Disability Resources

Behavior Analysis Services

Applied Behavior Analysis (ABA) is a well-known treatment for individuals with autism spectrum disorder (ASD) and other developmental disabilities (e.g. down syndrome, intellectual disabilities). For individuals with these disabilities, ABA can be an effective treatment throughout an individual’s life, but particularly for young children. Intensive ABA therapy can improve cognitive, language, social and self-help skills in children with developmental disabilities like ASD.

ABA is a Medicaid-covered service called Behavior Analysis. BA uses highly structured interventions and strategies to target maladaptive behaviors and increase desired behaviors. Generally, Medicaid covers BA services for individuals under the age of 21 that are medically necessary, unduplicated and meet the criteria of the Florida Medicaid Behavior Analysis Services Coverage Policy. In order to obtain BA services, an individual must undergo a behavior assessment at least yearly. The full review criteria for Medicaid BA services can be found in Appendix 9 of the Florida Medicaid Behavior Analysis Services Coverage Policy.

Tips for Navigating the Behavior Analysis Plan Approval Process

  • Description of maladaptive behaviors should be clear, concise, observable and measurable
    • Description of behaviors should contain definite on-set and off-set criteria (i.e. describe in detail how behaviors begin and end)
    • Each behavior should have a unique description (the description of one behavior should not duplicate the description of any other behavior)
  • Update data/graph time frame to six-month authorization period (for continuation of service requests) to clearly document individual’s progress with BA treatment
  • Goals should be clearly tied to maladaptive behaviors
  • Plan should conform with standards of care within the field of Applied Behavioral Analysis and according to the Agency for Health Care Administration's standards of care (See Florida Medicaid Behavior Analysis Services Coverage Policy, Agency for Health Care Administration, October 2017, p. 6-7)
    • Do not include treatment strategies that are inconsistent with “generally accepted professional medical standards” as determined by the Medicaid program (See Rule 59G-1.035, F.A.C.)
  • All requests for BA services should be based only on medical necessity to treat maladaptive behaviors
    • Requests based on “convenience” will be denied
      • Requests should not be based on availability of provider staffing
      • Requests should not be based on availability of the recipient or their caregiver
  • Request a Reconsideration or Fair Hearing if BA services are denied, reduced or terminated
    • If your previously authorized services are reduced or terminated and you want to continue to receive services pending an appeal, you must request a reconsideration or fair hearing within the deadline specified in the Notice
      • If you request services continue pending the outcome of the fair hearing, and the Final Order is not in your favor, AHCA may seek reimbursement from the representative for the services furnished during the pendency of the fair hearing
    • The Reconsideration process provides an opportunity to cure defects in the BA Plan
    • If needed, request a peer-to-peer review with eQHealth and your BA provider in order to discuss needed revisions to the BA Plan for authorization
    • If the Notice of Reconsideration Determination upholds denial, reduction or termination of BA services, you have the right to request a fair hearing within ninety (90) days of the Notice

Agency for Health Care Administration
Medicaid Hearing Unit
P.O. Box 60127
Ft. Myers, FL 33906

Common Reasons Behavior Analysis Plans are Denied, Reduced or Terminated

  • Behavior Plan is not “individualized and specific”
    • Plan may use unclear descriptions of maladaptive behaviors written with words like “includes, but is not limited to”
    • Plan may include the use of incorrect pronouns
      • For example, if the recipient uses feminine pronouns (i.e. she/her), the Plan should not use masculine pronouns (i.e. he/him) when referring to the recipient
  • Behavior Plan goals are unclear and/or not adequately connected to maladaptive behaviors
  • Behavior Plan does not contain needed data and/or graphs
    • Graphs should include baseline data (i.e. starting point of BA therapy)
    • Graphs should include behavior data collected over the previous authorization period
  • Behavior Plan includes the following treatment for functions of maladaptive behaviors which have been identified by Medicaid as not accepted within the field of behavior analysis:
    • deep breaths,
    • deep breathing,
    • systematic desensitization,
    • relaxation training,
    • relaxation,
    • required relaxation
    • sensory alternatives
    • sensory strategies
    • sensory activities
    • calming
    • calming techniques
    • coping strategies
    • art therapy
    • yoga or exercise
    • anger control therapy
    • self-regulation skills
    • self-calming
    • conflict resolution
    • problem solving techniques

Note and Disclaimer

The information contained in this fact sheet should not replace a conference with your doctor and/or behavior analysis provider with regard to Behavior Plan modifications and authorizations.

The information in this fact sheet does not constitute legal advice nor imply an attorney/client relationship. This information is for educational purposes only. 

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