Why does Florida spend so much money on treatment for children with autism and special needs?

Florida in the past two years has spent more money than any other state in the nation providing a therapy called applied behavior analysis (ABA) to children with special needs including autism — $6.57 billion between 2023 and 2025.

That’s the number Shena Grantham, Florida’s deputy secretary for Medicaid policy and quality, gave to members of a blue-ribbon panel in Tallahassee this week reviewing ABA services in the Medicaid program that covers about 55,000 children aged 20 and younger.

Indiana ranked a distant second to Florida, spending $1.65 billion over the same two years. North Carolina ran a distant third, at $1.53 billion.

“There’s something unusual happening … that deserves a closer look,” Grantham told members of the Applied Behavior Analysis Task Force, which held its inaugural meeting last week.

The legislatively mandated “closer look” comes as a number of other issues come to a head.

The Centers for Medicare and Medicaid Services (CMS) released the State Medicaid and CHIP Applied Behavior Analysis Toolkit, a 173-page document meant to “support state Medicaid and Children’s Health Insurance Program (CHIP) agencies in making decisions regarding ABA service provision for Medicaid and CHIP.”

The DeSantis administration announced in June that it was cracking down on fraud, waste, and abuse in Florida’s $38 billion healthcare safety net program. It was launched after the CMS sent a letter to Florida, as well as California, Maine, and New York, seeking information about Medicaid integrity and oversight and after CMS Director Mehmet Oz said on social media that “Florida has been a hotspot for health care fraud for years.”

Florida has switched its ABA delivery model to require managed care plans to cover services for children. Previously, patients, once authorized, saw the Medicaid ABA provider of their choice and the state paid for the services. Since 2025, the care must be provided by the state-contracted plans and the ABA providers who want to continue working with their clients are having to negotiate contracts with the plans in their regions.

Some providers are being dropped. Others have stopped treating Medicaid clients.

‘Agonizingly long waitlists’

Nicole Grabner is a disabled veteran and mother of two children with autism who drove four-plus hours from her home in Brevard County to Tallahassee to tell the task force she’s worried the cumulative changes are hurting Florida families who, she says, already are facing “agonizingly long waitlists” just to be approved for ABA.

Now, she said, the changes are interupting medically necessary care.

She told task force members that during her drive to Tallahassee she learned her youngest son had lost access to his ABA provider.

“These disruptions are kind of concerning, especially now that we are getting into the new school year, when consistency is most critical,” Grabner said. “Aggressive enforcement or administrative delays must never compound these delays for a child receiving early intervention services when a short pause in therapy causes devastating developmental regression.”

Applied behavior analysis uses structured interventions to decrease maladaptive behaviors and reinforce appropriate ones. ABA is common in the treatment of children diagnosed with autism spectrum disorder.

The Legislature established the 10-member task force as part of fiscal year 2026-27 budget negotiations. The task force is reviewing revisions of the state’s healthcare delivery model to “improve care experience and service continuity for enrollees and families receiving ABA services, while safeguarding long term program sustainability.”

Specifically, the legislation directs the task force to submit a report to the Legislature and governor by the end of the year examining at least six ideas:

• Clinical care models that lead to best practices for provision of therapy at the appropriate ages.
• Appropriate transitions for enrollees receiving ABA services across developmental, educational, and community settings.
• Quality metrics for ABA therapy services.
• Limits and use controls related to the length of time applied behavioral analysis services may be authorized.
• Potential caps on the number of months an enrollee may receive ABA services.
• Ways to enhance Medicaid provider enrollment and billing standards for ABA services, to promote program integrity and fiscal accountability.

The task force must submit its recommendations — along with the pros and cons of each proposal — to the governor and Legislature by Dec. 31.

‘Not set in stone’

Agency for Health Care Administration Secretary Shevaun Harris, chair of the panel as well as a non-voting member, suggested the group complete the bulk of its recommendations by the end of October, but added that the schedule was “not set in stone.”

Before a child can receive ABA services through Florida Medicaid, he or she must be referred by a doctor or child psychologist. The child also must undergo a comprehensive evaluation to formally diagnose or rule out autism and determine medically necessary therapies.

About 25% of children receiving Medicaid-covered ABA services — roughly 13,698 children — have not been diagnosed with autism spectrum disorder.

Despite cost-savings efforts in the past (which have included pilot programs and a moratorium on ABA provider enrollments) costs have continued to increase.

About 60,000 poor and low-income children in Florida receive applied behavioral analysis at a cost of about $2.3 billion, Grantham said, although she didn’t cite the year.

That’s more than Medicaid spent reimbursing hospitals caring for 966,900 children, covering prescription drugs for 1.4 million children, or paying for about 1.75 million doctor visits, she said.

Florida the outlier

Delivery of ABA services in Florida doesn’t track national trends.

AHCA’s data show that Medicaid doesn’t emphasize ABA services to children in Florida until they are older, compared to peers in other states.

While it doesn’t provide exact percentages, a chart prepared for the task force indicates fewer than 5% of children receiving ABA services in Florida were aged 2 or younger compared to more than 5% nationally. Likewise, fewer than 25% of the ABA services were provided to Florida children aged 3 to 5, compared to about 40% nationally.

About 45% of the Medicaid-covered ABA services are provided to children aged 6 through 10 in Florida compared to fewer than 40% nationally. And about 20% of the children receiving ABA services in Florida are between the ages of 11 and 15 compared to fewer than 15% nationally.

More than 5% of the children receiving ABA services in Florida were between the ages of 16 and 20 compared to fewer than 5% nationally.

According to Grantham, 99% of  Medicaid-covered ABA services for children are provided through managed care plans. The plans provide additional safeguards because they are in charge of ensuring a proper network of care providers are available for children, she said, and also are charged with ensuring authorization requirements are followed.

Florida Medicaid in February 2025 adjusted the rates it pays the managed care plans to include costs of ABA services. In June, Pediatric Associates  filed a challenge in state administrative court alleging Medicaid reduced payments paid to pediatricians by nearly $300 million over the past 20 months to increase reimbursements to managed care plans for providing the ABA services.

Largest Medicaid pediatric provider sues DeSantis administration over pay rates

The healthcare provider asserted the agency adopted the rates in violation of state and federal statutes and is asking a state administrative judge to issue a final order banning the state from applying them. It also is asking the judge to require the agency to recalculate rates going forward.

A final hearing in the challenge has been scheduled for Oct. 1-2.

Before filing the suit, Pediatric Associates maintains, it met with AHCA “at least five times” between January and May to discuss the new Medicaid payments and errors it alleges the agency made in determining the rates.

AHCA acknowledged in an April 17 correspondence to Medicaid managed care plans that inclusion of ABA services in value-based contracts that the managed health plans sign with providers “has the potential to result in access issues.”