---
title: "Children's Medical Services Health Plan ABA coverage (Florida specialty plan)."
url: "https://carelu.com/payers/cms-health-plan-florida"
markdown_url: "https://carelu.com/payers/cms-health-plan-florida.md"
state: FL (Florida)
payer: "Children's Medical Services (CMS) Health Plan (FL)"
kind: Medicaid managed care plan (MCO)
parent_program: Florida Medicaid (AHCA)
description: "How the Children's Medical Services Health Plan — Florida's specialty plan for children with chronic conditions, operated by Sunshine Health — handles Behavior Analysis: Sunshine's BA process, the 7-day determination clock, and Title 21 (CHIP) PA requirements."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Children's Medical Services Health Plan ABA coverage (Florida specialty plan).

_Payer Guide · CMS Health Plan (FL) · Last updated September 2026 · 5 primary sources_

> Specialty plan for children with chronic conditions; Sunshine machinery, 7-day clock.

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.

This plan administers the **Florida Medicaid (AHCA)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Florida Medicaid — Behavior Analysis Services (AHCA) guide](https://carelu.com/payers/florida-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — via Sunshine Health's BA process (portal or BA fax 1-844-208-9113); Title 21/CHIP members included [1][2]
- **Prior auth for treatment**: Required — determinations within 7 calendar days (vs. 5 on other Sunshine lines) [3]
- **Autism diagnosis required?**: No — state BA policy applies: physician referral + order + CDE, no autism-diagnosis requirement [5][1]

## At a glance

- **Plan type:** SMMC specialty plan (Title XIX/XXI), operated by Sunshine Health
- **Clinical rules:** AHCA BA Coverage Policy, via Sunshine's BA process
- **Prior auth:** Required — Sunshine portal or BA fax 1-844-208-9113; CHIP members too
- **Determinations:** 7 calendar days (the longest clock among Sunshine lines)
- **Population:** Children with chronic conditions — high per-member ABA relevance
- **Rates:** Contracted via Sunshine; state fee schedule baseline

## A Sunshine line with two differences

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]

## Intake gates

The questions that decide whether a family can start with Children's Medical Services (CMS) Health Plan (FL), and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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]
- **Referral required?**: 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]
- **Telehealth**: 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]

## Delivery and billing rules

Coverage decides whether Children's Medical Services (CMS) Health Plan (FL) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: 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]
- **Concurrent billing (97153 + 97155)**: 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.
- **Daily limits / MUEs**: 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.
- **Session-note signature**: 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]
- **Place of service**: 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]
- **Bill as provider**: 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]

## What intake should collect for Children's Medical Services (CMS) Health Plan (FL)

- **Title 19 vs. Title 21:** Both require PA for ABA codes — but capture which program the member is in for eligibility hygiene.
- **Referral + order + CDE:** The state gate applies; no autism diagnosis required.
- **Medical complexity picture:** Chronic-condition membership means richer clinical records — gather co-occurring diagnoses for the most specific coding.
- **Timeline expectations:** The 7-day determination clock is the longest of the Sunshine lines — communicate it to families.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Children's Medical Services (CMS) Health Plan (FL) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Behavioral health administrator:** none
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required | 24 units per initial behavior assessment (max); the reassessment variant, billed with modifier TS, caps at 18 units — same $19.05/unit rate either way. per per assessment/reassessment (not daily) — a new authorization is required each time, not a recurring daily allotment. | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | TS — reassessment variant, same $19.05 rate, separate 18-unit cap (vs. 24 for the initial assessment) |
| 97152 | Yes | Required | 8 units per assessment (max). per per assessment (not daily). | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | — |
| 97153 | Yes | Required | No code-specific unit cap on the fee schedule; counts toward the aggregate 40 hrs/week (≈160 units/week) BA-intervention cap set by the coverage policy §4.2.2. per week (aggregate across all treatment codes together, not per-code). | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | XP — concurrent-supervision supervisee line, not separately reimbursed (the supervisor bills 97153/97155/97155-HN instead) |
| 97154 | Yes | Required | Max 6 participants per group (coverage policy §4.2.2); the group also counts toward the aggregate 40 hrs/week cap. Rendered by Lead Analyst, BCaBA, or RBT. per week (aggregate) plus a 6-participant group-size ceiling. | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | UN (2 clients, $7.58/unit), UP (3 clients, $7.08/unit), UQ (4 clients, $6.58/unit), UR (5 clients, $6.08/unit), US (6 clients, $5.58/unit) |
| 97155 | Yes | Required | No code-specific unit cap on the fee schedule; counts toward the aggregate 40 hrs/week cap. per week (aggregate across all treatment codes). | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | HN — BCaBA tier, $15.37/unit (vs. $19.17 Lead Analyst base rate), XP — concurrent-supervision supervisee line, not separately reimbursed |
| 97156 | Yes | Required | No code-specific cap on direct/in-person units; the TELEHEALTH variant (GT modifier) is separately capped at 2 hrs/week (8 units/week). per week (telehealth portion); aggregate 40 hrs/week cap governs the rest. | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | Yes — the ONLY Florida Medicaid BA code with a confirmed telehealth allowance. GT modifier, up to 2 hrs/week, per Rule 59G-1.057, F.A.C. (coverage policy §4.2.2, FL.CP.BH.500). Not confirmed whether the telehealth allowance extends to BCaBA-rendered (HN-modifier) training — both the coverage policy and Sunshine's clinical policy name the "Lead Analyst" specifically. Separately: Sunshine's general (non-BA) telehealth billing notice instructs POS 02 with NO GT/95/CR modifier appended, which appears to conflict with the BA-specific GT-modifier requirement — an unresolved discrepancy, flagged rather than guessed at; confirm the correct billing combination with each plan before submitting a 97156 telehealth claim. | GT — telemedicine delivery, same $19.05 rate, capped at 2 hrs/wk, HN — BCaBA tier, $15.24/unit (vs. $19.05 Lead Analyst base rate) |
| 97157 | No — absent from both the 2025 and 2026 AHCA Behavior Analysis fee schedules and not listed among the covered service categories in the Dec 2024 coverage policy §4.2.2. Cross-confirmed absent from Sunshine Health's own coding table (FL.CP.BH.500) and Humana's Florida Medicaid PA list too — three independent primary sources agree on the omission. This is NOT a formal written exclusion statement (no document states "97157 is excluded"), so treat this as verified-absent-from-the-billable-set rather than a proven-impossible claim. | N/A — not on the state's billable BA code set per the fee schedule and PA lists reviewed. | N/A per N/A | — | N/A | — |
| 97158 | Yes | Required | Max 6 participants per group; rendered by Lead Analyst or BCaBA only (NOT RBT, per the coverage policy — contrast 97154, which RBTs can render). per week (aggregate) plus a 6-participant group-size ceiling. | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | UN (2 clients, $9.58/unit), UP (3 clients, $9.08/unit), UQ (4 clients, $8.58/unit), UR (5 clients, $8.08/unit), US (6 clients, $7.58/unit) |
| 0362T | Yes | Required, and conditioned on medical necessity for the extra-technician protocol per the coverage policy. | 16 units per initial assessment or reassessment (max). per per assessment/reassessment. | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | — |
| 0373T | Yes | Required, and conditioned on medical necessity for the extra-technician protocol. | No distinct unit cap beyond the underlying code's session limits — the fee schedule doesn't publish one separately for this add-on. | home (categorical — no CMS POS-code number published anywhere in FL BA documentation, state or plan level), office/clinic (categorical), school (categorical — IEP/504 plan, or a documented explanation, required with the PA request per the coverage policy §7.2), community/other (categorical, per plan PA-form checkboxes) | No — not authorized for this code under the AHCA BA Coverage Policy. Only 97156 (family/caregiver training) has a stated telehealth allowance in Florida Medicaid BA; every other code is telehealth:'No' by policy design, not by omission. | — |

Code notes:

- **97151:** Physician referral + order + Comprehensive Diagnostic Evaluation gate the very first assessment request (no autism-diagnosis requirement) — see the guide's prose for the intake sequence. These are the statewide AHCA BA Coverage Policy mechanics, binding on Sunshine Health per the policy's plan-compliance clause (§1.2); Sunshine Health's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Sunshine Health provider relations before quoting a family.
- **97152, 97156:** These are the statewide AHCA BA Coverage Policy mechanics, binding on Sunshine Health per the policy's plan-compliance clause (§1.2); Sunshine Health's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Sunshine Health provider relations before quoting a family.
- **97153:** Billed at the SAME $12.26/unit rate whether rendered by an RBT, BCaBA, or Lead Analyst — Florida does not tier 97153 by staff credential (contrast 97155/97156, which do via the HN modifier). Sunshine's own BA QRG confirms an industry-reported network-enrollment pause on adding new practitioners to existing BA provider groups: effective 2025-10-01 in all AHCA regions except A and B (Sunshine newsroom, aba-pause.html), partially lifted in Regions E and F starting 2026-03-01 (pause-ends.html). Verify current status by region with Sunshine provider relations before promising a new hire's start date. These are the statewide AHCA BA Coverage Policy mechanics, binding on Sunshine Health per the policy's plan-compliance clause (§1.2); Sunshine Health's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Sunshine Health provider relations before quoting a family.
- **97154:** The modifier documents group size, not staff credential — rate scales DOWN as the group grows. Sunshine's PA form doesn't restate the UN–US group-size modifier letters (says only "see fee schedule for participant amount") — the letters themselves are inferred from the AHCA fee schedule. These are the statewide AHCA BA Coverage Policy mechanics, binding on Sunshine Health per the policy's plan-compliance clause (§1.2); Sunshine Health's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Sunshine Health provider relations before quoting a family.
- **97155:** Rendered by Lead Analyst or BCaBA only — RBTs do not bill 97155 in Florida. These are the statewide AHCA BA Coverage Policy mechanics, binding on Sunshine Health per the policy's plan-compliance clause (§1.2); Sunshine Health's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Sunshine Health provider relations before quoting a family.
- **97157:** If a family reports a Florida plan authorizing/paying 97157, verify directly with that plan — it would be an accommodation outside the state fee schedule, not the documented default. Independently cross-confirmed absent from Sunshine's own FL.CP.BH.500 coding table — not just the AHCA fee schedule. These are the statewide AHCA BA Coverage Policy mechanics, binding on Sunshine Health per the policy's plan-compliance clause (§1.2); Sunshine Health's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Sunshine Health provider relations before quoting a family.
- **97158:** Sunshine's PA form doesn't restate the UN–US group-size modifier letters — inferred from the AHCA fee schedule. These are the statewide AHCA BA Coverage Policy mechanics, binding on Sunshine Health per the policy's plan-compliance clause (§1.2); Sunshine Health's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Sunshine Health provider relations before quoting a family.
- **0362T:** Requires an on-site physician/QHP plus 2+ technicians for severe/destructive-behavior assessment support; billed alongside 97151/97151-TS, not standalone. These are the statewide AHCA BA Coverage Policy mechanics, binding on Sunshine Health per the policy's plan-compliance clause (§1.2); Sunshine Health's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Sunshine Health provider relations before quoting a family.
- **0373T:** Requires an on-site physician/QHP plus 2+ technicians for severe/destructive-behavior exposure treatment; billed alongside 97153/97155. These are the statewide AHCA BA Coverage Policy mechanics, binding on Sunshine Health per the policy's plan-compliance clause (§1.2); Sunshine Health's own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with Sunshine Health provider relations before quoting a family.

### Contacts

- **Provider services phone:** 1-844-477-8313
- **Hours:** Shared Sunshine Health machinery — same Provider Services / UM line, Monday–Friday 8 a.m.–8 p.m. Eastern (CMS Health Plan’s own determination clock runs 7 calendar days rather than Sunshine’s 5, per florida.ts prose, but the contact channel is identical).
- **Portal:** [Sunshine Health Secure Provider Portal](https://www.sunshinehealth.com/login.html)
- **Fax:** 1-844-208-9113

Questions to ask on a verification call:

- Does CMS Health Plan use its own EDI payer ID, or does it ride on Sunshine Health’s payer ID (68069) for 270/271 eligibility checks? Do you support real-time checks?
- Which service-type code do you return ABA benefit details under?
- Does the deductible apply to ABA services, and is the cost share a copay or coinsurance?
- Is any copay charged per visit or per day for ABA codes?
- Does the member’s out-of-pocket maximum apply to ABA benefits?
- For telehealth-delivered 97156, should claims use the GT modifier or POS 02 with no modifier?

### VOB data sources

- https://www.sunshinehealth.com/providers/Billing-manual/ba.html (accessed 2026-07-23)
- https://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/COMPANION%20GUIDES/FMMIS_5010_270_271_Companion%20Guide_v4_0_04272023.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.flrules.org/gateway/readRefFile.asp?refId=17525&filename=Florida%20Medicaid%20Behavior%20Analysis%20Services%20Coverage%20Policy.pdf (accessed 2026-07-23)
- https://ahca.myflorida.com/content/download/26138/file/2025%20Behavior%20Analysis%20Fee%20Schedule.pdf (accessed 2026-07-23)
- https://www.sunshinehealth.com/content/dam/centene/Sunshine/pdfs/SH-PRO-BH-BA-PA-Request.pdf (accessed 2026-07-23)
- https://www.sunshinehealth.com/content/dam/centene/Sunshine/policies/clinical-policies/FL.CP.BH.500.pdf (accessed 2026-07-23)
- https://www.sunshinehealth.com/newsroom/aba-pause.html (accessed 2026-07-23)
- https://www.sunshinehealth.com/newsroom/pause-ends.html (accessed 2026-07-23)
- https://www.sunshinehealth.com/newsroom/telehealth-billing-update.html (accessed 2026-07-23)

## Common questions

### Does the CMS Health Plan cover ABA?

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.

### How is CMS Health Plan different from regular Sunshine Health for ABA?

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.

## Primary sources

1. [Sunshine Health — BA Provider Quick Reference Guide](https://www.sunshinehealth.com/providers/Billing-manual/ba.html)
2. [Sunshine Health — PA required for ABA CPT codes incl. CMS Title 21 (plan notice)](https://www.sunshinehealth.com/newsroom/aba-cpt-codes.html)
3. [Children’s Medical Services Health Plan Provider Manual (CMS_10234, © 2025 Sunshine Health)](https://www.sunshinehealth.com/content/dam/centene/Sunshine/pdfs/CMS-PRO-PE-Manual.pdf)
4. [Sunshine Health — BA PA Request Form (fax 1-844-208-9113)](https://www.sunshinehealth.com/content/dam/centene/Sunshine/pdfs/SH-PRO-BH-BA-PA-Request.pdf)
5. [Florida Medicaid BA Services Coverage Policy (Dec 2024)](https://www.flrules.org/gateway/readRefFile.asp?refId=17525&filename=Florida%20Medicaid%20Behavior%20Analysis%20Services%20Coverage%20Policy.pdf)
6. [AHCA SMMC Model Health Plan Contract — Attachment II Core Provisions (update 10/1/2025), §V.6 and §XI.D](https://ahca.myflorida.com/content/download/27248/file/Attachment%20II-%20-%20Core%20Contract%20Provisions%20Oct%202025.pdf)
7. [Rule 59G-1.052, F.A.C. — Third-Party Liability Requirements (AHCA)](https://ahca.myflorida.com/content/download/5929/file/59G_1052_TPL_Requirements.pdf?version=1)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.