Is ABA Therapy Covered by Medicaid in Delaware?

Understanding ABA Therapy and Medicaid in Delaware

If your child has an autism diagnosis and you live in Delaware, you may be wondering if applied behavior analysis (ABA) therapy is covered by Medicaid. The short answer is yes: Delaware's Medicaid program covers ABA therapy for eligible children and adolescents under the age of 21. This coverage is part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which ensures that children receive medically necessary services to address developmental and behavioral health needs.

ABA therapy is an evidence-based approach that uses principles of behavior to improve social, communication, and learning skills while reducing challenging behaviors. Delaware Medicaid recognizes ABA as a medically necessary treatment for autism spectrum disorder (ASD) when prescribed by a physician and delivered by a board-certified behavior analyst (BCBA) or a supervised registered behavior technician (RBT).

For families navigating this process, it is important to understand the specific requirements, steps to get coverage, and how to find a provider. ABA For My Child is a free matching service that can connect you with vetted, BCBA-led providers in Delaware who accept Medicaid, making the journey smoother.

🔗 Related reading: Ohio Parent's ABA Therapy Start Checklist · Local ABA Therapy

Who Is Eligible for ABA Coverage Under Delaware Medicaid?

Eligibility for ABA therapy through Delaware Medicaid depends on several factors, including age, diagnosis, and the type of Medicaid plan you have. Here is what you need to know.

Age and Diagnosis Requirements

Delaware Medicaid covers ABA therapy for children and adolescents under the age of 21 who have a diagnosis of autism spectrum disorder (ASD). The diagnosis must come from a qualified professional, such as a developmental pediatrician, child psychiatrist, or licensed psychologist. Coverage is not limited to young children; teens can also access services if they meet medical necessity criteria.

In some cases, children with other developmental disabilities may also qualify for ABA if it is deemed medically necessary, but autism is the most common condition covered.

Medicaid Plans in Delaware

Delaware's Medicaid program is called the Diamond State Health Plan (DSHP). Most Medicaid beneficiaries are enrolled in a managed care plan through DSHP, which is administered by Highmark Health Options. There is also a fee-for-service option for certain populations, such as children in foster care or those with complex medical needs. Both managed care and fee-for-service plans are required to cover ABA therapy under the EPSDT benefit.

If your child is enrolled in Delaware's Children's Health Insurance Program (CHIP), known as CHIP in Delaware, ABA therapy is also covered for eligible children with autism. CHIP is separate from Medicaid but follows similar coverage rules.

What ABA Services Does Delaware Medicaid Cover?

Delaware Medicaid covers a range of ABA services, provided they are medically necessary and prescribed by a doctor. The specific services include:

• Comprehensive assessment and functional behavior assessment (FBA) by a BCBA to identify your child's strengths and needs.
• Individualized behavior intervention plans (BIP) developed by a BCBA.
• Direct one-on-one therapy delivered by a BCBA or RBT under BCBA supervision.
• Parent training and caregiver support to help families implement strategies at home.
• Supervision and oversight by a BCBA, including progress monitoring and plan adjustments.

There is no fixed limit on the number of hours covered, but prior authorization is required. The number of hours approved depends on your child's individual needs, as determined by the BCBA and physician. Typically, hours range from 10 to 40 per week, with higher hours for younger children or those with more significant needs.

🔗 Related reading: Is ABA Therapy Covered by Medicaid in South Carolina? · Nearby ABA Therapy

How to Get ABA Therapy Covered by Delaware Medicaid

Getting coverage for ABA therapy involves several steps. Here is a practical guide to help you navigate the process.

Step 1: Obtain a Formal Diagnosis

If your child does not already have an autism diagnosis, you will need to get one from a qualified professional. This can be done through a developmental pediatrician, a child psychologist, or a diagnostic clinic in Delaware, such as those at Nemours Children's Health in Wilmington or ChristianaCare. The diagnosis must include a written report that documents the criteria for ASD.

Step 2: Get a Prescription for ABA

Your child's primary care physician or a specialist must write a prescription for ABA therapy. The prescription should state that ABA is medically necessary for treating autism. This is a key document for prior authorization.

Step 3: Choose a BCBA-Led Provider

You will need to select an ABA provider that accepts Delaware Medicaid. Not all providers do, so it is important to verify. ABA For My Child can help you find vetted, BCBA-led providers in Delaware who accept Medicaid, saving you time and effort. Simply visit abaformychild.com and complete the free matching form.

Step 4: Submit for Prior Authorization

The ABA provider will typically handle the prior authorization process with your Medicaid plan. They will submit the diagnosis, prescription, and a treatment plan that outlines the proposed hours and goals. Approval can take a few weeks, so plan ahead.

Step 5: Begin Therapy

Once authorized, your child can start ABA therapy. The provider will schedule sessions, which may take place at their clinic, in your home, or in community settings. Regular progress reports are sent to your Medicaid plan to ensure continued coverage.

Common Mistakes to Avoid When Seeking ABA Coverage

Navigating Medicaid coverage for ABA can be tricky. Here are some pitfalls to watch out for.

• Not having a formal diagnosis. Without a written diagnosis from a qualified professional, coverage will not be approved. Make sure the diagnosis is specific to autism spectrum disorder.
• Choosing a provider that does not accept Medicaid. Always confirm that the provider is in-network with your specific Medicaid plan. Some providers may say they accept Medicaid but are not contracted with Diamond State Health Plan.
• Delaying the prior authorization process. Start the paperwork as soon as you have a diagnosis and prescription. Delays can mean months without therapy.
• Assuming all ABA providers are the same. Look for a provider led by a BCBA with experience in autism. ABA For My Child can help you find qualified providers.
• Not asking about parent training. Parent training is a covered service and is crucial for success. Make sure your provider includes it in the treatment plan.

What If Your Child Has Private Insurance?

If your child has private insurance through a parent's employer or the individual market, ABA coverage may also be available. Delaware has a state autism mandate that requires most private health plans to cover ABA therapy for autism. However, private insurance often has different rules, such as annual caps on benefits or higher copays. If you have both Medicaid and private insurance, Medicaid may act as a secondary payer to cover costs not paid by the primary plan.

For families without insurance, Delaware Medicaid is a vital resource. The program covers ABA with no copays or deductibles for eligible children, making it accessible regardless of income.

How ABA For My Child Can Help

Finding the right ABA provider who accepts Delaware Medicaid can be overwhelming, especially when you are already managing your child's care. ABA For My Child is a free service that simplifies this process. We match families with vetted, BCBA-led providers in Delaware who have experience with Medicaid and autism. Our team understands the local landscape and can connect you with providers who are accepting new patients.

To get started, visit abaformychild.com and complete a short questionnaire. Within a few days, you will receive personalized provider matches. There is no cost to you, and we do not share your information without your permission. Let us help you get the ABA therapy your child needs.

Frequently Asked Questions About ABA and Delaware Medicaid

Here are answers to common questions families have about ABA coverage in Delaware.

Does Delaware Medicaid cover ABA for adults?

No, Delaware Medicaid's EPSDT benefit covers ABA only for individuals under 21. Adults with autism may need to seek other funding sources, such as private insurance or state developmental disability services.

Is there a waiting list for ABA therapy in Delaware?

Wait times vary by provider and region. Some areas, like New Castle County, may have shorter waits, while rural areas may have longer delays. Using a matching service like ABA For My Child can help you find providers with availability.

Can ABA be done at home or in school?

Yes, Delaware Medicaid covers ABA in various settings, including home, clinic, school, and community. The setting depends on your child's needs and the provider's offerings.

What if my child is denied coverage?

If your prior authorization is denied, you have the right to appeal. Your ABA provider can help you submit additional documentation. ABA For My Child can also connect you with providers who have experience with appeals.

Does Delaware Medicaid cover both in-person and telehealth ABA?

Yes, Delaware Medicaid covers both in-person and telehealth ABA services. Telehealth can be a convenient option for families in rural areas or those with scheduling challenges.

How long does it take to get approved?

Approval typically takes 2 to 4 weeks after the provider submits the prior authorization request. Delays can occur if documentation is incomplete, so work closely with your provider.