Florida’s ABA Task Force heard CMS, FSU, and education officials on hours and schools. A provider and parent who applied for its vacant seat is still waiting.
Key Takeaways
- The assessment question: A federal official described a diagnosis-to-treatment-plan process that can take up to 20 hours; Florida’s fee schedule caps the behavior assessment itself at six.
- The federal position on limits: CMS told the panel that states may tier ABA hours but cannot impose hard caps, because EPSDT requires room to move when a child’s medical necessity changes.
- The provider view: Kate Sallade, who runs three centers in Volusia County, says managed care rate cuts have left her carrying debt and prioritizing commercially insured referrals over Medicaid ones.
- What comes next: No recommendations were adopted. Managed care plans present on September 28, the seat reserved for a parent is still vacant, and the report is due December 31.
On the last day of August, the Applied Behavior Analysis Task Force that Florida’s Legislature created this year met for six hours at the Agency for Health Care Administration’s headquarters in Tallahassee, and most of that time belonged to its presenters. There were four: a federal Medicaid official who spoke without slides, a Florida State University researcher who served on the DSM-5 work group on neurodevelopmental disorders, a Department of Education administrator, and the agency’s own policy lead, who brought a state-by-state survey of how the benefit is run elsewhere. When the meeting adjourned that afternoon, the task force had adopted no recommendations, and Secretary Shevaun Harris, who chairs it, asked members to bring their own to the next session.
Kate Sallade watched that meeting from the audience. She is the Founder and Chief Executive Officer of Behavioral Foundation Centers, which operates two centers in Deltona and one in Daytona, employs about 75 people, and serves roughly 65 patients from eighteen months to twenty-one years old. She has worked in ABA since 2008, has been a Board Certified Behavior Analyst since 2011, and founded the company in 2019. She is also the mother of three autistic sons, the youngest born with a brain abnormality, and is autistic herself. She has also applied for the seat the statute reserves for a family member of an enrollee receiving ABA services, and said that as of the August meeting she had heard nothing back. The seat is still listed as vacant on AHCA’s roster.
The panel opened its review on August 12 with a $6.57 billion spending figure. Its second meeting, listed by AHCA as a session on clinical evidence, transitions, and comparative Medicaid models, drew the boundaries the members will work within: a federal view that limits on therapy hours must bend to medical necessity, a researcher’s reading of the evidence on intensity, an education official’s account of what schools owe students, and a list of policy questions the agency’s presenter said were the task force’s to answer. The full meeting is archived by The Florida Channel, and the presentations are posted in AHCA’s meeting materials.
What CMS Told Florida About Limits on ABA Hours
Dr. Caprice Knapp, Principal Deputy Director of the Center for Medicaid and CHIP Services, walked the members through the ABA toolkit her agency released this summer, and she began with what the document is not. “A toolkit is not a rule,” she said, and its recommendations do not bind the states. CMS wrote it, she explained, after states and managed care plans began asking how to read the growth in their own ABA numbers.
On hours, her position had two parts. States may sort children into tiers of weekly service, she said, but under EPSDT, the federal guarantee of medically necessary care for Medicaid enrollees under 21, a child must be able to move between tiers when the clinical picture changes, in either direction. “We always have soft limits at CMCS,” she said. “We do not have hard limits.” At the same time, she told the panel that 40-hour weekly schedules draw scrutiny from federal auditors, who ask how a young child fits in naps, meals, and bathroom breaks, and that CMS has recovered money from states on the strength of those findings. She suggested that states require written policies on breaks and reconsider billing arrangements that let a day’s 15-minute units be consolidated onto a single claim line.
Asked by Harris which recommendation CMS considered essential, Knapp named conflict-free care planning: separating the professional who writes a child’s treatment plan from the provider paid to deliver it, as Medicaid already requires in its waiver programs. Harris noted that because ABA is a state plan service in Florida, the children receiving it have no mandatory case management. Knapp also cautioned against diagnoses made in a single brief visit or entirely over telehealth.
How Florida’s ABA Assessment Rules Compare
One figure from Knapp’s remarks resurfaced later in the day. Experts and parents told CMS, she said, that the process of reaching an individualized treatment plan “can take up to 20 hours.” When Shena Grantham, AHCA’s Assistant Deputy Secretary for Medicaid Policy and Quality, reached reimbursement in her own presentation that afternoon, she returned to the same estimate, observing that some states pay for assessments as a bundle rather than by the 15-minute unit, an approach she said might reduce administrative complexity.
Florida divides that path into parts. Its coverage policy requires a comprehensive diagnostic evaluation before a child is referred, then a behavior assessment before treatment begins. The state’s fee schedule caps that behavior assessment at 24 units, or six hours, and reassessments at 18 units, or four and a half hours, with separate limits for supporting assessment codes. When a family changes providers, the policy says only that a full assessment “may be requested.”
What the assessment decides is not only how many hours a child receives but where. Sallade said her practice treats the second question as seriously as the first, matching families to the setting most likely to work rather than defaulting to a center. Two of her three sons have received ABA, one for less than two years and the other long term, given his support needs. The science, she noted, is broad enough to be applied to nearly anything, from toilet training and communication to weight loss and smoking cessation. “I don’t think that just because ABA can work for everybody means that everybody needs ABA,” she said. Her point was not about the treatment’s value, which she described as the only empirical, research-based treatment for autism available today, but about fit: a treatment that can work for anyone does not mean everyone qualifies for insurance-funded services, or that other treatments would not also work in a given case.
Defining ABA and the 25-Hour Question
Dr. Amy Wetherby, a Distinguished Research Professor at Florida State University’s College of Medicine, had been asked to define applied behavior analysis. She described a continuum that runs from traditional discrete trial training, through naturalistic developmental behavioral interventions, which she called the contemporary and evidence-based form of ABA, to developmental relationship-based approaches, which she said are not intensive enough to fall under the label. Pointing to a diagram, she drew a line between what she called “little ABA and big.”
Then she turned to intensity. Wetherby served on the National Research Council committee whose 2001 report, Educating Children with Autism, remains a reference point for the field, and she told the members the committee found no evidence that anything beyond 25 weekly hours “did anything better than 25 hours a week.” Newer research, she said, has gone further, with some studies finding that hours do not relate to outcomes at all, and children identified early “don’t need 25 hours a week of individual therapy.” Her strongest recommendation was to invest in detection by 18 months of age, using screening tools developed by her FSU team that she said can be applied over telehealth.
The report itself, in its written recommendations, calls for “a minimum of 25 hours a week, 12 months a year” of engaged, systematically planned activity. During public comment, a Registered Behavior Technician pressed that reading, telling the panel the figure “is a floor, not a ceiling.” Mariel Fernandez, Vice President of Government Affairs at the Council of Autism Service Providers, agreed that not every child needs 40 hours a week but cautioned against “hard caps where a child can never receive more than 25 hours per week,” which she said would conflict with EPSDT. She pointed the members to a recent meta-analysis by Sigmund Eldevik and colleagues, arguing that intensity and medical necessity are multidimensional and turn on more than symptom severity. CASP’s current guidance, built on that line of research, sorts comprehensive treatment into intensity bands that reach 26 to 40 hours, and seven providers who compared their outcomes against those bands reported more improvement at higher intensity, one data point in a broader debate over the 40-hour default.
Sallade, watching from the audience, took the discussion of the DSM-5 severity levels as an admission that they rest on thin ground. Wetherby’s own account was that the work group was asked to produce levels, then told not to, then asked again near the end of its work, and that the result has drawn heavy criticism, including for limiting access to services rather than widening it. She said she has since worked with colleagues on a commentary proposing a different way to think about severity, and that she was concerned to see the current levels invoked in the federal toolkit. Sallade’s objection was to the sequence. Florida is weighing policy that leans partly on those levels, she said, while the levels themselves remain unsettled, and in her telling nobody has checked whether the cost-saving measures under discussion would save anything.
Sallade’s objection to the hours debate is that it skips a prior step. “There’s a huge difference between comprehensive and focused services,” she said, a distinction that decides what a given number of hours is meant to accomplish. The task force has not worked through it yet. Dr. Yanerys León, a Speaker of the House appointee who is also President of the Florida Association for Behavior Analysis, asked the panel to define comprehensive and focused ABA before setting authorization rules. The agency has since scheduled Dr. Thomas Frazier of CentralReach to open the September 28 meeting on exactly that question.
ABA in Florida Schools and the IEP Question
The afternoon turned to schools, where a large share of the money goes. AHCA’s data show that school settings accounted for $620.7 million in behavior analysis spending and 50.9 million service units in state fiscal year 2025-26, second only to homes. Dr. Peggy Aune, Vice Chancellor for Strategic Improvement in the Department of Education’s Division of Public Schools, reported 71,688 students with autism spectrum disorder as their primary eligibility in the 2025-26 school year, up from 51,448 four years earlier. She also walked through House Bill 795, the 2023 law that lets parent-selected Registered Behavior Technicians work in classrooms as private instructional personnel.
Her central point concerned the individualized education program.
Services written into a student’s IEP must be delivered, she said, whether by district staff, contractors, or both: “If it’s within the student’s IEP, it needs to be provided.” Parents can reconvene the IEP team at any time, she added, and may not realize that a service they are seeking in the community is available at school.
Members asked how often that happens in practice. Dr. Kerri Peters, Administrative Director of the UF Health Center for Autism and Neurodevelopment and the immediate past president of the Florida Association for Behavior Analysis, said a review of district job postings a few years ago found fewer than 20 percent of districts with a Board Certified Behavior Analyst on staff, and asked for data on behavior analysts in schools and on IEPs that call for one. Aune said districts also contract for those services, so vacancy listings may not reflect their staffing. Harris said AHCA has received requests to let districts bill Medicaid for ABA through its school-based services program, but the agency has been “reluctant to add that into the menu of services” until other concerns with the benefit are addressed.
Sallade, whose practice sends staff into public schools in west Volusia County, listened to that exchange as a warning. “If [AHCA] stopped paying for ABA providers to go into public schools, you are going to have a mass public school crisis because the public schools do not have behavior analysts,” she said. “They do not have RBTs. Certainly not enough to handle children.”
She has also been on the other side of the table. Her youngest son, who is nonverbal, has seizures that stop his breathing and needs medication within three minutes. Only two people in his school were certified to give it, she said, and district rules did not allow the staff member trained on his medication to be trained on behavioral intervention, so a second adult would have been needed to keep him from leaving the classroom. The district’s answer, she said, was hospital homebound status, which brought a teacher to the house for an hour a day, up to four days a week, “if it was convenient for her.” Faced with a choice between a teacher for no more than four hours a week and the state voucher program for privately sourced services, she said, the decision was easy. Her son has been on the voucher program for three years, using it for speech, occupational, physical, and music therapy as well as private tutoring. She acknowledges that the voucher draws money away from the public schools. For children like her son, she said, there is not much of a choice when a district effectively opts out of its obligation to provide a free appropriate public education by labeling a student hospital homebound.
ABA Authorization, Duration, and the Wait for Services
Grantham’s comparison laid out the levers other states have pulled. California triggers utilization review above 25 hours a week, Virginia requires detailed justification above 20, and North Carolina shortens authorizations to three months above 16 hours; Indiana has adopted a 4,000-hour lifetime limit. Florida authorizes services for six months, limits treatment to 40 hours a week, and, according to the agency’s slides, does not currently address higher-intensity services in policy. Florida children receive behavior analysis for an average of 32.5 months, and the agency’s chart shows roughly 10,000 who have received it for more than five years. Grantham said the literature suggests many children can meet their goals in 12 to 24 months, and she presented each figure as a question for the members. “I only present the questions,” she said, “not the answers.”
Sallade’s frustration with that exercise was that the answers were unavailable. Members asked Grantham several questions about the outcomes of cost-saving measures in other states, she said, and every answer amounted to the same thing: no one knows yet.
She also finds the discussion of hours and duration, including the federal concern about naps, meals, and breaks inside a 40-hour week, “tone deaf to the true lived experience of families of children with Level 3 or ‘profound’ autism.” Her youngest son is generally awake from six in the morning until nine at night and requires one-on-one supervision within arm’s reach at all times because of self-injury and risky behavior. Forty hours a week, she said, would not cover half of that. Many autistic children have sleep disorders and stop napping young, and for children like hers, toileting and mealtimes are not breaks from therapy but some of its central targets, work she said speech, occupational, and physical therapists do not take on. Her son lost the ability to speak and eat after brain surgery at 20 months old. ABA, she said, is the only treatment that has gotten him back to eating pureed foods rather than depending on nutritional shakes and a feeding tube for the rest of his life.
She also noted that ABA is classified as a habilitative service, meaning a child’s needs grow as the skills expected of them become more advanced. Children with Level 3 or profound autism, in her view, will need more intensive services for longer to keep closing that gap in a meaningful way, and to avoid outcomes such as a lifetime of higher-level care.
Stella Johnson, Chief Executive Officer of the Jacksonville nonprofit Hope Haven, said children diagnosed at 18 to 24 months are now waiting six to 12 months for ABA, and asked what role the initial authorization plays. Since Florida moved behavior analysis into managed care in February 2025, Harris explained, each plan runs its own authorization process, some through subcontractors. She said the delay may also reflect families who cannot find a provider accepting new patients, and she stressed the importance of the first decision: “If you authorize too many, it’s hard to walk that back.”
What the Managed Care Transition Looks Like From Volusia County
Sallade’s account of that transition begins with what preceded it. Under fee-for-service Medicaid, she said, the rules were demanding but predictable: billing entered by Wednesday produced an invoice on Saturday and payment the following Thursday. “Follow the rules. You’ll get paid, you’ll get your authorizations,” she said. “It’s just a matter of learning and integrating those rules into your practice.”
Managed care divided that single payer into several. On the first day of the transition, Sallade said, Sunshine Health and Simply Healthcare cut her rates by exactly 20 percent, and other managed care plans, including Humana, have since followed. “Hey, tomorrow I want you to do the exact same job as what you’re doing now, but I’m just going to pay you 20 percent less because I think so,” she said, describing how the change landed. Her company has taken on roughly $400,000 in debt since February 2025, which she attributes to variation in plan payment, and Sunshine, she said, has lately been holding payments. She has raised caseloads and pulled back on scheduling stability for staff to keep up with lease payments, changes she called compromises to the practice’s effectiveness. Simply Healthcare Plans disputes that account. Asked about the reductions, the plan said that when Florida transitioned behavior analysis services to managed care in February 2025, it “contracted with BA providers at 100% of the applicable Florida Medicaid reimbursement rate,” and clarified that it meant the full rate established by Florida Medicaid at the time rather than a percentage of it. Sunshine Health declined to comment.
The two accounts are hard to square from the public record, and they may not be in conflict. Florida’s published behavior analysis fee schedule did not change at the transition: 97153, the technician delivery code that carries most ABA hours, has paid $12.26 per 15-minute unit since the state moved to CPT billing in 2022. Sallade described a 20 percent reduction in what her practice was paid, which is a different measure than the fee schedule itself. A practice paid above the schedule before February 2025, or paid under terms that changed when its contract moved to a plan, could see its revenue fall while a plan accurately says it contracts at the full Medicaid rate. What a plan pays a particular practice is a contract term, and those contracts are not public, which is why the gap cannot be closed from the outside. Acuity has asked the agency whether plans are required to reimburse at the published rate or may negotiate below it.
The agency has intervened once already in how plans handled the new benefit, though on a different front. In an April 17 policy transmittal, Deputy Secretary for Medicaid Brian Meyer told the managed care plans that folding behavior analysis into value-based purchasing arrangements with downside risk could create access problems for children, because a practice carrying significant losses may not be able to keep providing care. Adding the benefit to managed care was a change exceeding $2 billion in annual utilization, the transmittal says, and the agency found no evidence that plans had told providers in those arrangements what it would mean for their financial exposure. Plans were given 45 days to renegotiate with affected providers, ordered to stop recoupment efforts in the meantime, and required to report back within 60 days.
The consequence she returns to is who gets seen. Deltona is a heavily Medicaid community, and her waitlist there runs about three years. Her practice was roughly 70 percent Medicaid and has been diversifying toward commercial insurance, which has meant pausing Medicaid intakes in favor of families further down the list with other coverage. It is a choice she said she is neither happy nor comfortable making. “It feels like we have to say, ‘I’m sorry, because you’re poor, I have to set you aside,’” she said, “‘and I have to take a family that has enough money to have the privilege of private insurance.’”
On fraud, which the CMS toolkit devotes a chapter to and which has driven much of the political attention to ABA, she drew a distinction. There is fraud in ABA, she said, as in every industry, and she pointed to a large Orlando case. Her argument is that the state’s response has not matched the problem: since 2019 she has recommended that AHCA tighten access to provider Medicaid identification numbers, which can be used to enroll a clinician into a company without that clinician’s knowledge, and those recommendations went nowhere. Rate reductions, in her reading, lower the bill without closing the gaps in security that allow fraud in the first place.
Public Comment and the Task Force’s Next Meeting
About 15 people signed up for public comment, each asked to keep to a minute and a half. Dr. Melissa Olive, Executive Director of FABA, endorsed Wetherby’s emphasis on early intervention and described reports of “classrooms that have 13 children with 13 RBTs sitting at the back of the classroom,” which she said does not meet the definition of the science. She asked for spending data broken out by age and setting together, noting that most children served are older than six while most services are delivered at home. Rachel Morales, a mother who traveled from Miami, told the panel her children’s hours had been reduced “from 20 to zero” and that three months of complaints had not resolved it. Harris offered to speak with her afterward and said senior staff would stay behind to help parents in the room with their cases.
For Sallade, the arithmetic of that hour is the problem. Ninety seconds a speaker, in a meeting held in Tallahassee, in a process due to report by December 31, is not enough to learn what the members would need to know. By her count, parents got two of those slots, three minutes out of a six-hour meeting. Morales was the only speaker who addressed the panel as a parent before the microphone moved on to clinicians, association representatives, and a physical therapist. “They have excluded the community that they are about to devastate from this process,” she said. During an earlier round of proposed Medicaid changes in 2019, she held a rally in Orlando and hosted legislators at her offices, and the state, she noted, took its meetings around Florida then. Her recommendation now is procedural: survey families, examine waitlists, and gather the data before writing recommendations.
She also said the panel is short of people who have lived what it is deciding, a judgment about a body whose appointments are complete but for the seat she applied for. What she says she is protecting is a chain of dependence she can count: three sons, 75 employees, 65 patients, a husband who left work to care for their youngest. “I’m not fighting for me,” she said. “I’m fighting for 300 people.”
According to the task force’s AHCA page, the third meeting is scheduled for September 28 and a fourth for October 5. The September 28 agenda runs from Frazier on focused versus comprehensive ABA through a presentation from the Agency for Persons with Disabilities, a provider’s perspective on prior authorization from Abbye Chappell of Cayer Behavioral Group, and a managed care panel on utilization management with Simply Healthcare, Sunshine Health, and Humana Healthy Horizons. Harris has said formal votes on recommendations will come at the end of the process. The Governor has since filled two of his three appointments, naming Kale Baker, a Vice President at Molina Healthcare, and David Brown, Co-Founder and President of Family Initiative. The members now have Washington’s boundaries and their own agency’s questions. The parent’s seat is still open.
