cap ABA at a CPI-adjusted maximum, $38,601.65 per person from April 1, 2026 to March 31, 2027, with no visit limits. The mandate covers individuals under 21. Self-funded plans follow their own documents.
Delaware issues no behavior-analyst license. The mandate’s DHSS standard deems a BCBA qualified to provide ABA. Highmark still credentials you itself.
Delaware law guarantees at least 180 days from the date of service on state-regulated plans, and a clean claim must be acted on within 30 days.
Yes. Highmark’s prior-authorization requirements apply to services from out-of-area providers who participate with their own local Blue plan, and claims for listed services without authorization are denied. The out-of-state provider requests authorization through its local Blue plan’s portal and bills its local plan.
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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