Open Letter to Florida Legislators and Healthcare Administrators
Regarding Centene Corporation / Sunshine Health and Their Handling of Behavior Analysis Services for Children with Developmental Disorders under Medicaid Managed Care - What Needs to Change

1. Sunshine Health’s Use of Psychiatrists to Review Behavior Analysis (BA) Service Requests

Centene Corporation, operating in Florida as Sunshine Health, has employed psychiatrists to review and authorize Behavior Analysis (BA) service requests for children with developmental disorders under Medicaid Managed Care.

Psychiatrists are highly trained in the diagnosis and treatment of mental health conditions, but their expertise typically does not include applied behavior analysis. Behavior Analysis treatment plans—often called Behavior Intervention Plans (BIPs)—are complex, data-driven, clinical documents developed by Board-Certified Behavior Analysts (BCBAs). These plans are grounded in the science of learning and behavior, and they rely on data analysis, functional behavior assessments (FBAs), and evidence-based interventions.

Reviewing such plans requires familiarity with behavior-analytic principles and data interpretation methods. Without this specialized training, reviewers may misinterpret the data or the intent of the interventions.

There have been consistent reports from providers indicating that:

• Some Sunshine reviewers appear unfamiliar with behavior-analytic data graphs or the purpose of FBAs.
• Certain reviewers have suggested interventions inconsistent with the practice of ABA, such as recommending "talk therapy" for nonverbal children with autism.

It is currently estimated that these reviews have resulted in partial or full denials of services in 50%-80% of cases. These are authorizations that were previously approved under standard Medicaid review procedures conducted by behavior analysts. These denials are often accompanied by generic, non-specific justification letters that do not reflect individualized clinical review.

Recommendation:
Centene/Sunshine Health and the Florida Agency for Health Care Administration (AHCA/CMS) should ensure that all Behavior Analysis service requests and treatment plans are reviewed by qualified peers—Board-Certified Behavior Analysts (BCBAs) or, at minimum, Board-Certified Assistant Behavior Analysts (BCaBAs)—consistent with established Medicaid and industry standards.

 
2. Use of “Outdated” Diagnostic Evaluations (CDEs) to Deny ABA Services

Sunshine reviewers have reportedly denied service requests based on the age of a child’s Comprehensive Diagnostic Evaluation (CDE), with some claiming that evaluations older than three years or five years are “outdated."

A CDE is a standardized diagnostic assessment used to determine the presence of developmental disorders such as Autism Spectrum Disorder (ASD). The diagnostic tools used—such as the ADOS, CARS, or GARS—are designed to establish a medical diagnosis, not to measure progress or ongoing treatment response.

Autism is a lifelong condition, and there is no medical or regulatory requirement that a diagnostic evaluation be repeated every three or five years. Clinical progress is more appropriately tracked using assessment tools like the Vineland Adaptive Behavior Scales (Vineland) or the Behavior Assessment System for Children (BASC), which are already used by ABA providers and parents at regular intervals. The results are submitted to Sunshine/CMS and other insurances.

Requiring families to obtain new diagnostic evaluations introduces unnecessary expense and delay, potentially disrupting continuity of care.

Recommendation:
The State of Florida should clarify that a valid autism diagnosis does not expire and that re-evaluation should only occur when clinically indicated. This clarification would prevent unnecessary service disruptions and reduce administrative burden.

 
3. Impact on Families and Providers

When authorizations for ABA services are delayed or denied, children lose valuable therapy time during critical developmental periods. Early and consistent intervention is essential for effective outcomes, and extended gaps in services can impede progress.

Families often face uncertainty about how to appeal denials or when services might resume. Many depend solely on Medicaid coverage for their child’s care and have limited alternative options.

These issues also affect providers. ABA agencies report reductions in authorized hours, staffing challenges, and difficulty maintaining service capacity within the Medicaid network. As qualified providers leave the system, access to care diminishes further for children who rely on these services.

Recommendation:
Florida policymakers should review the current Sunshine Health authorization process to ensure that:

• Qualified reviewers with appropriate clinical credentials conduct BA plan reviews;
• Authorization decisions are made within reasonable timeframes; and
• Denials include individualized, evidence-based rationales.

 
Conclusion

Florida’s children with autism and related developmental disorders require timely access to medically necessary, evidence-based treatment. Behavior Analysis services must be evaluated by qualified professionals who understand the discipline’s methods and standards.

The current review process used by Centene/Sunshine Health raises concerns regarding:

• The use of reviewers without behavior-analytic training,
• The misapplication of diagnostic criteria as a basis for denial, and
• The resulting barriers to continuity of care for children and families.

We respectfully urge the Florida Agency for Health Care Administration, the Florida Legislature, and the Florida Office of Insurance Regulation to review Sunshine’s practices and implement measures to ensure appropriate peer review, transparency, and consistency in decision-making.

By doing so, the State of Florida can help maintain access to essential ABA services and uphold the integrity of care for children with developmental needs.