Getting Autism Therapy Covered by Insurance in Delaware

Delaware’s mandate

18 Del. C. § 3366, enacted 2012, requires state-regulated health plans in Delaware to cover the diagnosis and treatment of autism spectrum disorder, including applied behavior analysis.

Ages covered: Under 21.

Dollar cap: $36,000 per 12-month period for ABA — but that is the 2012 figure and it does NOT stay there. The Insurance Commissioner must publish a CPI adjustment in the Delaware Register of Regulations by 1 April each year, and the adjusted figure applies to policies issued or renewed after it. Ask for the current year's number. Two protections sit alongside it: there is no limit on the number of visits, regardless of where services are delivered, and payments for treatment unrelated to ABA do not count toward the ABA maximum.

The clause to quote is in subsection (a): coverage shall not be denied on the basis that the treatment is HABILITATIVE OR NONRESTORATIVE in nature. Delaware also bars an insurer from terminating or refusing coverage because the individual OR A FAMILY MEMBER has been diagnosed with or treated for autism — the family-member protection is unusual and worth knowing if a sibling's diagnosis is being held against a policy.

Whether the mandate applies to your plan

This is the question to settle first, because the answer decides whether anything above is enforceable for you. State insurance mandates bind fully insured plans. Self-funded employer plans — where the employer pays claims itself and an insurer only administers them — are generally exempt under federal ERISA, and they cover roughly six in ten people with employer coverage.

Ask your HR department, in writing, which type your plan is. If it is self-funded, 18 Del. C. § 3366 does not compel coverage — but federal parity law may still help, and many large self-funded employers cover ABA voluntarily. Ask what the plan actually covers rather than assuming the answer is no.

The Medicaid route

Delaware Medicaid covers ABA for members under 21 through EPSDT, without the ABA maximum.

How Medicaid waivers work covers the route for families who do not qualify on income alone.

When you are denied

1. Get the denial reason in writing. Insurers must give a specific reason, and the appeal has to answer that reason rather than restate the diagnosis.
2. File the internal appeal within the deadline on the denial letter, with a letter of medical necessity that addresses the stated reason directly.
3. Request external review if the internal appeal fails. Fully insured plans carry external review rights, and an independent reviewer overturns denials more often than families expect.
4. Complain to the Delaware Department of Insurance on 1-800-282-8611 if you believe 18 Del. C. § 3366 is being violated. Their consumer pages are here.