Delaware Diamond State Health Plan and ABA Therapy: What Families Need to Know

What Is the Delaware Diamond State Health Plan?

The Diamond State Health Plan is Delaware's Medicaid program, providing health coverage to low-income children, pregnant women, parents, and individuals with disabilities. For families raising a child with autism, this plan can be a lifeline-covering essential therapies like Applied Behavior Analysis (ABA) that help children build communication, social, and daily living skills.

Administered by the Delaware Department of Health and Social Services (DHSS), Diamond State Health Plan contracts with managed care organizations (MCOs) to deliver services. Most ABA therapy is covered through these MCOs, but the specific approval process and provider networks can vary slightly depending on your child's plan.

🔗 Related reading: Texas Autism Support Groups: A Parent's Guide · Local ABA Therapy

Does Diamond State Health Plan Cover ABA Therapy?

Yes. Delaware law requires that the Diamond State Health Plan cover medically necessary ABA therapy for children diagnosed with autism spectrum disorder (ASD). This coverage extends to children under 21 who have a valid prescription from a licensed physician or psychologist.

What ABA Services Are Covered?

Covered services typically include:

• Comprehensive diagnostic evaluation to confirm the autism diagnosis and assess the child's needs.
• Behavioral assessment by a Board Certified Behavior Analyst (BCBA) to create a treatment plan.
• Direct one-on-one therapy with a registered behavior technician (RBT) under BCBA supervision.
• Parent and caregiver training to reinforce skills at home.
• Treatment plan updates and progress monitoring by the BCBA.
• Social skills groups and other evidence-based interventions as deemed medically necessary.

Coverage is generally provided in the child's natural environment-home, school, or community-but may also be available in a clinic setting if that's more appropriate.

What Are the Limits?

While the plan covers ABA, it may have annual or lifetime caps on therapy hours or dollar amounts. These limits are set by the state and can change. As of 2024, Delaware does not have a hard cap on ABA hours for children under 21, but requests must be justified by medical necessity. Prior authorization is required before services begin, and ongoing authorization is needed every few months.

It's also important to note that ABA is covered only when provided by a BCBA or a supervised RBT. Unlicensed providers or those without BCBA oversight are not reimbursable.

How to Get ABA Therapy Through Diamond State Health Plan

Navigating the system can feel overwhelming, but the process is straightforward once you know the steps.

Step 1: Get a Diagnosis and Prescription

Your child must have a formal autism diagnosis from a licensed professional (developmental pediatrician, child psychiatrist, or psychologist). Ask for a written prescription for ABA therapy that specifies medical necessity.

Step 2: Find a BCBA-Led Provider

You'll need to find an ABA provider who accepts Diamond State Health Plan. This is where ABA For My Child can help. As a free matching service, we connect families with vetted, BCBA-led providers in Delaware who are experienced with Medicaid billing. We ask about your child's needs, your location, and your insurance, then match you with providers who have availability and accept your plan.

Step 3: Obtain Prior Authorization

Your chosen provider will submit a treatment plan and request for prior authorization to your child's MCO. This process typically takes 2-4 weeks. The provider will need to document the child's diagnosis, the number of recommended hours, and how the therapy will address specific behavioral goals.

Step 4: Begin Therapy

Once authorized, therapy can start. Sessions are usually scheduled weekly, with the BCBA overseeing the RBT and adjusting the plan as needed. Reauthorization is required every 6 to 12 months, depending on the MCO.

🔗 Related reading: SC Early Intervention Programs: A Parent's Guide · Nearby ABA Therapy

Costs and Financial Considerations

For families enrolled in Diamond State Health Plan, ABA therapy is provided at no cost. There are no premiums, deductibles, or copays for covered services. This is a huge relief, as private ABA therapy can cost $50,000 to $100,000 per year.

However, if your child has a secondary insurance (like a parent's employer plan), that plan may be billed first. In that case, you might have some out-of-pocket costs depending on your secondary plan's ABA coverage. Always check with the provider's billing department to understand your financial responsibility.

Common Mistakes to Avoid

Families often encounter delays or denials. Here's how to avoid the most common pitfalls:

• Not getting a proper diagnosis first. Some providers require a specific evaluation tool (like the ADOS-2) to confirm the diagnosis. Make sure your child's evaluation meets the MCO's criteria.
• Assuming any provider will do. Not all ABA providers accept Medicaid or have experience with Diamond State Health Plan's authorization process. Using a matching service like ABA For My Child ensures you're connected with providers who are familiar with the system.
• Waiting too long to start. Early intervention is critical. If your child is under 3, also explore Delaware's Birth to Three early intervention program, which can coordinate with ABA therapy.
• Ignoring reauthorization deadlines. Your provider must submit reauthorization requests well before the current authorization expires. Missed deadlines can cause a gap in services.

ABA For My Child: Your Free Matching Service

Finding the right ABA provider who accepts Diamond State Health Plan can be time-consuming. That's why ABA For My Child exists. We're a free, nationwide matching service that connects families with vetted, BCBA-led providers. Simply tell us about your child's needs, your location in Delaware, and your insurance (including Diamond State Health Plan), and we'll match you with providers who have openings and accept your plan.

Our service is completely free to families-we're funded by the providers on our network. We don't recommend a single company; instead, we give you a shortlist of options so you can choose the best fit for your child.

Frequently Asked Questions About Diamond State Health Plan and ABA

Here are some common questions families ask:

Does Diamond State Health Plan cover ABA for adults? Coverage is primarily for children under 21. Adults may qualify through other Medicaid programs, but it's less common.

Can I choose any ABA provider? You can choose any provider who is in-network with your child's MCO and accepts Diamond State Health Plan. Out-of-network providers are not covered.

How long does prior authorization take? Typically 2-4 weeks, but it can vary by MCO and the complexity of the request.

What if my child's ABA is denied? You have the right to appeal. Your provider can help you submit additional documentation to show medical necessity.

Is ABA therapy covered in school? Yes, if the provider is contracted with the school and the therapy is part of the child's IEP. However, the school district may also provide some behavior support services separately.

How do I switch providers if I'm not satisfied? You can request a change at any time. Your new provider will need to obtain a new prior authorization. ABA For My Child can help you find a new provider who accepts your plan.