Florida PPEC: Fee-for-Service and Managed Care Billing in Practice

At a glance

215+

Active licensed PPEC centers in Florida, most serving clients across both the fee-for-service and managed care billing rails simultaneously.

2

Billing rails Florida PPEC operators must be prepared to support: FFS (AHCA) and MCO (plan-specific PA and claims). Both are active today.

Most

Florida PPEC clients are estimated to be voluntarily enrolled in SMMC managed care plans — making dual-rail authorization and billing the current baseline for most centers.

Florida’s Prescribed Pediatric Extended Care program has operated since its founding on a fee-for-service carve-out: centers bill AHCA directly through procedure codes T1025 and T1026, with prior authorization managed through a fee-for-service process. What is less widely understood is that PPEC clients voluntarily choose their Medicaid program participation. For a child enrolled in a Statewide Medicaid Managed Care plan, authorization and billing run through the client’s MCO — not through AHCA fee-for-service directly. With the majority of Florida PPEC clients enrolled in SMMC plans, most centers are already managing claims across both rails simultaneously.

For operators, this is not a rate change. It is a workflow question: which rail governs each client’s authorization and claims, and whether the center’s records can track both accurately in parallel.

The existing modelFee-for-service as a carve-out

Under the fee-for-service model, PPEC services for clients on the FFS rail flow through AHCA’s fee-for-service program. The authorization and billing workflow is uniform across all participating centers:

• Prior authorization requests go to AHCA’s fee-for-service PA system
• Approved authorizations are denominated in units consistent with T1025 (per diem) and T1026 (hourly)
• Claims are submitted to the state Medicaid fiscal agent
• PPEC-specific coverage policy is set uniformly at the state level by AHCA

This model has characterized Florida PPEC since the program was established under Florida Statutes §409.905(5) and the PPEC rule at Florida Administrative Code 59G-4.200. The result for operators has been a single set of coverage and documentation rules, a single authorization target, and a single claims submission workflow for FFS clients regardless of which Medicaid plan a client may also be enrolled in. The carve-out status is what produces this uniformity — for clients on the FFS rail.

The managed care railWhy both rails apply today

PPEC clients are voluntary participants in Florida’s Statewide Medicaid Managed Care program. Enrollment in SMMC is a choice each client’s family makes — it is not mandatory. A child enrolled in SMMC receives PPEC coverage through their MCO rather than through AHCA fee-for-service directly. A child not enrolled in SMMC, or between enrollment periods, remains on the fee-for-service rail.

Because SMMC enrollment is voluntary and widespread — the majority of PPEC clients are estimated to be enrolled in an SMMC plan — the managed care rail is not a future development for most Florida PPEC operators. It is the current baseline. A center with a mixed caseload will have clients on the FFS rail and clients on one or more MCO rails at the same time.

Under a managed care model, the authorization and claims workflow changes structurally:

• Prior authorization requests go to the client’s specific MCO, not to AHCA’s fee-for-service PA system
• Each MCO may apply plan-specific clinical criteria, documentation requirements, and authorization unit structures within the bounds of AHCA’s contract with the plan
• Claims are submitted to the MCO, not to the state fiscal agent
• PPECs must be contracted with each MCO serving their client population; a center that is not contracted with a client’s MCO cannot serve that client without a gap in reimbursement

A note on Florida Chapter 2025-88

Florida Chapter 2025-88 (signed 2025, effective July 1, 2025) is sometimes cited in the context of Florida PPEC managed care. The law transfers operation of the Children’s Medical Services (CMS) Managed Care Plan from the Florida Department of Health to AHCA. This is an administrative governance change affecting how the CMS Managed Care Plan is administered — it does not mandate PPEC services into managed care generally, and it does not alter the voluntary nature of SMMC enrollment for PPEC clients. Operators should not rely on Ch. 2025-88 as the basis for managed care planning. The managed care reality for PPEC operators follows from existing voluntary SMMC enrollment patterns in their client population.

Operations todayManaging the dual-rail environment

For most Florida PPEC operators, the dual-rail environment is already present. The practical question is not whether managed care will arrive — it is whether the center’s operations can manage two authorization and billing workflows simultaneously for the population it currently serves.

A PPEC with a mixed caseload will simultaneously have:

• Clients on the FFS rail: PA through AHCA, claims to the fiscal agent, AHCA documentation standards
• Clients on one or more MCO rails: PA through each client’s plan, claims to each MCO, plan-specific documentation standards

The MCO mix in Florida may include Humana, Molina, WellCare, Florida Community Care, Staywell, Simply Healthcare, Aetna Better Health, and others depending on region. There is a known billing split nuance: some plans bill Title 19 PPEC services differently from Title 21 (KidCare) day-care components — which may route to a different payer entity entirely. Operators should verify the correct billing path for each plan and enrollment category directly with each MCO.

MCO contracting is a precondition, not a billing step

Under managed care, a center that has not contracted with a client’s MCO cannot bill that MCO for authorized services. MCO contracting is not a claims process — it is a business relationship that must be established before care is authorized and billed. In Florida’s SMMC model, there are multiple plans per region; contracting with one plan does not cover the others serving the same geography.

Operators who have not confirmed their contracting status with the SMMC plans active in their region should do so before any new client enrollments where the client’s plan is not yet contracted.