The Children's Medical Services (CMS) Health Plan is Florida's Title XIX/XXI specialty plan for children with chronic conditions, operated by Sunshine Health on behalf of the state — which makes its membership disproportionately ABA-relevant and its BA process effectively a Sunshine line of business. Requests run through Sunshine's portal, form, and BA fax; the practical differences are a longer determination clock (7 calendar days instead of 5) and the fact that Title 21 (CHIP) members also require PA for ABA CPT codes.
Everything mechanical about CMS Health Plan BA is Sunshine Health: the Secure Provider Portal, the BA PA request form, the dedicated BA fax at 1-844-208-9113, in-house UM, and the AHCA clinical criteria underneath (referral + order + CDE, Vineland-3/BASC-3 reports, 6-month authorizations). The two differences worth building into intake: determinations take up to 7 calendar days rather than 5 — set family expectations accordingly — and PA applies to ABA CPT codes for Title 21 (CHIP) members as well as Title 19, so don't assume a CHIP card changes the workflow. Because the plan serves children with chronic and complex conditions, Florida's no-autism-diagnosis eligibility matters here more than anywhere: members with co-occurring medical conditions and functionally impairing behavior qualify through the referral gate without an ASD label.[1][3]
The questions that decide whether a family can start with Children's Medical Services (CMS) Health Plan (FL), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the Florida Medicaid rule: BA is for recipients under the age of 21 — and because this is the Title XIX/XXI specialty plan for children with chronic conditions, essentially the whole membership sits inside that window. Neither Sunshine’s BA materials nor the plan notice publishes a CMS-specific age limit, and the coverage policy forbids a plan from being more stringent than state policy.[5][1]
No autism diagnosis is required. The instrument clock is Sunshine’s, because CMS Health Plan runs on Sunshine’s BA process: the Vineland-3 and BASC-3 PRQ core assessments are required at the initial assessment and annually for reassessments, with complete scoring reports submitted at each prior-authorization request, on top of the state’s six-month reassessment and updated-behavior-plan cycle.[1][5]
The state rule, unchanged: the CDE must be led by a licensed practitioner working within their medical, developmental or psychological scope of practice, and the referral comes from an independent physician or qualifying practitioner. This matters more on this plan than anywhere else in Florida — members carry co-occurring chronic conditions and rich specialist records, and the no-diagnosis eligibility means functionally impairing behavior qualifies through the referral gate without an ASD label.[5][1]
The state pair, via Sunshine’s process: Vineland-3 Comprehensive Parent Interview Form (plus the Maladaptive Behavior Domain for ages 3 and older) and the BASC-3 PRQ for ages 2 through 18, with complete scoring reports attached to every PA request and re-administration annually.[1][5]
Required — the state referral plus physician order plus CDE, submitted through Sunshine’s BA process. Two CMS-specific mechanics: prior authorization applies to the ABA CPT codes for Title 21 (CHIP) members as well as Title 19, so a CHIP card does not shortcut the workflow; and determinations run up to seven calendar days rather than Sunshine’s five, which is the longest published clock among the Sunshine lines.[1][3][5]
Follows the Florida Medicaid rule as administered by Sunshine: telehealth is allowed only for 97156 caregiver training, within the state’s two-hours-a-week telemedicine cap, with a HIPAA-compliant platform and Florida Department of Health registration for an out-of-state rendering provider. No CMS Health Plan-specific telehealth expansion is published.[4][1][5]
CMS Health Plan runs its own, slower clock. Its provider manual: standard medical and behavioral health PA decisions “are made within seven calendar days of receipt of the request,” with one extension of “up to an additional four calendar days.” Urgent or expedited requests are decided “within 48 hours of receipt,” with a one-time one-day extension. Lead time: submit pre-scheduled services “within seven calendar days before the requested service date.” No separate BA reauthorization lead time is published. Note the gap with the AHCA contract: CMS Health Plan “must meet all other plan requirements for the MMA program,” and the MMA contract sets 5 days standard and 2 days expedited. Plan around the 7 days the plan publishes.[3][6]
CMS Health Plan’s manual: if “the member has other primary medical insurance, providers should submit the claim to that insurance as CMS Health Plan is always the payer of last resort. If an authorization is required, the providers still must obtain Sunshine Health authorization for the Medicaid portion of the bill.” Check the Coordination of Benefits tab in the Sunshine portal. Primary and secondary claims must be split and sent in order. File the COB claim within 90 days of the primary payer’s explanation of payment. Florida Medicaid pays last. Rule 59G-1.052 says: “Florida Medicaid is the payer of last resort. Providers must exhaust all TPL sources of payment, such as Medicare, TRICARE, private health insurance … prior to submitting or resubmitting a claim.” The AHCA contract binds every MMA plan to that rule. Two consequences for intake: Medicaid pays only “the difference between the Florida Medicaid rate and the third-party payment,” and it pays nothing when “the provider’s TPL claim is denied for failing to obtain the appropriate authorization from the third-party.” So get the commercial plan’s own ABA authorization first.[3][7]
Coverage decides whether Children's Medical Services (CMS) Health Plan (FL) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Sunshine’s machinery on the state floor: RBTs under a BCBA or BCaBA, BCaBAs under a BCBA, supervision intensity per the Council of Autism Service Providers standards as set out in the supervision plan inside the approved behavior plan, which must name the authorized supervisors.[5][1]
The state rule governs and Sunshine publishes no CMS-specific variation: the supervisee is not reimbursed when the supervisor is reimbursed for the same time period, and simultaneous services by more than one BA provider are non-covered unless medically necessary, prior authorized and indicated in the approved behavior plan.[5]
Ask the plan: Sunshine UM at 1-844-477-8313, which administers CMS Health Plan BA, for whether a specific plan may carry 97153 and 97155 on the same clock time.
The state weekly ceiling: up to 40 hours per week of BA intervention as prior-authorized in the behavior plan, with EPSDT available to exceed policy and fee-schedule limits when medically necessary, and group treatment capped at six participants. No per-day unit ceiling is published for this plan.[5][1]
Ask the plan: Sunshine UM for any per-day claim edit; the current AHCA BA fee schedule for per-assessment unit caps.
The state rule, unchanged: session notes are signed and dated by the rendering practitioner and must carry date, time, location, duration, behaviors observed, skills targeted, the recipient’s response, any protocol modification or therapist direction, an explanation if the parent or guardian was absent, and the participants. The behavior assessment and behavior plan are signed by the Lead Analyst and the parent or guardian.[5][1]
The state rule: a school-based request must include the IEP, or a 504 plan, or documentation naming the school and explaining that neither exists; 1:1 shadow, personal care, companion and chaperone services are non-covered regardless of setting, as is travel time; BA is non-covered on the same day as behavioral health overlay, therapeutic behavioral on-site, or therapeutic group care services — a same-day conflict worth checking on a chronic-condition population that often carries other Medicaid benefits.[5]
Claims run through Sunshine on the state enrollment structure: every rendering practitioner enrolls with AHCA (Lead Analyst 392, BCaBA 391, RBT 390), with 390s and 391s enrollable only as members of an enrolled BA group (393), and the PA request carries the supervising BCBA or licensed clinician’s NPI plus the group NPI and tax ID.[5][4]
Yes — it administers the Florida Medicaid BA benefit for its specialty population through Sunshine Health's process, on the state clinical criteria. No autism diagnosis is required; the physician referral + order + CDE gate applies.
Same portal, form, fax, and criteria — but determinations take up to 7 calendar days instead of 5, and Title 21 (CHIP) members also need PA for ABA CPT codes.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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