What Insurance Covers: Children’s Therapy in Florida

What Florida law requires

Florida has a statute written specifically for this. It is section 627.6686, known as the Steven A. Geller Autism Coverage Act.

What it requires plans to cover:

• Screening for autism at well-baby and well-child visits.
• Treatment of autism and Down syndrome through speech therapy, occupational therapy, physical therapy, and applied behavior analysis (ABA).

Who the law covers: people under 18, or 18 and older who are still in high school, diagnosed with a developmental disability at age 8 or younger.

Two more conditions. The treatment has to be prescribed by the treating physician as part of a treatment plan, and ABA has to be delivered by someone holding the certification or license the state requires.

The caps almost nobody mentions

The required coverage has a limit: $36,000 a year and $200,000 over a lifetime.

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.

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.

The detail that surprises people: the law does not apply to every plan

The statute binds plans regulated by the state of Florida: fully insured large group plans, HMOs, and the state employee plan.

It does not bind self-funded plans, 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.

Sitting outside the mandate does not mean no coverage. 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.

Individual and small group plans follow a different route, through essential health benefits. Those also have to be checked one by one.

What this means in practice: 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.

If you have Medicaid

Florida Medicaid covers therapy for children, and this is usually better news than people expect.

Behavior analysis services (ABA): covered for recipients under 21 when medically necessary. All ABA services require prior authorization.

Occupational, physical, respiratory, and speech therapy: covered for recipients from birth through age 20, when medically necessary.

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.

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 plan’s network, not Medicaid’s in general. The Florida Medicaid helpline is 1-877-254-1055.

What prior authorization actually is

It is the permission your insurer gives before sessions start. Without it, even a covered service does not get paid.

How it works, in order:

1. The evaluation happens.
2. The clinic writes a treatment plan with goals, frequency, and duration.
3. The physician’s order or prescription is needed.
4. Everything goes to the insurer.
5. The insurer authorizes a specific number of sessions or hours, for a specific period.
6. When that period ends, it has to be renewed with a progress report.

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.

If you are denied

A denial is not the end. You appeal, and appeals are won often.

Get the denial in writing and find the exact reason. Frequently it is not that the service is not covered. It is a miscoded claim, a missing document, or a treatment plan that did not explain medical necessity well enough.

Ask which process you are in. There is an internal appeal with the insurer and, after that, an external review by someone outside it. The deadlines are short, so write the dates down the same day.

Ask the clinic for help. Strengthening the treatment plan with more clinical detail is what changes the outcome most, and they write that, not you.

If you have Medicaid, there is also a fair hearing process. Ask about it.

Which insurers we work with

This list changes as contracts close, so we keep it current in one place: Insurance We Accept.

As of today we are in network with Aetna and Curative across all four disciplines, with United, Optum, and American Specialty Health for speech, occupational, and physical therapy, and with Cigna / Evernorth for ABA. We are also an approved Step Up provider in all four disciplines.

Two things worth saying plainly. Several more contracts are signed and waiting on an effective date, including Tricare and Oscar. And we are not yet in network with any Florida managed Medicaid plan — those applications are in review. If you have Medicaid, call us anyway and we will tell you where that stands and what your options are.

Eight questions to ask your insurer

Call the member services number on the back of your card and ask these, in this order. Write down the name of the person who helps you and the date.

1. Is my plan fully insured or self-funded?
2. Does it cover applied behavior analysis, speech therapy, occupational therapy, and physical therapy for children?
3. Is prior authorization required? For which ones?
4. Is a referral or physician order required?
5. What is my copay per session, and how much of my deductible is left?
6. Is there an annual session cap or a dollar limit?
7. Which providers are in network near my ZIP code?
8. How long does an authorization usually take?

With those eight answers you know exactly where you stand. It is half an hour on the phone and it saves you months of guessing.