If your family's insurance card says Personify Health, you may not find much online about ABA coverage. That is not a mistake on your part. Personify Health runs health plans for employers, and each employer decides what its plan covers. This guide explains what that means for ABA therapy in Florida, how it differs from a traditional insurance plan, and exactly what to ask so you get a clear answer.
What is Personify Health?
Personify Health describes its plan administration service as "helping self-funded employers build healthier, more engaged workforces and achieve measurable savings," including "medical, dental, and vision claims management." It also tells employers they can "Choose your networks, PBMs, stop-loss partners, and point solutions." In other words, it works as a third-party administrator (TPA): it processes claims and runs the plan, while the employer funds the benefits and sets the rules.
Personify Health describes itself more broadly as "a personalized health platform," so its name can appear on more than one kind of program. For ABA, what matters is who administers your medical plan and who pays the claims. If you are not sure, ask HR: "Is our medical plan self-funded, and is Personify Health the plan administrator?"
Does Florida's autism law apply to a Personify Health plan?
Usually not. Florida's Steven A. Geller Autism Coverage Act applies to fully insured plans from Florida-licensed insurers and HMOs, plus the state employee plan. It does not reach self-funded employer plans. The Florida Department of Financial Services says it "does not have authority over self-insured plans under the Employee Retirement Income Security Act of 1974."
| Question | Fully insured Florida large-group plan | Self-funded plan run by a TPA |
|---|---|---|
| Who pays claims? | The insurance company | The employer (often with stop-loss insurance) |
| Does Florida's autism mandate apply? | Yes, for eligible children | No |
| Who decides if ABA is covered? | State law sets a floor; the certificate of coverage adds detail | The employer, in the plan document |
| Federal parity law | Applies | Applies if the employer has more than 50 employees |
| Where to complain | Florida DFS | U.S. Department of Labor (EBSA), for private employers |
| Key document | Certificate or evidence of coverage | Summary Plan Description (SPD) and plan document |
A self-funded plan can still cover ABA, and many employers choose to. It is the employer's decision, written into the plan. For more, see fully insured vs self-funded plans.
Government employers are different. For a self-funded city, county or school district plan, DFS advises contacting local officials first, then the federal Department of Health and Human Services at phig@cms.hhs.gov.
Is there a Personify Health ABA policy I can read?
We looked for a published Personify Health ABA medical policy and did not find one. Some administrators publish ABA documentation requirements, and some do not; others use criteria from a partner company. Because of that, we do not describe Personify Health's ABA rules here. The reliable sources are:
- your Summary Plan Description and full plan document;
- the plan's written answer to your questions; and
- any medical necessity criteria the plan uses for ABA, which you can request.
Federal parity law says the criteria for medical necessity decisions on mental health benefits "shall be made available by the plan administrator ... to any current or potential participant, beneficiary, or contracting provider upon request." See mental health parity and ABA denials.
What should I ask about ABA?
Call the member services number on your card. Ask each question, and ask for the answers in writing. Our insurance call script gives you a notes sheet.
| Ask | Why it matters |
|---|---|
| "Does the plan cover applied behavior analysis (ABA) for autism? For Down syndrome?" | The employer decides; there is no state requirement |
| "Is prior authorization or a pre-determination required? Who reviews ABA requests?" | Tells you who your provider will deal with and what they need |
| "Which network does my plan use for behavioral health and ABA?" | Personify Health plans can use different networks chosen by the employer |
| "Are there limits on ABA hours, visits, age or dollars?" | Federal rules restrict some limits, so get them in writing |
| "What are my deductible, copay or coinsurance and out-of-pocket maximum for ABA?" | ABA involves many sessions, so these drive your cost |
| "Are school, home and center sessions all covered?" | Some plans exclude services that are mainly educational |
| "What diagnosis documents and treatment plan details do you need?" | Avoids delays at the start |
| "How often must ABA be reauthorized?" | Helps you avoid a gap in services |
Write down the date, the name of the person you spoke with and a reference number for each call.
How do I get the plan documents?
- Ask HR or the benefits office for the Summary Plan Description and any ABA or behavioral health amendment.
- Check the member portal. Plan documents are often posted there.
- Make a written request to the plan administrator named in the SPD, usually your employer. Federal law gives participants in private employer plans the right to request plan documents. For mental health benefits, the federal agencies' parity FAQ Part 45 says participants "are entitled to comparative information on medical necessity criteria" for medical and mental health benefits.
Search the documents for "applied behavior analysis," "ABA," "autism," "behavioral health" and "exclusions."
What will an ABA request probably need?
Even without a published Personify Health policy, you can prepare. The ABA policies we reviewed from other payers (Aetna, Cigna's Evernorth, Optum, UMR and TRICARE) ask for the same building blocks, and a self-funded plan's reviewers are likely to ask for similar documents:
- an autism diagnosis from a qualified professional, with the evaluator's name, credentials and date (an IEP alone is usually not enough);
- a standardized assessment and a written treatment plan with measurable goals;
- parent or caregiver training goals;
- a plan for fading services and discharge; and
- reauthorization about every six months with progress data.
Treat this as a preparation list, not as Personify Health's rules. Your plan's written answer is what counts. See the diagnosis paperwork you need before ABA.
What if the plan does not cover ABA, or denies it?
- Get the decision in writing, with the plan language it relies on.
- Appeal. Self-funded employer plans must offer an internal appeal and, in most cases, an independent external review. See how to appeal an ABA denial in Florida.
- Ask about parity. If the plan covers other mental health care for autism but excludes ABA, ask how that exclusion meets federal parity rules.
- Talk to your employer. Because the employer designs the plan, it can add ABA at renewal. See how to ask your employer to add ABA.
- Get outside help. For private employer plans, the U.S. Department of Labor's Employee Benefits Security Administration helpline is 1-866-444-3272.
How Hope Center works with Personify Health plans
Hope Center for Behavior Change works with Personify Health. Because each employer's plan can have its own ABA terms and network, we check your specific plan through a free benefits check before services begin: whether ABA is covered, what authorization is needed and what your share is likely to be. We also work with Blue Cross Blue Shield (Florida Blue), Aetna, Cigna (Evernorth), UMR and TRICARE East, and self-pay with a sliding scale is available. See insurance at Hope Center, request a free benefits check, or call 561-337-8865. For how the check works, see what happens during your benefits check.