Can You Pay Privately for ABA if Your Child Has Medicaid?

Some families whose child has Florida Medicaid think about paying for ABA themselves: the in-network provider has no openings, hours were cut, the family wants a provider who speaks their language, or they simply want a different approach. Whether and how that can work is partly a legal question, and the answer depends on the provider's relationship with Medicaid. This guide explains what Florida's Medicaid rules say, in plain language, so you know what to ask before you pay anyone.

This is general information, not legal advice. Rules can apply differently to your child's plan and to a particular provider, so get answers in writing from the provider and your child's plan, and talk to a Florida attorney or legal aid office if you are unsure.

Why is this complicated?

Medicaid has strong rules that protect families from being billed. Florida Statute 409.907(3)(j) requires every Medicaid provider agreement to make the provider "accept Medicaid payment as payment in full" and bars the provider from "billing or collecting from the recipient or the recipient's responsible party any additional amount," except allowed copays. Federal rules say the same thing in 42 CFR 447.15. Medicaid BA services have no copay at all.

Those protections are the reason private payment is not as simple as handing over a card. The questions are: is the provider enrolled in Medicaid, is the service one Medicaid would cover, and were you told in advance and in writing that you would pay?

What do Florida's rules say about billing a Medicaid recipient?

Rule 59G-1.050 of the Florida Administrative Code (General Medicaid Policy) sets requirements for "all providers rendering Florida Medicaid services to recipients." Section (2), "Billing the Recipient," says providers must tell a recipient about their responsibility to pay for services Florida Medicaid does not cover, and document that they did so, "prior to rendering each service." It then lists when a provider may seek payment from a recipient:

1. The recipient is not eligible for Florida Medicaid on the date of service.
2. The service is not covered by Florida Medicaid, if the provider charges all patients for that service.
3. The provider verifies that the recipient has exceeded the Florida Medicaid coverage.
4. The recipient is enrolled in a Medicaid managed care plan and is informed that the plan denied authorization for the service, or that the treating provider is not in the plan's network.

The same rule also says providers may not charge recipients for missed appointments, and that once a provider has submitted a claim to Medicaid for a covered service, it may not then bill the family, put a lien on the family, or send the account to collections for it.

Reading the rule plainly, it contemplates situations where a family in a managed care plan pays a provider who is outside the plan's network, as long as the family was informed beforehand and the provider documents it. How that applies to a specific provider and a specific plan is something to confirm, not assume.

Does it matter whether the provider is enrolled in Medicaid at all?

Probably, yes. Rule 59G-1.050 and s. 409.907 are written for providers enrolled in Florida Medicaid. A provider that is not enrolled in Medicaid has no Medicaid provider agreement and cannot bill Medicaid. Whether, and how far, Medicaid's billing protections still reach a provider outside the program is a legal question we cannot answer for you, and the answer may depend on facts such as whether the provider ever enrolled, or contracts with any Medicaid plan.

What you can do is ask both sides the same questions and get the answers in writing:

• Ask the provider: "Are you enrolled in Florida Medicaid or in any Medicaid managed care plan network? What is your written policy on serving a child who has Medicaid as a private-pay client?"
• Ask your child's plan: "If we pay a provider outside your network for behavior analysis, does that affect my child's Medicaid authorization or benefits, and is there anything we must report?"

If either answer is unclear, ask a Florida attorney, Disability Rights Florida or a legal aid office before you sign. See getting help from Disability Rights Florida.

Can my child get Medicaid ABA and private-pay ABA at the same time?

We found no Florida Medicaid rule that speaks directly to this. A few things are worth knowing:

• Medicaid approves hours based on medical necessity in a behavior plan. If two providers are working on the same goals, tell each one about the other so plans do not conflict.
• The BA coverage policy expects parents to take part in treatment when possible, and requires the IEP (or a 504 plan) with school-based requests. A second provider adds coordination work for everyone.
• Ask your Medicaid plan whether services from another provider would affect its review of your child's hours.

If your child also has a parent's private insurance, that coverage pays first and Medicaid is the payor of last resort (s. 409.910). That is a different situation from self-pay. See Medicaid as secondary insurance.

Before you pay: a written-agreement checklist

Whatever the provider, put these in writing before the first session:

1. The provider's Medicaid status: enrolled in Florida Medicaid or not, and in network with your child's plan or not.
2. A statement that you chose private pay and were told, before services, that you would be responsible for payment.
3. A Good Faith Estimate. When you are not using insurance, CMS says providers usually must give a good faith estimate of expected charges if you ask, or if you schedule care at least 3 business days ahead. You need the estimate to dispute a bill later. See your right to a Good Faith Estimate.
4. The rate, the planned hours and how often the plan will be reviewed.
5. Who does what: the BCBA who writes and supervises the plan, and the RBTs who deliver it.
6. Cancellation and missed-session terms.
7. How the provider will coordinate with any Medicaid provider, school or doctor, with your consent.
8. Whether any sliding scale or payment plan applies, and how it is decided.

Two red flags: a provider who is enrolled in your child's Medicaid plan and asks you to pay for services the plan already authorized, or anyone who offers you money or gifts to switch providers. Florida's General Medicaid Policy rule forbids kickbacks and patient brokering for Medicaid services. Report concerns to AHCA through the Florida Medicaid complaint form or the Medicaid Helpline at 1-877-254-1055.

Other ways to pay that do not raise these questions

• A parent's employer plan or a HealthCare.gov plan, if your family can get one. See moving from Medicaid to private insurance.
• TRICARE, for eligible military families, through the Autism Care Demonstration. See the TRICARE ACD guide.
• The FES-UA scholarship, which can pay for ABA from approved providers for students not enrolled full time in public school. See FES-UA when Medicaid ABA falls through.
• An appeal, if the problem is a denial or a cut in hours. See Medicaid ABA appeals.

How Hope Center can help

Hope Center for Behavior Change does not see a child who has Medicaid on a self-pay basis. This is center policy, so private pay at Hope Center is not an option while your child has Medicaid. Your family can add employer or Marketplace insurance, which we accept, and our sliding scale, based on household income and family size, can help with your share after insurance. We work with Blue Cross Blue Shield (Florida Blue), Aetna employer plans, Cigna (Evernorth), UMR, Personify Health and TRICARE East. If you are considering self-pay with another provider outside Medicaid, raise these questions with that provider and your child's plan so they can be answered in writing before anything starts. See sliding scale and self-pay at Hope Center, contact us for a free consultation, or call 561-337-8865.