The question we get most on the phone is not what ABA is. It is how much it will cost. And the short answer, for most families in Miami-Dade, is that ABA therapy with Medicaid in Miami is covered when the child has a diagnosis and a doctor recommends it in writing.

The long answer is the rest of this article: exactly what Florida Medicaid requires, which papers you will be asked for, why some authorizations come through fast and others take longer, what to do if your request was denied and which other insurance plans we accept at Mayoral Behavioral Services. This is the English version of the guide we wrote for Spanish-speaking families, and we serve families in both languages.

Does Medicaid cover ABA therapy in Florida?

Yes. Florida Medicaid covers behavior analysis services, which is the official name for what most of us know as ABA therapy. Coverage applies to children and young people under 21 who have Medicaid, as long as the service is medically necessary. It is not an optional benefit or an exception you have to fight for from scratch: it sits within the program’s pediatric coverage.

Everything depends on that phrase: medically necessary. It does not mean someone decides whether your child deserves therapy. It means there has to be a clinical document explaining why he needs it, what will be worked on and how many hours. That is exactly what the behavior assessment produces.

What Medicaid does not do is pay for therapy without a diagnosis. If your child does not have one yet, that is the first step and it does not depend on us: an authorized professional issues it.

What you need before approval

Three pieces, in this order:

1. The diagnosis

A developmental pediatrician, a psychologist, a psychiatrist or a pediatric neurologist evaluates your child and issues a report. It can be autism, and it can also be other developmental conditions. Mayoral Behavioral Services does not issue diagnoses. We can do an initial behavior assessment to plan treatment, which is something different. If you are missing the diagnosis, ask your pediatrician for a referral to a specialist.

2. The medical recommendation

The insurer wants to see that an authorized professional recommends behavior analysis for this child. Sometimes it is inside the same diagnostic report, sometimes it is a separate letter. Without that paper, the request stops before it starts.

3. The behavior assessment and the plan

This is where we come in. A certified behavior analyst observes your child, talks with you and writes the plan: the concrete goals, the hours per week and who works with him. That plan is the document that goes to the insurer.

The documents you will be asked for

Have these ready before you call us and the process moves much faster. This is the list we always ask for:

• Your child’s Medicaid card, or the managed care plan card if he is already enrolled in one.
• The complete diagnostic report, not just the first page.
• The medical recommendation or the pediatrician’s referral.
• Your ID and proof that you are the parent or legal guardian.
• School reports, the individualized education plan (IEP) or speech therapy reports, if you have them. They are not required, but they help justify the hours.
• A phone number and an email you check often, because the plan sometimes calls to confirm details.

If you are missing something on this list, call us anyway. It is better to start with half the list and find the rest than to wait six months until you have everything.

How to verify your coverage, step by step

You do not have to do this alone. But it helps to know what is happening at each stage.

• You give us the insurance details. Medicaid or plan number, your child’s full name, date of birth.
• We verify the benefits directly with the plan: whether it covers behavior analysis, what it authorizes and whether there is a copay or deductible.
• We explain the result plainly, in English or Spanish. If your plan does not cover behavior analysis, we tell you on that call and not after three appointments.
• The behavior assessment is done and the treatment plan is put together.
• The authorization request is sent. Timelines vary by plan and time of year, so we will not give you a made-up date. We tell you where it stands every time you ask.
• The authorization arrives and sessions begin. The authorization covers a number of hours for a period, not forever.

Other insurance plans we accept

Medicaid is the most common among the families we serve, but it is not the only one. At Mayoral Behavioral Services we work with:

• Medicaid
• Sunshine Health
• Simply Healthcare
• Children’s Medical Services (CMS) Health Plan
• Aetna (commercial plans)
• Cigna
• Florida Blue / BlueCross BlueShield
• Magellan Health
• Tricare

If your plan is not on the list, call us anyway. In some cases we can work with out-of-network benefits, and we can always talk through payment options. We serve families in Miami-Dade, Broward and nearby areas.

If your request was denied

It happens often, and many times the reason is in the paperwork and not in the child. The most common ones are these:

• The diagnostic report does not clearly state the child’s condition or is missing a signature.
• There is no written medical recommendation, only a passing mention.
• The plan asked for more hours than that insurer usually authorizes on a first request.
• An eligibility document was missing, or the policy moved to a different managed care plan and nobody said so.
• The previous authorization expired and the renewal was sent late.

You can appeal, and the plan is required to explain in writing why it denied the request. Keep that letter: it says exactly what to fix. We review the documents with you, gather what is missing and send the request again.

What happens after approval

Approval is not the goal, it is the starting line. The first weeks are spent helping your child feel comfortable with his therapist, and the heavy work begins once that is in place.

• Sessions follow the authorized plan, with data from each one. That data is what supports the next renewal.
• Every few months the goals are reviewed: the ones already met come off and new ones come in.
• Parent training is part of the program. Your child spends two or three hours in therapy and the rest of the day outside it, so what is practiced at home counts for a lot.
• If the goal is for him to play and share with other children, that is worked on in social skills training.
• Tell us as soon as anything changes with your insurance. A mid-year plan change is one of the most common reasons a therapy already underway gets interrupted.

And one thing we always say, even though it does not help sell: nobody can promise you a result. What we can commit to is measuring, showing you the data and changing the plan when the data says it needs to change. You can see how we work on our ABA therapy page.

Frequently Asked Questions