The Children's Medical Services (CMS) Health Plan is Florida's Title XIX/XXI specialty plan for children with chronic conditions, which makes its membership disproportionately ABA-relevant. It changed hands on October 1, 2026: AHCA selected Molina Healthcare to administer the plan, and every CMS Plan member moved from Sunshine Health to Molina automatically. Sunshine ran it through September 30, 2026. For a BA practice this means a new payer ID, a new portal (Availity), new documentation rules from Molina's BA guide, and — because Sunshine contracts do not transfer — a new contract for anyone who wants to keep serving these children after the continuity window.
AHCA's transition page is plain: “Sunshine State Health Plan currently operates the CMS Plan. The Agency for Health Care Administration has selected Molina Healthcare to assume responsibility for administering the CMS Plan,” and “all current CMS Plan members will automatically transition to Molina on October 1, 2026.” Benefits do not change; the plan administering them does. Molina will “accept and honor existing authorizations.” For children moving over from Sunshine, the continuity-of-care period runs “up to 240 days (through May 29, 2027),” or until the member's new care plan is finalized, whichever comes first. Children joining from another SMMC plan or fee-for-service get up to 180 days. Continuity covers existing services only: “Continuity of Care does not apply to new services.”[3][4][5][6]
What to do with a Sunshine authorization: keep delivering. Molina says “we will not change Sunshine authorization numbers,” so bill under the existing number while it runs. If it is not visible in Availity, submit a request with a copy of the current authorization. For authorizations ending between September 30 and November 30, submit a continuation request with supporting documentation; Molina “may issue up to a 60-day administrative extension.” Authorizations ending December 1 or later, and all new services, need a full new request. During continuity, non-participating providers are paid the rate they received just before the transition, with proof; “default reimbursement is 100% Medicaid.” After it, Sunshine contracts “will not transfer to Molina Healthcare,” so contract with Molina now.[3][4][5][6]
Requests go through Availity Essentials. The Prior Authorization Code Lookup Tool shows which codes need PA. Behavior identification assessment (97151) needs none; 97153, 97154, 97155, 97156 and 97158 do, before services begin and at least every 180 days. Molina's BA guide is unusually specific about what a complete request contains. The CDE must be done by a listed practitioner and must state a formal diagnosis — scores from CARS or ADOS alone are not a diagnosis. The Vineland-3 and BASC-3 PRQ behavior assessment is a separate document, and a private CDE that happens to include those scores does not replace it. Any behavior-reduction goal needs an FBA/BIP with member-specific frequency, duration and severity data. The request also needs the PCP's signed referral and a weekly schedule that fits the hours the child is actually available.[7][6][8]
The clock is short. The CMS Plan exhibit of the AHCA contract sets standard decisions at no more than 3 days, against 5 for the MMA plans; expedited decisions take 2. Molina asks for reauthorizations 30 to 10 days before the end date. From November 1, 2026, Molina moves BA authorizations to weekly units: bill no more than the week's authorized hours, and several weeks can go on one claim if no week exceeds its limit. Because the plan serves children with chronic and complex conditions, Florida's no-autism-diagnosis eligibility matters here — but Molina still wants a formal diagnosis in the CDE, whether ASD or another qualifying condition.[7][6][8]
Florida writes the claim clock for Medicaid health plans, Children’s Medical Services Health Plan included into statute: “Managed care plans shall comply with ss. 641.315, 641.3155, and 641.513” (§ 409.967(2)(j)). Under § 641.3155 a provider must send the claim to the plan “within 6 months after” the date of service (and to a secondary payer within 90 days of the primary’s final determination). For an electronic claim the plan must acknowledge receipt within 24 hours of the next business day and, within 20 days, pay it or notify the provider that it is denied or contested, with an itemized list of what is missing (the provider then has 35 days to supply it). Every claim must be paid or denied within 90 days of receipt, and failure to do so within 120 days “creates an uncontestable obligation to pay the claim.” Paper claims run 40, 120 and 140 days. Late payments bear 12% simple interest.[2][11][12]
Since October 1, 2026 the plan is run by Molina, and Molina’s Florida Medicaid manual (9/9/2026) covers it: “Any reference to Members means Molina Healthcare Medicaid and CMS Plan Members.” Claims “must be submitted by the Provider to Molina within six (6) months after … the date of service for outpatient services”; when Molina is not primary, “within ninety (90) days after final determination by the primary payer”; and “Corrected Claims must be sent within six months of Date of Service or most recent adjudicated date of the Claim.” No weekly cutoff or check-run day is published.[2][11][12]
The questions that decide whether a family can start with Children's Medical Services (CMS) Health Plan (FL), and what they have to bring. Each maps onto something intake should ask on the first call.
BA members must “be under 21 years of age.” The plan itself enrolls Medicaid children ages 0–20 and CHIP (Title XXI) children ages 1–18 who also meet the Department of Health’s clinical eligibility, so essentially the whole membership sits inside the BA window.[6][9]
The Comprehensive Diagnostic Evaluation has no expiry: Molina’s guide says it “does not carry a defined expiration date for Medicaid/CMS Members,” though “Molina reserves the right to request a new CDE” after a significant change such as school entry, puberty or a change in diagnosis. The instrument clock is annual: complete Vineland-3 and BASC-3 PRQ scoring reports “at the initial authorization and at least every 12 months thereafter,” with updated findings for shorter reauthorization periods, and authorizations renewed at least every 180 days.[7]
Molina lists who may perform the CDE: a PCP in family practice, internal medicine or pediatrics; a board-certified or board-eligible physician in developmental-behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology or adult/child psychiatry; a child psychologist (PhD or PsyD); a licensed school psychologist (“an unlicensed school psychologist may not conduct a CDE”); or a multidisciplinary team led by one of them. “A CDE performed outside this practitioner list will not satisfy authorization requirements.” Molina accepts privately obtained CDEs that meet the standard. The referral must come from the member’s assigned PCP.[7]
Two separate requirements. The CDE must report standardized diagnostic testing with scoring and interpretation — Molina’s examples are the ADI-R, ADOS-2, CARS-2 and DISCO — and “school accommodation letters alone are not sufficient.” Separately, every authorization needs the behavior assessment: the Vineland-3 Comprehensive Parent Interview Form for all members (Maladaptive Behavior Domain from age 3) and the BASC-3 PRQ for ages 2 through 18, with complete scoring reports. Vineland or BASC scores inside a private CDE do not replace it: “Both documents are required.”[7]
Required: a “signed referral from the member’s assigned Primary Care Provider (PCP)” that must specify ABA services — “Molina requires a referral from the PCP for the initiation of BA services and must be provided with the initial auth request.” The initial request also carries the CDE, the Vineland-3/BASC-3 behavior assessment, a behavior plan covering the full period (up to 6 months), an FBA/BIP for any behavior-reduction goal, a weekly schedule by code and place of service, other services the child receives, caregiver-training goals, the supervision plan and a transition/discharge plan.[7][6]
Follows the Florida Medicaid rule: the only telemedicine provision is up to two hours per week of Lead Analyst caregiver training (97156) under Rule 59G-1.057, F.A.C. Molina’s BA guide adds only that “modifiers, including telehealth modifiers, should follow the current Medicaid Fee Schedule,” and it calls in-person evaluation best practice for the CDE because “virtual-only assessments may miss critical behavioral cues.”[9][7]
Shorter than the MMA standard. The CMS Plan exhibit of the AHCA contract overrides the 5-day MMA standard: the plan “shall provide standard authorization decisions within no more than three (3) days following receipt of the request for service.” Expedited decisions follow the core contract: “no later than two (2) days after receipt,” extendable by one day. Molina publishes the same 3 days for CMS Title 19 and Title 21 — its BA guide says business days, its CMS training deck says calendar days — and urgent requests within 2 calendar days. Submit reauthorizations “as early as 30 days prior to the authorization end date, but no later than 10 days before the end date”; routine reauthorizations should not be sent as expedited. Before 10/1/2026 Sunshine’s CMS Health Plan manual published a 7-calendar-day standard clock; that no longer applies.[8][14][7][6]
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 the CMS 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. Molina’s CMS Plan materials list the primary payer’s explanation of benefits among the documents for a COB claim dispute but publish no BA-specific COB procedure.[15][6]
Ask the plan: Molina Provider Services (855) 322-4076: whether Molina wants the commercial EOB before its claim, and whether its BA authorization is still required when a commercial plan pays first.
Coverage decides whether Children's Medical Services (CMS) Health Plan (FL) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
The state floor: supervision of BCaBAs and RBTs per the Council of Autism Service Providers standards, set out in the supervision plan inside the approved behavior plan. Molina’s initial-request checklist asks the supervision plan to name the “authorized supervisor(s): BCBA for RBTs and BCaBAs,” and BA providers must “comply with supervision requirements” for BCaBAs and RBTs.[7][9]
By the week. “Services are authorized based on a weekly hour total. Providers must submit claims that do not exceed the number of hours authorized for that week.” Molina’s CMS BA training announces a new weekly unit structure effective November 1, 2026: approved units are set per week rather than per authorization total, and hours above the weekly limit are denied or adjusted; claims already submitted are unaffected. Units follow the 8-minute rule. The state ceiling of up to 40 hours per week, with EPSDT above it, sits underneath. No per-day unit table is published. At the claim level Molina’s Florida manual, which covers CMS Plan members, applies NCCI edits including “Medically Unlikely Edits (MUE)” and the stricter of a state benefit limit or the federal MUE; the public Medicaid MUE for 97153 is 32 units per claim line.[2][1][7][6][9]
Molina restates the state rule: “all session notes must be signed and dated by the rendering practitioner” and carry date, time, location and duration; maladaptive behaviors observed, “noted explicitly even if none occurred”; the skills targeted; the member’s individualized response; protocol modifications; parent or guardian presence, with a reason if absent; and the participants. “Templated, copied forward” notes “may be flagged during records review.” The behavior plan carries the parent or guardian’s signature.[7][9]
Home, clinic and school, named on the request with a weekly schedule. For school-based BA, Molina’s table follows the state rule: submit the current IEP; if the IEP omits BA, the IEP plus a justification and an estimated date BA will be added; a 504 plan in place of an IEP; or, where the school does neither, the school’s name and a written explanation. For a child not yet in school, confirm enrollment status and timing. Outside school, no IEP is required. Molina lists as non-covered: supervision, personal care, companion, chaperone or shadow services; caregiver or childcare services; same-day behavioral health overlay, TBOS or therapeutic group care; and travel time.[7][6]
Professional claims (CMS-1500/837P) to Molina Healthcare of Florida — Availity Essentials preferred, EDI payer ID 51062, or paper to PO Box 22812, Long Beach, CA 90801 — with codes, modifiers and units per the Rule 59G-4.002 fee schedule. The state enrollment structure decides whose NPI may render: Lead Analyst 392, BCaBA 391, RBT 390, with 390s and 391s enrollable only inside an enrolled BA group (393). Non-participating providers are paid “100% of the Medicaid rate unless a single-case agreement applies” and must put the authorization number on the claim. Sunshine contracts “will not transfer to Molina.”[7][6][4][9]
Molina restates the state rule: “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.” Simultaneous services by more than one BA provider are non-covered unless authorized. Molina publishes nothing on whether 97153 and 97155 may overlap when both practitioners are delivering treatment.[7][6]
Ask the plan: Molina Utilization Management (855) 322-4076 — ask whether an authorization may carry 97153 and 97155 on the same clock time.
Six months from the date of service under Molina’s Florida Medicaid manual, which covers CMS Plan members from October 1, 2026; 90 days after the primary payer’s final determination when the plan pays second; corrected claims within six months.
Molina Healthcare of Florida, from October 1, 2026. Sunshine Health operated the plan through September 30, 2026, and members moved to Molina automatically. Benefits did not change; the payer ID (Molina 51062), portal (Availity) and BA documentation rules did.
Yes, during continuity of care: up to 240 days (through May 29, 2027) for members who transferred from Sunshine, or until Molina finalizes a new care plan. Molina keeps the Sunshine authorization number. Authorizations ending September 30–November 30 need a continuation request; later ones and all new services need a full new request.
Yes — Behavior Analysis for members under 21, on the Florida Medicaid criteria. No autism diagnosis is required as such, but Molina's CDE must state a formal diagnosis (ASD or another qualifying condition), and the PCP's signed referral must accompany the first request.
Within 3 days for standard requests under the CMS Plan contract exhibit (Molina says 3 business days in its BA guide), and 2 days for expedited ones. That is shorter than the 5-day standard the core contract sets for the MMA plans.
Not published as a yes or no. Florida law lets MMA plans “limit the providers in their networks based on credentials, quality indicators, and price” (s. 409.975(1), F.S.), so a plan may decline a new BA group. Ask the CMS Health Plan’s provider relations or contracting team whether it is adding BA groups in your region.
AHCA’s BA coverage policy, which every MMA plan must follow, says “a full assessment may be requested if there is a change in provider,” and a change in a practitioner’s credential (an RBT becoming a BCaBA) is not grounds for a reassessment. Expect the new agency to request its own assessment and treatment authorization; ask the CMS Health Plan how it closes the previous provider’s authorization.
Florida law binds Children’s Medical Services Health Plan as an MMA plan (§ 409.967(2)(j) → § 641.3155): pay or send a denial/contest notice within 20 days of an electronic claim (40 for paper), pay or deny within 90 days (120 for paper), and 12% interest on late payments. The statute also requires providers to file within 6 months of the date of service.
Molina's checklist for the initial request includes the Comprehensive Diagnostic Evaluation and a signed referral from the member's assigned PCP that specifies ABA services. It also needs Vineland-3 and BASC-3 PRQ scoring reports, a behavior plan covering the full period (up to six months), an FBA/BIP for any behavior-reduction goal, and a weekly schedule by code and place of service. Add other services the child receives, caregiver-training goals, the supervision plan and a transition or discharge plan. The CDE has no set expiry, but Molina may ask for a new one after a significant change.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 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.
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