Some Florida children have two kinds of coverage at once: Medicaid and a parent's job-based plan, or Medicaid and TRICARE. That can be a real help with ABA costs, but it also changes how claims are paid and which providers make sense. This guide explains the payer-of-last-resort rule, how it plays out for ABA, and the trade-offs when choosing a provider.
What does "payer of last resort" mean?
Medicaid.gov puts it plainly: "By law, all other available third party resources must meet their legal obligation to pay claims before the Medicaid program pays for the care of an individual eligible for Medicaid." Medicaid calls those other sources "third parties." Its examples include:
- group health plans and self-insured (self-funded) employer plans;
- managed care organizations;
- Medicare;
- court-ordered health coverage; and
- other state or federal coverage programs, unless the law specifically excludes them.
People who are eligible for Medicaid assign their rights to third-party payments to the state Medicaid agency. That means the state can collect from the other coverage if Medicaid paid something the other plan should have paid.
States also look for other coverage on their own. Medicaid.gov says states collect information about other coverage when families apply and update it at each renewal, and that they run data matches, including with the Department of Defense to find enrollees who have TRICARE.
How does this work for ABA?
For a child with Florida Medicaid and other coverage, the typical order looks like this:
- The other plan pays first, under its own rules: its network, prior authorization, medical necessity criteria, deductible and copays. Florida's autism insurance law lets covered plans apply "coordination of benefits, participating provider requirements" and utilization review (s. 627.6686(4)(d)).
- Medicaid considers what is left, under Medicaid's rules. Florida Medicaid behavior analysis (BA) services also need their own prior authorization, and Medicaid reimburses only providers enrolled with Florida Medicaid who meet its qualifications.
Florida Medicaid's BA policy says there is no copayment or coinsurance for BA services under Medicaid. How Medicaid handles a primary plan's deductible and copays for a child with both depends on Medicaid's payment rules and your child's Medicaid plan, so ask the plan and the provider's billing office to explain how they coordinate before services start.
Who pays first in common situations?
| Coverage combination | Pays first | Pays next | Pays last |
|---|---|---|---|
| Parent's employer plan + Medicaid | Employer plan | (none) | Medicaid |
| Two parents' employer plans + Medicaid | The two plans, in the order their coordination of benefits rules set | Medicaid | |
| TRICARE + Medicaid | TRICARE | (none) | Medicaid |
| Young adult with disability-based Medicare + Medicaid | Medicare (for services Medicare covers) | (none) | Medicaid |
| Medicaid + APD iBudget waiver (adults and some children) | Medicaid state plan, school services and private insurance | (none) | iBudget waiver funds |
Two notes on the table. First, Medicare.gov says "Medicaid never pays first for services Medicare covers." Medicare has no specific ABA benefit, so see coverage order for young adults for how that plays out. Second, for the Agency for Persons with Disabilities (APD) iBudget waiver, Florida law (s. 393.0662) requires clients to use Medicaid state plan services, school services, private insurance and other resources before iBudget funds. See iBudget vs insurance: what pays first.
When a child has two private plans, the order between them follows the plans' coordination rules. Our guide to coordination of benefits for two plans explains how that works.
How does Medicaid as secondary affect your choice of provider?
This is the part families most often miss. Medicaid can only pay a provider that is enrolled with Florida Medicaid, and since February 2025 most children's BA is managed through a Statewide Medicaid Managed Care plan with its own network. Your primary plan has its own network too. That leaves three common situations:
| Provider is in network with | What happens to claims | Trade-offs |
|---|---|---|
| Both your primary plan and your child's Medicaid plan | Primary plan pays first; Medicaid can consider the remainder | Often the lowest out-of-pocket cost. Two sets of authorizations and rules to follow |
| Your primary plan only | Primary plan pays; Medicaid does not pay this provider | You owe the primary plan's usual cost sharing. You may gain wider choice, shorter waits or services a Medicaid-network provider does not offer |
| Your child's Medicaid plan only | Medicaid will generally expect the other coverage to be used first | Can work in some cases, but ask the Medicaid plan how it handles a primary plan that the provider does not bill |
Here is an example, for illustration only. A child has a parent's employer plan and Medicaid. The family picks a provider in both networks. The provider gets approval from the employer plan, then from the Medicaid plan, bills the employer plan first, and sends the remainder to Medicaid with the employer plan's explanation of benefits. If the family instead picks a provider in the employer plan's network only, the employer plan pays and the family pays the plan's cost sharing.
None of these is right for every family. The choice depends on cost sharing, availability, the services your child needs, location and language. Our guide to Medicaid vs private insurance for ABA compares the two systems side by side.
Checklist: before you choose an ABA provider with two kinds of coverage
- Is the provider in network with your primary plan? Ask for it in writing.
- Is the provider enrolled with Florida Medicaid and in your child's Medicaid plan network?
- Who will request prior authorization from each plan, and in what order?
- What is your expected cost per month after the primary plan pays, and will Medicaid pay any of it with this provider?
- Does the primary plan have a deductible that resets in January, and what does that mean for the first months of the year?
- Has the provider worked with your exact combination of plans before?
- If the primary plan denies ABA, what happens next with Medicaid?
Do you have to tell Medicaid about other coverage?
Medicaid asks about other coverage when you apply and at each renewal, and states run data matches to find it. Tell your child's Medicaid plan and every provider about all coverage your child has. Leaving a plan off can lead to denied claims, delays and later repayment requests. If a parent gains or loses job-based coverage, report it at the next renewal or sooner if your plan asks.
What if the primary plan denies ABA?
A denial from the primary plan does not end your options. You can appeal under that plan's process, and if it is a large-group plan regulated by Florida, the state's autism insurance law may apply. See how to appeal an ABA denial in Florida. Separately, your child's Medicaid plan can review a BA request under Medicaid's rules. Ask the Medicaid plan what documents it needs from the primary plan, such as the denial letter or explanation of benefits.
The Florida Medicaid Helpline (1-877-254-1055) can answer questions about how Medicaid coordinates with other coverage for your child.
How Hope Center fits
Hope Center is in network with Blue Cross Blue Shield (Florida Blue), Aetna, Cigna (Evernorth), UMR, Personify Health and TRICARE East. If your child has one of these plans as primary coverage, that plan's usual cost sharing applies to our services. Because Hope Center does not accept Medicaid, and a child who has Medicaid cannot be seen self-pay here (center policy). If you add employer or Marketplace coverage and keep Medicaid, call us to ask how Medicaid would work alongside that plan for your child. Our sliding scale, based on household income and family size, can help with your share after the primary plan pays, and we can run a free benefits check so you can compare costs before deciding. We have no waitlist. See our insurance page or contact us.