We are calling on Sunshine Health and Florida Medicaid leadership to immediately review and revise implementation of the recently announced “Frequency-Based Authorization Enhancement” for Applied Behavior Analysis (ABA) services.

ABA therapy is a medically necessary treatment for many children with autism and developmental disabilities. These services are individualized, dynamic, and medically driven. Treatment intensity and supervision needs can change from week to week based on the child’s behavior, safety needs, learning progress, staffing changes, caregiver needs, and clinical presentation.

Under current Florida Medicaid policy, ABA services are typically authorized as a total number of units across a multi-month authorization period, often up to six months. However, providers have recently been informed that claims may now deny based on weekly utilization limits — even when authorized units still remain available within the authorization period.

Providers have also been advised that:

Weekly limits may not be visible within the authorization itself
Unused units cannot be carried over between weeks
Claims may deny if weekly thresholds are exceeded
Providers may need to end and resubmit authorizations or appeal denials after services are delivered
This creates serious concerns for providers, families, and children receiving medically necessary ABA services.

We are especially concerned about the impact on CPT code 97155, the service used by Board Certified Behavior Analysts (BCBAs) to:

modify treatment when behaviors change,
adjust interventions,
respond to safety concerns,
train staff,
and ensure treatment remains clinically appropriate and effective.
By design, 97155 is intended to be responsive to the child’s changing needs. Increased BCBA involvement may be medically necessary during periods of:

behavioral escalation,
safety concerns,
significant treatment changes,
staff turnover or onboarding,
or regression in skills and functioning.
Rigid weekly adjudication limits may prevent BCBAs from responding appropriately when children need additional clinical oversight and treatment modification. Instead, providers may be forced to:

delay treatment modifications,
reduce clinically necessary supervision,
or make scheduling decisions based on claims limitations rather than medical necessity.
This concern is not about eliminating utilization management or avoiding medical necessity review. Providers understand the importance of accountability and appropriate authorization practices.

Rather, we are requesting:

transparent and visible authorization standards,
operationally workable billing requirements,
reasonable flexibility for medically necessary care,
and alignment between claims adjudication practices and Florida Medicaid coverage policy.
We respectfully ask Sunshine Health and Florida Medicaid leadership to:

Reevaluate implementation of undisclosed weekly utilization limits for ABA services
Ensure providers can reasonably comply with authorization requirements
Preserve the ability for 97155 services to remain responsive to changing clinical needs
Prevent disruptions to medically necessary care for children receiving ABA services
Provide clear and transparent operational guidance before enforcement
Children receiving medically necessary autism services deserve continuity of care, individualized treatment, and responsive clinical oversight. Providers deserve authorization structures that align with clinical reality, medical necessity, and Florida Medicaid policy.

Please sign and share to support Florida children and families receiving medically necessary ABA services through Medicaid.