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Medicaid Behavior Analysis (BA) Value Based Program

As we further integrate BA services into managed care, we’re excited to announce a new Value Based Performance Program that rewards providers who deliver measurable, high-quality outcomes for our members.

This strategic enhancement reflects our commitment to ensuring our members receive exceptional care and that we deliver value for the state of Florida. By shifting the focus from volume to value, we’re encouraging providers to follow clinical best practices to tailor services to each child’s unique needs to ensure the best outcomes.

By aligning payment with quality and impact, we’re building a future where every child receives the right support, at the right time, from the right provider.

This program will reward eligible BA practitioners who deliver recommended hours for children with autism spectrum disorder and other diagnoses based on their age and developmental needs based on nationally recognized practice guidelines.

This program is based on the following metrics:

Evidence-Based Hourly Benchmarks by Age: (delivered by RBT or BCBA)

  • Younger than 4 years: 30-40 hours per week total
  • 4-6 years: 20-30 hours per week total
  • 7-12 years: 10-15 hours per week total
  • 13+ years: 5-10 hours per week total (focused on skill-building and transition goals)

Performance Metrics and Payment Tiers

  • Tier 1 (98+% compliance): 100% of Medicaid
  • Tier 2 (95-97%+ compliance): 90% of Medicaid
  • Tier 3 (90-94% compliance): Preferred Provider Indicator

Timeframe

  • Quarterly review of claim utilization with 3 months run out starting July 1, 2025
  • July 1, 2025-September 30, 2025, with run out December 31, 2025: estimated payout in January 2026
  • October 1, 2025-December 31, 2025, with run out March 31, 2026: estimated pay out in April 2026

New: Enhanced Provider Support

Sunshine Health now has a dedicated team of Provider Engagement Account Managers throughout Florida to support BA providers with any needs. Your dedicated Provider Engagement Account Manager will meet with you regularly to review your performance and progress toward this program. We also host Provider Town Halls customized for BA providers to cover helpful information on clinical best practices, benefits and services and billing. Additional resources are available in our Behavior Analysis (BA) Provider Quick Reference Guide.

Eligibility Criteria

  1. The BA Value Based Program applies to providers serving Medicaid members in our MMA, SMI and HIV products.
  2. Claims will be retroactively adjusted for the payment deferential.
  3. Providers must be in good standing, as determined by the Health Plan, to participate in the Program. All providers must: (a) be in a participation agreement with Sunshine Health, either directly or indirectly through a vendor, from the effective date and continually through the dates the bonus payments are made, and (b) be in compliance with their participation agreement. That includes completing required training or education programs requested or required by Sunshine Health.
  4. The bonus payment earned through this program is in addition to the compensation arrangement set forth in your participation agreement, as well as any other Sunshine Health performance programs you participate in. At Sunshine Health’s discretion, providers who have a contractual or other quality incentive arrangement with Sunshine Health either directly or through an IPA/vendor may be excluded from participating in this program.
  5. The terms and conditions of the participation agreement, except for appeal and dispute rights and processes, are incorporated into this program. That includes all audit rights of Sunshine Health, and the provider agrees that Sunshine Health or any state or federal agency may audit their records and information.
  6. The program is discretionary and subject to modification due to changes in government healthcare program requirements or as determined by Sunshine Health. Sunshine Health will determine if the requirements are satisfied. Payments will be made solely at Sunshine Health’s discretion. There is no right to appeal any decision made under the program.
  7. Sunshine Health reserves the right to withhold payment of any bonus that may have otherwise been paid to a provider that has received or retained an overpayment (any money to which the provider is not entitled, including, but not limited to, fraud, waste, or abuse) from Sunshine Health. If Sunshine Health determines a provider has been overpaid, Sunshine Health may offset any bonus payment that may have otherwise been paid to the provider against overpayment.
  8. Sunshine Health shall make no specific payment, directly or indirectly under a provider performance program, to a provider as inducement to reduce or limit medically necessary services to an enrollee. This program contains no provisions that provide incentives, monetary or otherwise, for withholding medically necessary care. All services should be rendered in accordance with professional medical standards.