Florida Medicaid Outlines Daily and Case Rates Ahead of Nov. 17 ABA Vote

TALLAHASSEE, FLORIDA – On Oct. 29, Florida’s Medicaid agency presented two alternatives to its 15-minute fee-for-service payment model for applied behavior analysis (ABA): a set payment per covered day, or one payment for a defined case or episode of care. The state’s ABA task force is scheduled to vote on recommendations Nov. 17.

The Agency for Health Care Administration (AHCA) described both as potential alternatives, without proposing rates or cost estimates. Its slides also compared service-authorization rules across states and reviewed electronic visit verification, which Florida discontinued for ABA in 2022. As of Nov. 9, AHCA’s task force page did not include draft recommendations for the panel’s vote.

Florida recorded $6.57 billion in Medicaid ABA payments from 2023 through 2025, the highest state total in federal data presented to the panel in August by Shena Grantham, AHCA’s assistant deputy secretary for Medicaid policy and quality. Lawmakers created the task force in the 2026 budget-implementing law and required a report to the governor and legislative leaders by Dec. 31, including the advantages and disadvantages of each recommendation.

Paying by the Day or the Case

Grantham presented the payment alternatives on Oct. 29. Florida’s 2026 fee-for-service schedule sets a maximum of $12.26 per 15 minutes for individual treatment following a protocol, billed under CPT 97153. That equals $49.04 an hour.

The case-rate idea was already before the panel. In slides for the Oct. 5 meeting, Centria Autism proposed that every state adopt one payment per case, tied to defined clinical outcomes, with services ending when a child meets graduation criteria. The provider acknowledged that billing by the unit rewards more hours, including at Centria.

“Billable units reward more hours; reduction or discharge reduces revenue, for Centria too” – Centria Autism slides credited to Chief Clinical Officer Timothy Yeager; Oct. 5 meeting materials

Most recipients are covered through managed care. AHCA reported in August that 98.9% of Medicaid ABA recipients were enrolled in managed care plans, which pay providers through their own arrangements. The Oct. 29 slides said those plans must operate programs linking payment to quality or performance measures, but their application to ABA depends on the specific arrangements.

How Florida’s Hour Rules Compare

Florida Medicaid covers up to 40 hours of ABA intervention a week per recipient, with medically necessary exceptions available for those under 21. Plans require prior authorization and may cover up to six months. AHCA said it has no separate authorization period based solely on hours, though requests outside established standards of care or usual utilization may receive closer review.

Virginia requires extra documentation for requests above 20 hours a week. North Carolina requires reauthorization at least every 90 days above 16 hours a week, compared with 180 days at or below that level. A 2026 California proposal cited by AHCA used requests above 25 hours a week as an example of when additional review could apply.

The Florida Association for Behavior Analysis (FABA), whose past president, Yanerys León, holds a voting seat on the task force, said service caps “should be soft caps with exceptions based on individual need” in its October recommendations.

The Visit Check Florida Dropped

AHCA’s Oct. 29 slides also covered electronic visit verification (EVV), which records when and where a session happens, who delivers it, and who receives it. The presentation described Florida’s former ABA-specific EVV program as discontinued.

AHCA announced a pilot in 2019 for eight counties from Indian River and Okeechobee south to Monroe. After delays, billing through the system became mandatory on Feb. 1, 2021. AHCA allowed providers to resume direct billing through the state portal on Jan. 10, 2022, and discontinued the EVV system on Feb. 5.

FABA’s October recommendations support EVV designed to work with common electronic medical record (EMR) systems and ABA service models.

In Congress, Rep. Gabe Evans, a Colorado Republican, introduced H.R. 10618 on Sept. 28. The bill would require electronic verification of Medicaid ABA services from Jan. 1, 2027, with an exemption for states that already require it when the law is enacted and continue to do so. As of Nov. 9, its latest recorded action was referral to the House Energy and Commerce Committee.

The Nov. 17 Agenda

The meeting is scheduled for 11 a.m. to 5 p.m. Eastern at AHCA headquarters in Tallahassee. The agenda lists discussion of recommendations, a vote, and public comment, in that order.

AHCA’s task force page did not include Oct. 29 minutes as of Nov. 9. Its roster listed eight of the nine voting seats as filled, with Secretary Shevaun Harris serving as nonvoting chair. The remaining seat, reserved by law for a family member of a Medicaid managed care enrollee receiving ABA, was listed as pending appointment. The governor makes that appointment.

AT A GLANCE

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