Eligible Recipient

POLICY:

General Criteria

An eligible recipient must be enrolled in or any third-party entity responsible for reimbursement of services, including but not limited to Medicaid, Medicare, commercial insurance carriers, managed care organizations (MCOs), and private insurers. commercial program on the date of service and meet the criteria provided in this policy. Providers must verify each recipient's eligibility each time a service is rendered.

Who Can Receive

Individuals eligible for coverage under Medicaid or other applicable third-party payers who meet medical necessity criteria for behavior analysis services. For Florida Medicaid recipients, coverage is limited to individuals under the age of 21 years. Some services may be subject to additional coverage requirements as defined by the applicable payer and outlined in the Coverage Information Section.

Coinsurance and Copayment

For clients funded by Florida Medicaid, there is no coinsurance or copayment for this service in accordance with section 409.9081, F.S. For more information on copayment and coinsurance requirements and exemptions, please refer to Florida Medicaid's General Policies on copayment and coinsurance.

For all other insurance plans or funding sources, any applicable copayments, coinsurance, or deductibles are the responsibility of the client or financially responsible party and are governed by Appendix 2- COPAYMENTS, COINSURANCE, AND COST-SHARING POLICY. The agency will verify coverage, inform families of their obligations, and collect payments in accordance with federal and state regulations, contractual agreements, and ethical guidelines.