--- title: "Florida Medicaid Behavior Analysis (BA) coverage: the intake guide." url: "https://carelu.com/payers/florida-medicaid" markdown_url: "https://carelu.com/payers/florida-medicaid.md" state: FL (Florida) payer: "Florida Medicaid — Behavior Analysis Services (AHCA)" kind: State Medicaid program description: "How Florida Medicaid covers ABA under the Behavior Analysis (BA) benefit — no autism diagnosis required, the February 2025 SMMC 3.0 carve-in to nine MMA plans, Acentra/eQSuite for fee-for-service, Vineland-3 and BASC-3 documentation, 180-day authorizations, and the low fee schedule." last_reviewed: September 2026 vob_data_updated: 2026-07-23 --- # Florida Medicaid Behavior Analysis (BA) coverage: the intake guide. _Payer Guide · Florida Medicaid · Last updated September 2026 · 16 primary sources_ > No autism dx required; BA carved INTO nine MMA plans 2/1/2025; 97153 at $12.26/unit. Florida Medicaid covers ABA as "Behavior Analysis (BA) Services" for recipients under 21 — and its front door is one of the widest in the country: no autism diagnosis is required. Eligibility turns on behavior that impairs a major life activity, gated by an independent physician's referral. The structure changed fundamentally on February 1, 2025, when SMMC 3.0 carved BA INTO the nine Managed Medical Assistance plans: most families now get BA through their plan's network with prior authorization routed to the plan, while the shrinking fee-for-service remainder still authorizes through Acentra Health's eQSuite. The trade-off for the wide front door is heavy documentation (Vineland-3 and BASC-3 with every request) and some of the lowest ABA rates in the Southeast. ## Prior authorization and diagnosis at a glance - **Prior auth for the assessment**: Required — FFS via Acentra's eQSuite (assessment codes submitted separately from treatment); MMA enrollees via their plan [3][1] - **Prior auth for treatment**: Required — authorization before initiation and at least every 180 days; behavior plan covers up to 6 months [1][3] - **Autism diagnosis required?**: No — eligibility is functional impairment of a major life activity, gated by a physician referral + order + Comprehensive Diagnostic Evaluation (no F84.x requirement) [1] ## At a glance - **Covers ABA?:** Yes — under 21, via the BA benefit (EPSDT can exceed policy limits) - **Autism dx required?:** NO — functional-impairment eligibility; physician referral + order + CDE instead - **Prior auth:** Required for all BA services — via the MMA plan, or Acentra (eQSuite) for FFS - **Auth periods:** Up to 180 days / 6 months; reassessment + updated behavior plan to renew - **Hour cap:** Up to 40 hrs/week as prior-authorized in the behavior plan - **Rates (per 15 min):** 97151 $19.05 · 97153 $12.26 · 97155 $19.17 · 97156 $19.05 - **Administered by:** Nine MMA plans (since 2/1/2025) + Acentra FFS for non-enrolled recipients - **Staff screening:** Level 2 fingerprint (FDLE + FBI) via the Clearinghouse — every rendering practitioner, employer-renewed every 5 years ## The February 2025 carve-in: who authorizes what now For years Florida ran BA as a fee-for-service carve-out with all prior authorization through eQHealth (now Acentra Health). SMMC 3.0 ended that on February 1, 2025: BA moved into the nine MMA plans — Aetna Better Health, Children's Medical Services Health Plan, Community Care Plan, Florida Community Care, Humana Healthy Horizons, Molina, Simply Healthcare, Sunshine Health, and UnitedHealthcare Community Plan. If the family is enrolled in an MMA plan, the plan's process (portal, UM vendor, fax, turnaround) governs the PA; only recipients NOT enrolled in a plan remain fee-for-service with authorization through Acentra's eQSuite portal at fl.acentra.com (customer service 855-444-3747). At the transition, plans had to honor pre-existing Acentra authorizations — AHCA's baseline was ~90 days of auth protection, and UHC, Humana, and Florida Community Care each publicly committed to 120 days plus paying non-par providers at prior rates. The first intake question in Florida is therefore: which plan — because it decides where the paperwork goes. [1][5][4] One guardrail keeps the nine plans aligned: the coverage policy requires managed care plans to comply with its service coverage requirements and forbids more stringent limits than Florida Medicaid policy. Plans differ on process — portals, delegated UM vendors, faxes — not clinical criteria. The per-plan guides below cover those mechanics. [1][5][4] ## No autism diagnosis required — the referral gate instead Florida's eligibility test is functional, not diagnostic: recipients under 21 "requiring medically necessary BA services to address behavior that impairs a recipient's ability to perform a major life activity" — safety, communication, self-care, self-stimulating and other behaviors all qualify. There is no F84.x requirement. What gates entry instead is a referral from an independent physician or practitioner (a PCP in family practice, internal medicine, or pediatrics; a developmental-behavioral or neurodevelopmental pediatrician; a pediatric neurologist; a psychiatrist; or a child psychologist), and that referral must include a physician's order for BA services plus a Comprehensive Diagnostic Evaluation (CDE) performed to national evidence-based practice standards, led by a licensed practitioner. Claims still need the most current, most specific diagnosis code that supports medical necessity, plus co-occurring disorders — but for intake, the practical checklist is referral, order, and CDE, not a diagnosis hunt. Families waiting on an autism evaluation don't have to wait for BA. [1] ## Authorization mechanics & the documentation stack All BA services require prior authorization — assessment included. On the FFS side, assessment requests (97151, 97152, 97151-TS) are submitted separately from treatment codes in eQSuite; initial ("admission") requests go in at least 5 business days before the start date, reauthorizations ("continued stay") 10–30 business days before the current period ends, with decisions in 3 business days at first level (5 at physician level) once information is complete, and reconsideration available within 30 calendar days of a denial. Authorizations run up to 180 calendar days; renewing one takes a reassessment and an updated behavior plan at least every 6 months, with the core instruments re-administered every 12 months. [3][1] The documentation stack is Florida's real workload: every PA request must attach complete scoring reports for the Vineland-3 (Comprehensive Parent Interview Form, plus the Maladaptive Behavior Domain for ages 3+) and the BASC-3 PRQ (ages 2–18). School-based BA needs the IEP (or 504 plan, or a documented explanation) with the request, and reauthorizations must include data on parent/guardian participation — so caregiver engagement is a renewal variable from day one. Interventions cap at 40 hours/week as prior-authorized in the behavior plan, though EPSDT allows exceeding policy and fee-schedule limits when medically necessary. Billing runs on the 8-minute rule for 15-minute units; supervisor and supervisee can't both bill the same time; group treatment maxes at 6 participants; travel time and 1:1 shadow/personal care are explicitly non-covered. [3][1] ## Rates: among the lowest in the Southeast The January 1, 2025 BA fee schedule (still operative through 2026) pays per 15-minute unit: 97151 behavior assessment $19.05 (max 24 units per assessment; reassessment 97151-TS $19.05, max 18 units), 97153 direct treatment $12.26 (RBT, BCaBA, or Lead Analyst — same rate regardless of credential), 97155 protocol modification $19.17 at the Lead Analyst tier ($15.37 with the HN modifier for BCaBA), and 97156 family training $19.05 (telemedicine 97156-GT at the same rate, max 2 hours/week). The $12.26 on 97153 — the code that fills most of a week — is the number to build Florida Medicaid unit economics around, and it has barely moved: the August 2022 schedule paid $12.19. A caveat on sourcing: AHCA's fee-schedule PDFs block automated retrieval, so the 2025/2026 figures here are cross-verified from two secondary trackers and anchored against the archived 2022 AHCA schedule — confirm the current PDF from AHCA directly before contracting. MCO-contracted rates use the state schedule as the reference baseline. [6][5][7] ## Staffing & credentialing: who you can hire, and what they must clear Florida licenses no behavior analysts: s. 393.17, F.S. instead recognizes certification from a national credentialing board — the BACB — and the FL-CBA is a closed legacy credential (the BACB absorbed the old state program in October 2003; no new FL-CBAs are issued, and a lapsed one requires requalifying as a BCBA). Under the December 2024 coverage policy, technicians must be BACB-credentialed RBTs working under a BCBA or BCaBA, and the Lead Analyst on every case must be a BCBA, an FL-CBA, or a practitioner licensed under chapter 490 or 491. The policy adds no training hours beyond the BACB's own RBT requirements (40-hour training, competency assessment, exam, plus the BACB's own criminal-background and abuse-registry check within 180 days of applying). The staffing catch is enrollment: every rendering practitioner individually enrolls in Florida Medicaid — Lead Analysts as provider type 392, BCaBAs as 391, RBTs as 390, with 390s and 391s enrollable only as members of an enrolled BA group (type 393). Each application needs a color copy of the BACB certification matching the applicant's legal name (black-and-white copies are rejected) and a completed background screening — AHCA says missing screenings and missing tax-ID proof are the two most common causes of BA application delays. [8][9][1][10][11][12][13][14][15][16] The background screening reaches far past owners: s. 409.907(8)(a), F.S. requires a Level 2 screening not just for the provider and each principal (officers, directors, managing employees, 5%+ owners) but for anyone who participates "by way of rendering services to Medicaid recipients or having direct access to Medicaid recipients" — i.e., every RBT, BCaBA, and analyst on the schedule. Mechanics: the employer initiates the screening through the Care Provider Background Screening Clearinghouse; the candidate submits fingerprints and a photo at an approved Livescan provider; FDLE runs the statewide check and the FBI the national one, plus sex-offender registry searches in states of residence over the preceding 5 years; the eligibility determination must be in hand before employment begins, and for Medicaid enrollment the screening must be within the last 5 years. Prints are retained — FDLE automatically reports new Florida arrests against them — and the employer must initiate a Clearinghouse renewal via the Clearinghouse Results Website before the 5-year expiration (the window opens 60 days out); miss it and the prints drop, the determination expires, and the employee re-fingerprints at a Livescan provider at higher cost. Since January 1, 2024, employers must also register with the Clearinghouse and report employment-status changes within 5 business days. One honest gap: neither the coverage policy nor AHCA's BA enrollment materials publish an OIG-LEIE/SAM.gov exclusion-screening cadence for BA staff — federal exclusion-screening obligations still apply, so set your own monthly-check policy rather than waiting for a state instruction. [8][9][1][10][11][12][13][14][15][16] Supervision floors: Florida sets no numeric ratio in rule. The coverage policy instead requires all BA services — including supervision of BCaBAs and RBTs — to follow "current practice standards as published by the Council of Autism Service Providers," as laid out in the supervision plan inside the approved behavior plan (which must name the authorized supervisors). The incorporated CASP standard is 1–2 hours of case supervision per 10 hours of direct treatment; the BACB's 5%-of-monthly-hours minimum for RBTs remains the floor underneath. Supervision is billable — the supervisor can be reimbursed for observing a supervisee implementing the plan, but the supervisee isn't paid for the same time period. At the plan level, the two MMA plans checked (Simply/Carelon and Humana) layer only administrative credentialing and portal registration on top — no evidence of employee-level screening beyond the AHCA Level 2/Clearinghouse baseline, which already covers every rendering practitioner through enrollment. [8][9][1][10][11][12][13][14][15][16] ## Intake gates The questions that decide whether a family can start with Florida Medicaid — Behavior Analysis Services (AHCA), and what they have to bring. - **Age limit**: Under 21, with no lower bound. The coverage policy covers “Florida Medicaid recipients under the age of 21 years requiring medically necessary BA services to address behavior that impairs a recipient’s ability to perform a major life activity.” No minimum age is set: the BASC-3 PRQ requirement starts at age 2 and the Vineland-3 Maladaptive Behavior Domain at age 3, but those are documentation thresholds, not eligibility floors. EPSDT sits on top — services for recipients under 21 “exceeding the coverage described within this policy or the associated fee schedule may be approved, if medically necessary.” [1] - **Diagnosis recency**: No autism diagnosis is required, so no diagnosis-recency rule exists — and the policy sets no maximum age for the Comprehensive Diagnostic Evaluation either. What is time-bound is the assessment cycle: a behavior assessment must be conducted before interventions begin; “a reassessment and updated behavior plan to renew prior authorization for continued services must be completed at least every six months”; and “the core instruments must be included with reassessments every 12 months.” More frequent assessment is required when new interfering behavior emerges. A full assessment may be requested on a change of provider, but a change in a practitioner’s status (an RBT becoming a BCaBA) is not grounds for one. [1] - Ask the plan: Whether a given MMA plan will accept an older CDE — the state policy sets no ceiling, but plans layer their own freshness rules (Carelon, for Simply members, requires the treatment plan and data to be no older than 30 days at submission). - **Who may diagnose**: No ASD diagnosis is required, so no diagnosing-provider rule gates entry — what gates it is who leads the Comprehensive Diagnostic Evaluation. The CDE “may be performed by a multidisciplinary team or individual practitioner. In any case, the CDE must be led by a licensed practitioner working within their medical, developmental, or psychological scope(s) of practice,” and it “must include assessment findings and treatment recommendations appropriate to the recipient.” Claims still carry “the most current and appropriate diagnosis code to the highest level of specificity that supports medical necessity,” plus any co-occurring disorders that affect medical necessity. [1] - **Diagnostic tools required**: Two core standardized instruments, named in rule and required at the initial assessment: the Vineland-3 Comprehensive Parent Interview Form for all recipients, plus the Maladaptive Behavior Domain for recipients ages 3 and older; and the Behavior Assessment System for Children, Third Edition, Parenting Relationship Questionnaire (BASC-3 PRQ) for all recipients ages 2 through 18. “The complete scoring report, including outcome measure scores, must be submitted with service prior authorization requests.” Additional tools are at the Lead Analyst’s discretion, and the two core instruments must be re-administered with reassessments every 12 months. [1] - **Referral required?**: Required — and in Florida the referral, not a diagnosis, is the front door. “The recipient must be referred by an independent physician or practitioner qualified to assess and diagnose disorders related to functional impairment,” namely a primary care physician with a family practice, internal medicine or pediatrics specialty; a board-certified or board-eligible physician specialising in developmental behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology or adult/child psychiatry; or a child psychologist. “The referral must include a physician’s order for behavior analysis services and a comprehensive diagnostic evaluation (CDE) performed according to national evidence-based practice standards.” “Independent physician” is defined by the financial-independence test at 42 U.S.C. 1395nn. The original referral documentation must be kept in the recipient’s medical record; the policy sets no expiry date on it. [1] - **Telehealth**: Narrow — one code. The only telemedicine provision in the coverage policy is caregiver training: “The Lead Analyst may provide up to two hours per week of training to parents or guardians via telemedicine in accordance with Rule 59G-1.057, Florida Administrative Code.” That is 97156 at the Lead Analyst level (billed with GT on the fee schedule), capped at two hours a week. The policy authorises no telemedicine delivery of 97153 direct treatment, 97155 protocol modification, or the assessment codes — plan for those to be in person. [1] - **Prior-auth decision time**: Fee-for-service BA requests go to Acentra (eQSuite), and Acentra measures the clock from a complete file: “The review completion timeframe is measured from the date eQHealth receives all required information.” First-level approvals come “within 3 business days”; cases needing physician review “within 5 business days”; reconsiderations within 3 business days. A request missing documents is pended, and if the missing items are not in “within two business day[s] the review request is Technically Denied” and must be resubmitted as a new case. Lead times: submit an initial (“admission”) request “at least 5 business days before services are initiated,” and a reauthorization (“continued stay”) “no less than 10 business days, but not more than 30 business days before the end of the current approval period.” Approvals run up to 180 calendar days. The federal FFS rule effective 1/1/2026 caps standard decisions at 7 calendar days and expedited at 72 hours from receipt (42 CFR 440.230(e)). Most children are in an MMA plan, and each plan runs its own clock. [3][17] - **Other insurance (who pays first)**: Florida Medicaid pays last. Rule 59G-1.052: “Florida Medicaid is the payer of last resort. Providers must exhaust all TPL sources of payment, such as Medicare, TRICARE, private health insurance, AARP plans, or automobile coverage prior to submitting or resubmitting a claim for reimbursement to Florida Medicaid.” Bill the commercial plan first, then send Medicaid the balance with proof of the other payer’s payment or denial. Medicaid pays only “the difference between the Florida Medicaid rate and the third-party payment,” and nothing if the other payer paid at or above the Medicaid rate. It also 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 ABA authorization. The rule’s only Medicaid-PA exemption is for “services approved by Medicare”; it gives none when a commercial plan is primary. Providers “must inquire if a recipient has third-party insurance coverage” at every visit, and may not refuse a Medicaid child because other insurance exists. Exceptions where Medicaid pays before another program include IDEA Part B/C funds and Indian Health Service. The rule publishes no pay-and-chase exception for EPSDT or preventive pediatric care. [18] ## Delivery and billing rules Coverage decides whether Florida Medicaid — Behavior Analysis Services (AHCA) 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**: A standards reference, not a ratio. “Florida Medicaid requires supervision of BCaBAs and RBTs in accordance with current practice standards as published by the Council of Autism Service Providers, and specified in the supervision plan of the approved behavior plan” — and that behavior plan must name the authorized supervisor(s). The structural floor is in who may render: a Lead Analyst is a BCBA, an FL-CBA, or a practitioner fully licensed under Chapters 490 or 491, F.S.; a BCaBA works under the supervision of a BCBA; an RBT works under a BCBA or a BCaBA. The incorporated CASP standard is 1–2 hours of case supervision per 10 hours of direct treatment, with the BACB’s 5%-of-monthly-hours RBT minimum underneath it. [1][15] - **Concurrent billing (97153 + 97155)**: No — not as a default, and Florida says so twice. On reimbursement: “The supervisor may be reimbursed for observing a supervisee implementing the behavior plan. The supervisee will not be reimbursed when the supervisor is reimbursed for the same time period.” On coverage: “services provided simultaneously by more than one BA provider” are non-covered “unless determined to be medically necessary, prior authorized, and indicated in the approved behavior plan.” So 97155 alongside 97153 for the same clock time is something the approved behavior plan has to carry, not a standing permission. One named exception: a recipient may receive BA from one rendering provider within a provider group while the parent, guardian or caregiver receives family adaptive behavior treatment guidance from a second rendering provider in the same group. [1] - **Daily limits / MUEs**: Florida caps by the week, not the day: “Florida Medicaid covers up to 40 hours per week of BA intervention services as indicated in the recipient’s prior-authorized behavior plan,” and EPSDT lets recipients under 21 exceed the policy and fee-schedule limits when medically necessary. Group adaptive behavior treatment — by protocol or with protocol modification — maxes at six participants. Units are 15 minutes on the CMS 8-minute rule: total minutes divided by 15, with a remainder of 8 minutes or more counting as one unit and a remainder under 8 not reimbursable. The fee schedule adds per-assessment ceilings (97151 to a maximum of 24 units per assessment; reassessment 97151-TS to 18) and caps 97156 telemedicine at two hours a week. No per-code per-day MUE ceiling is published in the coverage policy. [1] - Ask the plan: Which MUE table (CMS Medicaid NCCI vs. Practitioner) a plan’s claim editor applies, and the current per-assessment unit caps — AHCA’s fee-schedule PDFs block automated retrieval, so confirm the live schedule with AHCA or the MMA plan before modelling units. - **Session-note signature**: The person who delivered the service signs — “session notes must be signed and dated by the rendering practitioner” — with no supervising-analyst co-signature required. Each note must carry the date, time, location and duration of services; the maladaptive behaviors observed; the replacement/compensatory skills targeted; a description of the recipient’s response; any protocol modification, goal change or therapist direction given; an explanation if the parent or guardian was not present; and the participants, including observers, teachers, caregivers and other health care providers. Separately — and this is the signature most often missed at intake — “the behavior assessment and behavior plan must be signed by the Lead Analyst and the recipient’s parent or guardian.” [1] - **Place of service**: Setting is documented and gated rather than restricted by a code list: session notes must record the location, and the behavior plan must name the treatment setting(s). School is the gated one — “authorization requests for services to be delivered in a school must include the recipient’s Individualized Education Plan (IEP),” failing which the provider submits documentation justifying the services plus an estimated timeframe for the IEP; a 504 plan if the school does not conduct IEPs; and if it conducts neither, the school’s name with an explanation. Non-covered regardless of setting: recipient supervision, personal care assistance (acting as a 1:1 aide), companion, chaperone or shadow services “regardless of activity or setting,” caregiver or childcare services, and travel time. BA is also non-covered on the same day as behavioral health overlay services, therapeutic behavioral on-site services, or therapeutic group care. [1] - **Bill as provider**: A professional claim (837P / CMS-1500) under the enrolled rendering practitioner — Florida is unusual in enrolling the technicians themselves. Every rendering practitioner individually enrolls with AHCA: Lead Analysts as provider type 392, BCaBAs as 391 and RBTs as 390, with 390s and 391s enrollable only as members of an enrolled BA group (type 393). Each application needs a colour copy of the BACB certification matching the applicant’s legal name and a completed Level 2 background screening; AHCA names missing screenings and missing tax-ID proof as the two most common causes of delay. Credential level is priced into the code rather than a universal modifier set — 97155 pays at the Lead Analyst tier and at a lower rate with the HN modifier for a BCaBA, while 97153 pays the same whether an RBT, a BCaBA or a Lead Analyst renders it. [1][10] ## What intake should collect for Florida Medicaid — Behavior Analysis Services (AHCA) - **MMA plan (or FFS):** One of the nine plans, or unenrolled/FFS via Acentra — it decides the entire PA pathway. - **Physician referral + order + CDE:** The eligibility gate: independent physician referral with a BA order and a Comprehensive Diagnostic Evaluation. No autism diagnosis needed. - **Vineland-3 & BASC-3 PRQ scoring reports:** Complete scoring reports attach to every PA request — schedule the instruments as part of intake, not after. - **School status + IEP/504:** School-based BA requires the IEP or 504 (or a documented explanation) with the auth request. - **Caregiver participation commitment:** Reauthorizations must report parent/guardian participation data — set expectations at intake. Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf ## Verification of benefits (VOB) data How Florida Medicaid — Behavior Analysis Services (AHCA) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23. ### EDI routing - **Payer ID (Availity):** 77027 — 77027 is Florida Medicaid's own X12 payer ID per the FLMMIS companion guide (confirmed primary source); Availity's own current live payer list was not independently reachable (the fetched URL served a stale 2012 export that happens to list 77027 too) — confirm 77027 is still what Availity routes 270/271 through before automating on it. - **Supports 270/271 eligibility:** Yes - **Real-time eligibility:** Yes - **Behavioral health administrator:** none - **ABA rides on:** medical benefit - **Two-hop verification required:** No - **Where the 271 carries MCO enrollment:** Loop 2110C (Subscriber Eligibility or Benefit Information), "Eleventh Repetition – Managed Care": EB01='L' (PCP, individual) or 'MC' (MCO, entity), EB03=96 (Professional/Physician), EB04='MC' (Medicaid). MCO/PCP identity is carried in the nested Loop 2120C (Subscriber Benefit Related Entity Name): NM101='1P' (Provider), NM103=free-text plan/provider name, with contact phone in the PER segment. - **Eligibility span granularity:** Date range (RD8 format, CCYYMMDD-CCYYMMDD) via the Loop 2110C DTP segment (qualifier 307=Eligibility) for most repetitions; a few repetitions (e.g., Well Baby Care) use a single date (D8, qualifier 472=Service) instead. Not a fixed monthly bucket — driven by date-of-service. ### How the 271 reports ABA benefits - **ABA benefit bucket (service type code):** MH - **Cost-share type:** plan-dependent - **271 response quality for ABA:** high ### 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. - **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). - **97154:** The modifier documents group size, not staff credential — rate scales DOWN as the group grows. - **97155:** Rendered by Lead Analyst or BCaBA only — RBTs do not bill 97155 in Florida. - **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. - **0362T:** Requires an on-site physician/QHP plus 2+ technicians for severe/destructive-behavior assessment support; billed alongside 97151/97151-TS, not standalone. - **0373T:** Requires an on-site physician/QHP plus 2+ technicians for severe/destructive-behavior exposure treatment; billed alongside 97153/97155. ### Medicaid rates Source: AHCA Behavior Analysis Fee Schedule (2025 and 2026 — rates identical across both years) Effective 2025-01-01. | Code | Rate | Unit | Modifier tiers | | --- | --- | --- | --- | | 97151 | $19.05 | 15min | TS: $19.05 (reassessment; same rate, 18-unit cap vs. 24 for the initial assessment) | | 97152 | $12.19 | 15min | — | | 97153 | $12.26 | 15min | XP: Not reimbursed (concurrent-supervision supervisee line) | | 97154 | $7.58 (2 clients, UN) | 15min | UN: $7.58 (2 clients); UP: $7.08 (3); UQ: $6.58 (4); UR: $6.08 (5); US: $5.58 (6) | | 97155 | $19.17 (Lead Analyst) | 15min | HN: $15.37 (BCaBA); XP: Not reimbursed (concurrent-supervision supervisee line) | | 97156 | $19.05 (Lead Analyst) | 15min | GT: $19.05 (telemedicine — same rate, capped at 2 hrs/week); HN: $15.24 (BCaBA) | | 97157 | Not on the AHCA fee schedule (2025 or 2026) — not confirmed reimbursable under Florida Medicaid BA. | 15min | — | | 97158 | $9.58 (2 clients, UN) | 15min | UN: $9.58 (2 clients); UP: $9.08 (3); UQ: $8.58 (4); UR: $8.08 (5); US: $7.58 (6) | | 0362T | $12.19 | 15min | — | | 0373T | $12.19 | 15min | — | ### Contacts - **Provider services phone:** 1-800-289-7799 - **Phone menu path:** Option 4: Provider Enrollment Unit. Option 7: Medicaid Secure Portal (Web Portal) access. - **Portal:** [Acentra Health eQSuite (Florida Medicaid Behavior Analysis FFS authorizations)](https://fl.acentra.com/behavior-analysis/) Questions to ask on a verification call: - What payer ID do you use for pVerify and Change Healthcare 270/271 eligibility checks for Florida Medicaid (vs. Availity’s 77027)? - Is the ABA cost share for this member a copay or coinsurance, and does the deductible apply to ABA services? - Is any copay charged per visit or per day for ABA codes? - Does the member’s out-of-pocket maximum apply to ABA benefits? - What’s the cap period for 0373T (adaptive behavior treatment with protocol modification, 2+ techs)? ### VOB data sources - 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://portal.flmmis.com/FLPublic/Provider_ProviderServices/Provider_EDI/Provider_EDI_CompanionGuides/tabId/62/Default.aspx (accessed 2026-07-23) - https://pverify.com/wp-content/uploads/2026/06/pVeify-Payer-List-June-26.pdf (accessed 2026-07-23) - https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months) - https://ahca.myflorida.com/content/download/26138/file/2025%20Behavior%20Analysis%20Fee%20Schedule.pdf (accessed 2026-07-23) - https://ahca.myflorida.com/content/download/28096/file/2026%20BA%20Fee%20Schedule.pdf (accessed 2026-07-23) - https://www.flrules.org/gateway/readRefFile.asp?refId=17525&filename=Florida%20Medicaid%20Behavior%20Analysis%20Services%20Coverage%20Policy.pdf (accessed 2026-07-23) - https://portal.flmmis.com/FLPublic/Provider_ContactUs/tabId/59/Default.aspx (accessed 2026-07-23) - https://fl.acentra.com/behavior-analysis/ (accessed 2026-07-23; source document older than 18 months) ## Common questions ### Does Florida Medicaid require an autism diagnosis for ABA? No. Eligibility is functional — behavior that impairs a major life activity, for recipients under 21. The gate is a referral from an independent physician or qualifying practitioner, including a physician's order for BA services and a Comprehensive Diagnostic Evaluation. Claims carry the most specific supporting diagnosis, but no F84.x code is required. ### Who approves Florida Medicaid ABA prior authorizations now? Since February 1, 2025 (SMMC 3.0), the member's MMA plan — one of nine — authorizes BA for plan enrollees. Only recipients not enrolled in a plan still authorize through Acentra Health's eQSuite portal on the fee-for-service side. ### How long do Florida BA authorizations last? Up to 180 calendar days. Renewal requires a reassessment and an updated behavior plan at least every 6 months, with the Vineland-3 and BASC-3 core instruments re-administered every 12 months. ### What does Florida Medicaid pay for ABA? Per the January 2025 schedule: 97153 direct treatment $12.26 per 15-minute unit, 97151 assessment $19.05, 97155 $19.17 (Lead Analyst), 97156 family training $19.05 — among the lowest ABA rates in the Southeast. MCO contracts use the state schedule as the baseline. ## Primary sources 1. [Florida Medicaid Behavior Analysis Services Coverage Policy (Dec 2024, Rule 59G-4.125)](https://www.flrules.org/gateway/readRefFile.asp?refId=17525&filename=Florida%20Medicaid%20Behavior%20Analysis%20Services%20Coverage%20Policy.pdf) 2. [Rule 59G-4.125, F.A.C. (effective 2/10/2025)](https://www.flrules.org/gateway/ruleno.asp?id=59G-4.125) 3. [Acentra Health — Behavior Analysis Provider Manual 2026](https://fl.acentra.com/wp-content/uploads/sites/14/2026/05/Behavior-Analysis-Provider-Manual-2026.pdf) 4. [Acentra Health — Florida Medicaid Behavior Analysis (eQSuite)](https://fl.acentra.com/behavior-analysis/) 5. [Acuity News — Florida Medicaid ABA in 2026 (carve-in & rates)](https://acuity.news/regulation/florida-medicaid-aba-in-2026-managed-care-carve-in-a-refreshed-coverage-policy-and-where-ahca-rates-sit-across-the-southeast/) 6. [BellMedEx — Florida Medicaid ABA fee schedule rates 2026](https://bellmedex.com/florida-medicaid-applied-behavior-analysis-fee-schedule-rates/) 7. [Behavior Analysis Fee Schedule eff. 8/1/2022 (archived AHCA primary)](https://web.archive.org/web/20241006051746/https://fl.acentra.com/wp-content/uploads/sites/14/2024/03/BA_Services_2022_Fee_Schedule.pdf) 8. [Florida Statutes s. 393.17 (behavior analyst certification)](https://www.flsenate.gov/Laws/Statutes/2025/393.17) 9. [BACB — Florida Certified Behavior Analysts (FL-CBAs)](https://www.bacb.com/flcba/) 10. [AHCA — Enrolling as a Florida Medicaid Behavior Analysis Provider (webinar deck + FAQ)](https://ahca.myflorida.com/content/download/11448/file/Enrolling_as_a_Florida_Medicaid_Behavior_Analysis_Provider.pdf) 11. [Florida Statutes s. 409.907 (Medicaid provider agreements; background screening)](https://www.flsenate.gov/Laws/Statutes/2025/409.907) 12. [Florida Statutes s. 435.04 (Level 2 screening standards)](https://www.flsenate.gov/Laws/Statutes/2025/435.04) 13. [Florida Statutes s. 435.12 (Care Provider Background Screening Clearinghouse)](https://www.flsenate.gov/Laws/Statutes/2025/435.12) 14. [AHCA — Clearinghouse Renewals](https://ahca.myflorida.com/health-quality-assurance/bureau-of-central-services/background-screening/clearinghouse-renewals) 15. [CASP — ABA Practice Guidelines for the Treatment of ASD (3.0)](https://assets-002.noviams.com/novi-file-uploads/casp/pdfs-and-documents/ASD_Guidelines/ABA_Practice_Guidelines_3_0-70a721a1.pdf) 16. [BACB — RBT Handbook](https://www.bacb.com/wp-content/uploads/2022/01/RBTHandbook.pdf) 17. [42 CFR 440.230(e) — Medicaid fee-for-service prior authorization timeframes, from 1/1/2026 (eCFR)](https://www.ecfr.gov/current/title-42/section-440.230) 18. [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.