1 · Who qualifies
Florida Medicaid covers behavior analysis services for recipients under the age of 21 who need them because a behavior is impairing the child's ability to perform a major life activity. That last part is the test — not the diagnosis by itself.
The policy lists the kinds of behavior that count as functional impairment:
- Safety — aggression, self-injury, property destruction, elopement (leaving without permission)
- Communication — trouble with expressive or receptive language, poor understanding or use of non-verbal communication, stereotyped or repetitive language
- Self-stimulating — abnormal, inflexible or intense preoccupations
- Self-care — difficulty recognizing risk or danger, grooming, eating or toileting
- Other behaviors not listed above, including cases made complex by the treatment, the programming or the child's environment
2 · The referral and the evaluation
Your child must be referred by an independent physician or a practitioner qualified to assess and diagnose disorders related to functional impairment. The policy names who counts:
- Primary care physician in family practice, internal medicine or pediatrics
- Board certified or board eligible physician specializing in developmental behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, or adult or child psychiatry
- Child psychologist
The referral has to include two things:
- A physician's order for behavior analysis services
- A Comprehensive Diagnostic Evaluation (CDE) performed according to national evidence-based practice standards, led by a licensed practitioner working within their scope of practice
What the initial assessment must include
Before therapy starts, a behavior assessment is required. The policy requires two specific standardized instruments to be administered, scored and reported:
| Instrument | Who it applies to |
|---|---|
| Vineland-3 Comprehensive Parent Interview Form | All children — plus the Maladaptive Behavior Domain for ages 3 and older |
| BASC-3 Parenting Relationship Questionnaire | All children ages 2 through 18 |
The complete scoring report, including outcome measure scores, must be submitted with the prior authorization request.
3 · What is covered
Up to 40 hours per week of intervention
Covered as indicated in your child's prior-authorized behavior plan. The number of hours is set by clinical need and the authorization — 40 is the ceiling, not the default.
The service types
| Service | Who can deliver it |
|---|---|
| Adaptive behavior treatment by protocol — therapy delivered according to the authorized plan | Lead Analyst, BCaBA or RBT |
| With protocol modification — the plan is adjusted based on your child's response and progress | Lead Analyst or BCaBA |
| Group treatment by protocol — maximum six participants | Lead Analyst, BCaBA or RBT |
| Group with protocol modification — maximum six participants | Lead Analyst or BCaBA |
| Family adaptive behavior treatment guidance — training you on how to carry out the plan at home | Lead Analyst or BCaBA |
Parent participation
The policy says the parent or guardian should participate when possible and clinically appropriate, and that the provider must make every effort to accommodate that participation and document those efforts. If you cannot participate, the plan and session notes have to record why, what the likely impact is, and how the team is working around it.
Parent training does not always require your child to be present. Your child can be in session with one provider while you receive family training from another provider in the same group. And the Lead Analyst may deliver up to two hours per week of parent training by telemedicine.
Under 21: services can exceed the normal limits
Under the federal EPSDT requirement, services for recipients under 21 that exceed what this policy or the fee schedule describe may still be approved if they are medically necessary to correct or improve a condition. This is worth knowing — it means the published limits are not always the end of the conversation.
4 · What is not covered
Clinics rarely publish this list. We think you should see it before you start, so nothing comes as a surprise later.
Excluded from the ABA benefit
- Seclusion or restraint — any procedure or physical crisis management technique using seclusion, or manual, mechanical or chemical restraint to control behavior
- One-to-one aide, companion, chaperone or shadow services — supervision or personal care assistance, regardless of the activity or setting
- Caregiver or childcare services
- Psychological testing, neuropsychology, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy or long-term counseling
- Services funded under section 110 of the Rehabilitation Act of 1973
- Services not listed on the fee schedule
- Services on the same day as behavioral health overlay services, therapeutic behavioral on-site services, or therapeutic group care services — because those already include behavior analysis treatment
- Services delivered simultaneously by more than one ABA provider, unless it is medically necessary, prior authorized and written into the approved behavior plan
- Travel time
5 · Who is allowed to deliver the therapy
Florida Medicaid is specific about credentials. Services must be delivered by one of these:
| Role | Requirement |
|---|---|
| Lead Analyst | BCBA or Florida Certified Behavior Analyst credentialed by the Behavior Analyst Certification Board, or a practitioner fully licensed under Chapter 490 or 491, Florida Statutes, working within their scope |
| BCaBA | Board Certified Assistant Behavior Analyst, working under the supervision of a BCBA |
| RBT | Registered Behavior Technician, working under the supervision of a BCBA or BCaBA |
Supervision of BCaBAs and RBTs is required, in line with the practice standards published by the Council of Autism Service Providers, and it has to be written into the supervision plan of the approved behavior plan. If anyone offers your child ABA without a supervising analyst behind it, that is not what the policy allows.
6 · Authorization and paperwork
Authorization must be obtained from the quality improvement organization before services start and at least every 180 days after that. A new authorization is required if your child's clinical situation calls for a new assessment.
School-based services
If services are to be delivered at school, the authorization request must include your child's IEP. The policy allows for the realistic cases:
- No IEP, or the IEP does not include ABA services → the provider submits documentation justifying the request plus an estimate of when the IEP will be completed or updated
- The school does not do IEPs → a 504 plan can be submitted instead
- The school does neither → the provider submits the school's name and an explanation
Renewals
Requests to continue services must include data about parent or guardian participation. This is a common reason renewals get delayed, and it is avoidable: if you attend your training sessions and we document it, the renewal has what it needs.
What has to be in your child's record
The behavior assessment and behavior plan must be signed by the Lead Analyst and by you, and must include patient information, reason for referral, medical and developmental history (including any medications prescribed to address behavior), relevant family history, clinical interview, review of recent reports, assessment procedures and results, and the plan itself — with each goal defined in observable and measurable terms, a baseline, the procedures used, mastery criteria and the date it was introduced.
7 · When services end
Discharge is not arbitrary. The policy lists when a child is considered for discharge:
- No longer eligible under the coverage policy
- No longer meets medical necessity criteria as defined in Rule 59G-1.010, F.A.C.
- No longer engages in maladaptive behaviors
- Data shows the frequency and severity of the behavior, or the level of functional impairment, no longer blocks the child's ability to function in their environment
- The level of functional impairment no longer justifies continued services
- The parent or guardian withdraws consent for treatment
Notice that most of these are about progress. Discharge because your child no longer needs the service is the goal, not a loss of benefits.
8 · If your child is in a managed care plan
Most Florida Medicaid children are enrolled in a managed care plan — Sunshine Health, Simply, Molina, Humana and others. The policy is explicit about what that means:
Managed care plans must comply with the coverage requirements in this policy, and services must not be subject to more stringent coverage limits than the state policy sets.
In plain terms: your plan can have its own paperwork and its own network, but it cannot cover less than the state policy requires. If a plan tells you something is not covered and the state policy says it is, that is worth questioning — and we will help you do it.
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Florida Agency for Health Care Administration, Florida Medicaid Behavior Analysis Services Coverage
Policy, December 2024. Incorporated by reference in Rule 59G-4.125, Florida Administrative Code.
Legal authority: section 409.906, Florida Statutes. Copayment exemption: section 409.9081, Florida
Statutes. Medical necessity: Rule 59G-1.010, F.A.C.
Read the official policy (PDF) →
All Florida Medicaid coverage policies →
We keep this page aligned with the current policy. If AHCA updates it and you spot something out of date here before we do, tell us at compliance@americaninstituteofmentalhealth.com and we will correct it.