Important Change To Behavior Analysis (BA) Therapies for Medicaid Enrolled Children

Beginning in early 2025, Florida Medicaid will shift Behavior Analysis (BA) therapies into the Statewide Medicaid Managed Care (SMMC) program. This means that, if your child is enrolled in managed care, your child’s BA provider must be “in-network” with the managed care plan in which your child is enrolled.

Medicaid managed care plans for children in Florida include:  Aetna Better Health, Sunshine Health, Florida Community Care, Simply Health, Humana, Molina, and United Healthcare.

Below you will find a description of your child’s rights to continued BA therapy as this shift occurs.

Your child has a right to all Medicaid services necessary to correct or ameliorate their health condition under EPSDT.

• What is EPSDT?

For child Medicaid enrollees, states must cover “necessary health care, diagnostic services, treatment and other measures… to correct or ameliorate defects and physical and mental illnesses and conditions.” This requirement is known as “Early and Periodic Screening, Diagnosis and Treatment” or “EPSDT.”

• Does EPSDT have limits?

There are only a few, narrow limits to the EPSDT coverage mandate:

• The benefit or service must fall within Medicaid’s scope. EPSDT requires the state to cover all mandatory and optional services the state can cover under Medicaid, whether or not the state covers those services for adults. 
• The requested benefit or service cannot be experimental or investigational and must be medically necessary. For Florida Medicaid’s definition of medically necessary, see 59G-1.010. 
• The state (or plan) can deny the requested benefit or service and authorize a less costly one but the less costly benefit or service must be equally effective.  

For example, if it is medically necessary for your child to receive one hour of BA therapy three times per week for six months to correct or ameliorate a health problem, then EPSDT requires the state (or plan) to cover that amount of therapy.

• What are EPSDT rights in managed care? 
• The state must provide newly authorized services in a timely manner (within 90 days of the service being prescribed). Waitlists outside of 90 days are not allowed. 
• Hard caps on the amount of services are not allowed. 
• Managed care plans must make a provider available for all medically necessary services and cannot tell a child that there are no providers available.
• For already authorized services, including BA therapy, the child is entitled to continuity of care which is described in more detail below. 

Note: a child is not entitled to a specific provider. However, the managed care plan must ensure network adequacy as described in more detail below.

• Who can help coordinate my child’s EPSDT services? 

If your child receives nursing services, is in a PPEC or medical foster care, or is enrolled in the CMS Plan, then your child is entitled to a case manager to help you navigate all aspects of your child’s care including continuation of BA therapy without interruption.

Your child has a right to continuity of care.

• What is continuity of care? 

Continuity of care is the right for those individuals receiving Medicaid benefits and services through managed care to maintain their previously authorized benefits and services without interruption when the individual changes to a new plan or provider.

• What rights does your child have under continuity of care? 

If your child is in a managed care plan and receives therapy from a BA provider that will no longer be in-network with your child’s new plan, your child is entitled to 90 days of continuity of care. This means your child must continue to receive services at the same level for 90 days.

Additionally, your current provider is entitled to the same level of reimbursement for 60 days.

Your child has a right to an BA provider without a lengthy wait. 

• After my child’s last authorization for services expires and my current BA provider discharges us, how long will my child have to wait for a new provider?

Your child’s managed care plan must ensure a specialist is available to provide your child services no more than 60 days from the referral by your child’s pediatrician. Remember that your child is entitled to 90 days of continuity of care as well which means that there should be no interruption in your child’s care if you have to switch providers.

Your child has a right to appeal a denial, reduction, or termination of their ABA therapy. 

• How do I submit an appeal if my child’s ABA services are denied, reduced, or terminated?

Once you receive a Notice of Adverse Benefit Determination (NABD), you have 60 days from the date of the notice to file a written or oral appeal. For guidance on the appeals process, refer to our handout How to File A Medicaid Managed Care Appeal.

You have the right to complain if your child’s rights are violated.

If the rights discussed herein are violated, then you have the right to complain. There is an AHCA homepage for Florida Medicaid Complaints where you can submit a Complaint against your child’s managed care plan.

Once completed, you will be given a Complaint # which you can use to check the status of your complaint after 24-48 hours. Refer to FHJP’s handout on How to File a Managed Care Complaint for more information.

If you need legal assistance because your child is not receiving the BA therapy he or she needs, please contact Florida Health Justice Project.