Of all the things that stop a family after a diagnosis, this is the one most people let slide. It is not the waitlist and it is not the drive. It is not knowing whether they can afford it, and not asking because they are afraid of the answer.<\/p>\n\n\n\n
So let us start at the end: in Florida, many families have more coverage than they think.<\/strong> Others have less than they were told. It is worth knowing which group you are in before you decide anything.<\/p>\n\n\n\n Florida has a statute written specifically for this. It is section 627.6686, known as the Steven A. Geller Autism Coverage Act<\/em>.<\/p>\n\n\n\n What it requires plans to cover:<\/p>\n\n\n\n Who the law covers: people under 18<\/strong>, or 18 and older who are still in high school, diagnosed with a developmental disability at age 8 or younger<\/strong>.<\/p>\n\n\n\n Two more conditions. The treatment has to be prescribed by the treating physician<\/strong> as part of a treatment plan, and ABA has to be delivered by someone holding the certification or license the state requires.<\/p>\n\n\n\n The required coverage has a limit: $36,000 a year<\/strong> and $200,000 over a lifetime<\/strong>.<\/p>\n\n\n\n For many families those numbers never come into play. For families running an intensive ABA program they can, because a program of many hours a week uses up that annual figure before the year is out.<\/p>\n\n\n\n That is not a reason to wait. It is a reason to ask, from the very beginning, how many hours are being authorized and how much of the cap is being used. A clinic that handles this well tells you without being asked.<\/p>\n\n\n\n The statute binds plans regulated by the state of Florida<\/strong>: fully insured large group plans, HMOs, and the state employee plan.<\/p>\n\n\n\n It does not bind self-funded plans<\/strong>, which is what many large employers set up on their own. Those are governed by federal law rather than Florida law, and they sit outside the mandate.<\/p>\n\n\n\n Sitting outside the mandate does not mean no coverage<\/strong>. Plenty of self-funded plans cover ABA and therapies anyway, because they choose to or because their own policy includes it. It only means this particular law does not require it, so you have to ask them directly.<\/p>\n\n\n\n Individual and small group plans follow a different route, through essential health benefits. Those also have to be checked one by one.<\/p>\n\n\n\n What this means in practice:<\/strong> someone telling you “it’s required in Florida” is not enough. It depends on what kind of plan you have, and one phone call settles it.<\/p>\n\n\n\n Florida Medicaid covers therapy for children, and this is usually better news than people expect.<\/p>\n\n\n\n Behavior analysis services (ABA):<\/strong> covered for recipients under 21<\/strong> when medically necessary. All<\/strong> ABA services require prior authorization.<\/p>\n\n\n\n Occupational, physical, respiratory, and speech therapy:<\/strong> covered for recipients from birth through age 20<\/strong>, when medically necessary.<\/p>\n\n\n\n This rests on a federal rule known by its initials, EPSDT, which in practice means something fairly powerful: if a service is medically necessary to correct or improve a condition in someone under 21, Medicaid has to cover it.<\/p>\n\n\n\n If you are in a Medicaid managed care plan, the day-to-day rules come from your specific plan, and each plan has its own provider network. Before anything else, ask whether the clinic you want is in your<\/strong> plan’s network, not Medicaid’s in general. The Florida Medicaid helpline is 1-877-254-1055<\/strong>.<\/p>\n\n\n\n It is the permission your insurer gives before<\/strong> sessions start. Without it, even a covered service does not get paid.<\/p>\n\n\n\n How it works, in order:<\/p>\n\n\n\n Timelines vary a lot. Ask how long your plan usually takes and who at the clinic follows up on it, because authorizations get lost and somebody has to be chasing them.<\/p>\n\n\n\n A denial is not the end. You appeal, and appeals are won often.<\/p>\n\n\n\nWhat Florida law requires<\/h2>\n\n\n\n
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The caps almost nobody mentions<\/h2>\n\n\n\n
The detail that surprises people: the law does not apply to every plan<\/h2>\n\n\n\n
If you have Medicaid<\/h2>\n\n\n\n
What prior authorization actually is<\/h2>\n\n\n\n
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If you are denied<\/h2>\n\n\n\n