---
title: "Children's Medical Services Health Plan ABA coverage (Florida specialty plan)."
url: "https://carelu.com/payers/cms-health-plan-florida"
markdown_url: "https://carelu.com/payers/cms-health-plan-florida.md"
state: FL (Florida)
payer: "Children's Medical Services (CMS) Health Plan (FL)"
kind: Medicaid managed care plan (MCO)
parent_program: Florida Medicaid (AHCA)
description: "How the Children's Medical Services Health Plan — Florida's specialty plan for children with chronic conditions, run by Molina Healthcare from October 1, 2026 — handles Behavior Analysis: the Sunshine-to-Molina transition, the 240-day continuity window, the 3-day contract clock, and Molina's BA documentation rules."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Children's Medical Services Health Plan ABA coverage (Florida specialty plan).

_Payer Guide · CMS Health Plan (FL) · Last updated October 2026 · 13 primary sources_

> Specialty plan for children with chronic conditions; run by Molina from 10/1/2026 (Sunshine before), 3-day contract clock.

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.

This plan administers the **Florida Medicaid (AHCA)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Florida Medicaid — Behavior Analysis Services (AHCA) guide](https://carelu.com/payers/florida-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: From 10/1/2026 (Molina): not for 97151 — Molina's BA guide says the behavior identification assessment “does not require prior authorization” — but non-participating providers need authorization for all services and codes. Through 9/30/2026 the plan ran on Sunshine Health's BA process, where every BA code needed PA. [7][6]
- **Prior auth for treatment**: Required — for 97153, 97154, 97155, 97156 and 97158, before services begin and at each reauthorization (at least every 180 days), submitted through Availity Essentials (fax 866-440-9791 if the portal is unavailable). Title 19 and Title 21 (CHIP) members alike. [7][5]
- **Autism diagnosis required?**: No autism diagnosis specifically — the state BA policy applies (physician referral + order + CDE). But Molina's CDE checklist requires “a formal diagnosis made by the evaluating practitioner,” stated explicitly by the clinician; Molina describes BA as covered for members with “a diagnosis consistent with autism spectrum disorder (ASD) or other qualifying conditions.” [9][7][6]

## At a glance

- **Plan type:** SMMC specialty plan (Title XIX/XXI) — operated by Molina Healthcare from 10/1/2026 (Sunshine Health through 9/30/2026)
- **Continuity of care:** Existing Sunshine auths honored up to 240 days (through May 29, 2027); non-par paid at prior rate with proof, default 100% of Medicaid
- **Prior auth:** Availity Essentials (fax 866-440-9791 backup); 97151 exempt; all other BA codes need PA
- **Determinations:** 3 days standard (CMS Plan contract exhibit), 2 days expedited
- **Claims:** Molina payer ID 51062 via Availity or clearinghouse; weekly unit limits from 11/1/2026
- **Contact:** Molina Provider Services / UM (855) 322-4076

## Sunshine to Molina on October 1, 2026

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]

## How Molina runs CMS Plan BA authorization

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]

## How fast must Children’s Medical Services Health Plan pay an ABA claim?

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]

## Intake gates

The questions that decide whether a family can start with Children's Medical Services (CMS) Health Plan (FL), and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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]
- **Referral required?**: 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]
- **Telehealth**: 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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.

## Delivery and billing rules

Coverage decides whether Children's Medical Services (CMS) Health Plan (FL) 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**: 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]
- **Daily limits / MUEs**: 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]
- **Session-note signature**: 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]
- **Place of service**: 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]
- **Bill as provider**: 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]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: 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.

## What intake should collect for Children's Medical Services (CMS) Health Plan (FL)

- **Sunshine authorization on file:** Copy the current Sunshine authorization number and end date — Molina keeps the number, and it decides whether you need a continuation request (ending 9/30–11/30) or a full new request.
- **Title 19 vs. Title 21:** Both need PA for BA treatment codes — capture which program the member is in for eligibility hygiene.
- **PCP referral + CDE:** A signed referral from the assigned PCP specifying ABA, plus a CDE from a listed practitioner that states a formal diagnosis.
- **Vineland-3 & BASC-3 scoring reports:** A separate behavior assessment document at every initial request and every 12 months — not satisfied by scores inside the CDE.
- **Molina contract status:** Sunshine contracts do not transfer; after the continuity window, non-contracted providers need a Molina agreement.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Children's Medical Services (CMS) Health Plan (FL) ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (Availity):** 51062
- **Payer ID (Change Healthcare / Optum):** 51062 — Molina's CMS materials name payer ID 51062 for EDI claims through any clearinghouse and Change Healthcare/ECHO for payments; a Change Healthcare eligibility directory entry was not checked.
- **Supports 270/271 eligibility:** Yes — Molina's CMS training directs eligibility and benefits checks to Availity (or (855) 322-4076); a 270/271 companion guide for the CMS Plan was not reviewed.
- **Behavioral health administrator:** none
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Not required for participating providers — Molina's BA guide exempts 97151; non-participating providers need authorization for all services and codes. | 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. Molina's July 2026 BA guide: "Code 97151 (Behavior Identification Assessment) does not require prior authorization." Non-participating providers need authorization for all services and codes (Molina CMS BA training). These are the statewide AHCA BA Coverage Policy mechanics, binding on CMS Plan (Molina Healthcare of Florida) per the policy's plan-compliance clause (§1.2); CMS Plan (Molina Healthcare of Florida)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with CMS Plan (Molina Healthcare of Florida) provider relations before quoting a family.
- **97152:** These are the statewide AHCA BA Coverage Policy mechanics, binding on CMS Plan (Molina Healthcare of Florida) per the policy's plan-compliance clause (§1.2); CMS Plan (Molina Healthcare of Florida)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with CMS Plan (Molina Healthcare of Florida) provider relations before quoting a family.
- **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). CMS Plan by Molina Healthcare from October 1, 2026: BA is authorized as a weekly hour total, and Molina's CMS BA training announces weekly units replacing authorization totals effective November 1, 2026 (hours above the weekly limit are denied or adjusted). Existing Sunshine authorizations are honored during continuity of care, up to 240 days (through May 29, 2027). These are the statewide AHCA BA Coverage Policy mechanics, binding on CMS Plan (Molina Healthcare of Florida) per the policy's plan-compliance clause (§1.2); CMS Plan (Molina Healthcare of Florida)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with CMS Plan (Molina Healthcare of Florida) provider relations before quoting a family.
- **97154:** The modifier documents group size, not staff credential — rate scales DOWN as the group grows. CMS Plan by Molina Healthcare from October 1, 2026: BA is authorized as a weekly hour total, and Molina's CMS BA training announces weekly units replacing authorization totals effective November 1, 2026 (hours above the weekly limit are denied or adjusted). Existing Sunshine authorizations are honored during continuity of care, up to 240 days (through May 29, 2027). These are the statewide AHCA BA Coverage Policy mechanics, binding on CMS Plan (Molina Healthcare of Florida) per the policy's plan-compliance clause (§1.2); CMS Plan (Molina Healthcare of Florida)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with CMS Plan (Molina Healthcare of Florida) provider relations before quoting a family.
- **97155:** Rendered by Lead Analyst or BCaBA only — RBTs do not bill 97155 in Florida. CMS Plan by Molina Healthcare from October 1, 2026: BA is authorized as a weekly hour total, and Molina's CMS BA training announces weekly units replacing authorization totals effective November 1, 2026 (hours above the weekly limit are denied or adjusted). Existing Sunshine authorizations are honored during continuity of care, up to 240 days (through May 29, 2027). These are the statewide AHCA BA Coverage Policy mechanics, binding on CMS Plan (Molina Healthcare of Florida) per the policy's plan-compliance clause (§1.2); CMS Plan (Molina Healthcare of Florida)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with CMS Plan (Molina Healthcare of Florida) provider relations before quoting a family.
- **97156, 97158:** CMS Plan by Molina Healthcare from October 1, 2026: BA is authorized as a weekly hour total, and Molina's CMS BA training announces weekly units replacing authorization totals effective November 1, 2026 (hours above the weekly limit are denied or adjusted). Existing Sunshine authorizations are honored during continuity of care, up to 240 days (through May 29, 2027). These are the statewide AHCA BA Coverage Policy mechanics, binding on CMS Plan (Molina Healthcare of Florida) per the policy's plan-compliance clause (§1.2); CMS Plan (Molina Healthcare of Florida)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with CMS Plan (Molina Healthcare of Florida) provider relations before quoting a family.
- **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. Not on the AHCA BA fee schedule. Molina's CMS BA training slide on prior authorization groups 97156 and 97157 under caregiver training, but its July 2026 BA guide's code table omits 97157 — confirm with Molina before billing it. These are the statewide AHCA BA Coverage Policy mechanics, binding on CMS Plan (Molina Healthcare of Florida) per the policy's plan-compliance clause (§1.2); CMS Plan (Molina Healthcare of Florida)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with CMS Plan (Molina Healthcare of Florida) provider relations before quoting a family.
- **0362T:** Requires an on-site physician/QHP plus 2+ technicians for severe/destructive-behavior assessment support; billed alongside 97151/97151-TS, not standalone. These are the statewide AHCA BA Coverage Policy mechanics, binding on CMS Plan (Molina Healthcare of Florida) per the policy's plan-compliance clause (§1.2); CMS Plan (Molina Healthcare of Florida)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with CMS Plan (Molina Healthcare of Florida) provider relations before quoting a family.
- **0373T:** Requires an on-site physician/QHP plus 2+ technicians for severe/destructive-behavior exposure treatment; billed alongside 97153/97155. These are the statewide AHCA BA Coverage Policy mechanics, binding on CMS Plan (Molina Healthcare of Florida) per the policy's plan-compliance clause (§1.2); CMS Plan (Molina Healthcare of Florida)'s own documents don't restate full code-level unit-cap/POS detail beyond what's marked 'verified' above — confirm any 'inferred' field with CMS Plan (Molina Healthcare of Florida) provider relations before quoting a family.

### Contacts

- **Benefits by phone:** Yes
- **Provider services phone:** (855) 322-4076
- **Hours:** Molina Provider Services, Utilization Management and Behavioral Health share one line, Monday–Friday 8 a.m.–7 p.m. Eastern. The CMS Plan moved from Sunshine Health to Molina on October 1, 2026; Sunshine's line no longer handles it.
- **Portal:** [Availity Essentials (Molina Healthcare of Florida)](https://provider.molinahealthcare.com/)
- **Fax:** (866) 440-9791

Questions to ask on a verification call:

- Is this child a CMS Plan member moved over from Sunshine, and does the Sunshine authorization number show in Availity under the member's Molina ID?
- Does a CMS Plan eligibility check run on payer ID 51062 in Availity, and is 270/271 real-time or batch?
- Which service-type code do you return ABA benefit details under?
- Is the authorization written as weekly hours, and what is the weekly unit limit per code from November 1, 2026?
- Is 97151 billable without authorization for our contract status (participating vs. non-participating)?

### VOB data sources

- https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/fl/medicaid/09-25-26-MHFL-CMS-Transition-FAQs-508.ashx (accessed 2026-09-27)
- https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/fl/medicaid/09-03-26-MHFL-CMS-Plan-BA-Training-508.pdf (accessed 2026-09-27)
- https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/fl/medicaid/08-07-26-MHFL-Comprehensive-BA-QRG-508.ashx (accessed 2026-09-27)
- 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://www.flrules.org/gateway/readRefFile.asp?refId=17525&filename=Florida%20Medicaid%20Behavior%20Analysis%20Services%20Coverage%20Policy.pdf (accessed 2026-07-23)
- https://ahca.myflorida.com/content/download/26138/file/2025%20Behavior%20Analysis%20Fee%20Schedule.pdf (accessed 2026-07-23)
- https://www.molinahealthcare.com/-/media/Project/PWS/Healthcare/PDF/PDF/Providers/FL/Manuals/09-09-26-MHFL-Molina-Provider-Handbook-CMS-and-SMMC-508.pdf (accessed 2026-10-14)

## Common questions

### What is the timely filing limit for CMS Health Plan ABA claims?

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.

### Who runs the CMS Health Plan now?

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.

### Will Molina honor my Sunshine BA authorization?

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.

### Does the CMS Health Plan cover ABA?

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.

### How fast does the CMS Plan decide BA authorizations?

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.

### Is the CMS Health Plan’s BA network open to new providers?

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.

### What happens when a the CMS Health Plan member switches BA providers?

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.

### What is the payment turnaround for Children’s Medical Services Health Plan ABA claims?

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.

### What documents does the CMS Health Plan (Molina) need at intake for ABA?

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.

## Primary sources

1. [CMS — Medicaid NCCI Edit Files (practitioner MUE table effective 10/1/2026)](https://www.cms.gov/medicare/coding-billing/ncci-medicaid/medicaid-ncci-edit-files)
2. [Molina Healthcare of Florida — Medicaid Provider Manual for Molina Medicaid and CMS Plan members (9/9/2026)](https://www.molinahealthcare.com/-/media/Project/PWS/Healthcare/PDF/PDF/Providers/FL/Manuals/09-09-26-MHFL-Molina-Provider-Handbook-CMS-and-SMMC-508.pdf)
3. [AHCA — CMS Plan Transition](https://ahca.myflorida.com/medicaid/statewide-medicaid-managed-care/2025-2030-smmc-plans/cms-plan-transition.html)
4. [Molina — Children’s Medical Services (CMS) Plan Transition FAQs (9/25/2026)](https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/fl/medicaid/09-25-26-MHFL-CMS-Transition-FAQs-508.ashx)
5. [Molina — Authorization During CMS Plan Continuity of Care Period (updated 9/21/2026)](https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/fl/medicaid/09-16-26-MHFL-CMS-Plan-Authorization-During-COC-Provider-Guidance-508.pdf)
6. [CMS Plan by Molina Healthcare — Provider Orientation: Behavior Analysis Services (August 2026)](https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/fl/medicaid/09-03-26-MHFL-CMS-Plan-BA-Training-508.pdf)
7. [Molina Healthcare of Florida — Behavioral Analysis Services: Authorization & Documentation Guide (Comprehensive BA QRG, effective July 2026)](https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/fl/medicaid/08-07-26-MHFL-Comprehensive-BA-QRG-508.ashx)
8. [AHCA SMMC Model Health Plan Contract — Exhibit II-C, Children’s Medical Services Health Plan (July 2026 update)](https://ahca.myflorida.com/file/medicaid/Health_Exhibit%20II-C%20CMSPlan_July%202026.pdf)
9. [Florida Medicaid BA Services Coverage Policy (Dec 2024)](https://www.flrules.org/gateway/readRefFile.asp?refId=17525&filename=Florida%20Medicaid%20Behavior%20Analysis%20Services%20Coverage%20Policy.pdf)
10. [Fla. Stat. § 409.975 (2026) — Managed care plan accountability (provider networks)](https://www.flsenate.gov/Laws/Statutes/2026/409.975)
11. [Fla. Stat. § 409.967 (2026) — Managed care plan accountability (prompt payment, (2)(j))](https://www.flsenate.gov/Laws/Statutes/2026/409.967)
12. [Fla. Stat. § 641.3155 (2026) — Prompt payment of claims](https://www.flsenate.gov/Laws/Statutes/2026/641.3155)
13. [Molina Healthcare of Florida — Provider Communications (newsletters and notices by year; CMS Health Plan from 10/1/2026)](https://www.molinahealthcare.com/providers/fl/communications)
14. [AHCA SMMC Model Health Plan Contract — Attachment II Core Provisions (update 7/1/2026), §V.F.6](https://ahca.myflorida.com/file/medicaid/Health_Attachment%20II%20-Core%20Contract%20Provisions_July%202026.pdf)
15. [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 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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.