PPEC denied or hours cut in Florida? What to do next

If PPEC was denied in Florida, or your child's hours were cut, you can ask for a second look. Read the letter the day it arrives. It names who decided, the reason, and your deadline. You can ask for a reconsideration, then a Medicaid fair hearing. Your child's doctor's records are the heart of the request.

A denial letter is scary. Work, sleep and your child's care all feel at risk at once. This page explains the process in plain words, with the rules it comes from. It is general information, not legal advice for your family. Free legal help is listed below.

Talk with your child's doctor about the medical reasons for PPEC before you file anything. The doctor's records carry the request.

At a glance

• The denial letter must state the action, the reason, the rule, and how to ask for a hearing ¹.
• A hearing request about a PPEC decision from Florida Medicaid must reach the state within 90 days of the notice date ².
• If a Medicaid health plan sent the letter, appeal to the plan first, within 60 calendar days. The plan answers within 30 calendar days ³.
• After the plan's appeal decision, you have 120 days to ask for a fair hearing ².
• To keep care going, ask before the change date on the notice ⁴⁵.
• The hearing is by phone. A written final order comes within 90 days of your request ².

Why are PPEC requests denied in Florida?

A PPEC request is denied in Florida when the reviewer finds the care is not "medically necessary", or when paperwork is missing ⁷¹¹. Medically necessary means the service fits your child's diagnosis and needs, and is not more than needed ⁷. It also means no safe, cheaper option would work as well ⁷. A doctor's order alone does not prove it ⁷.

The PPEC rule adds two tests. Your child must need continuous treatments or skilled nursing supervision, and a doctor must say your child is medically stable ⁸. "Stable" means safe to spend the day in a center, not that the nursing can stop. Reviewers deny when the records do not show both.

A partial denial approves some hours or days and cuts the rest ¹¹. The letter must explain what happened to your child ¹.

Who decides? For PPEC, Florida Medicaid decides, through the state health agency (AHCA) and its review contractor, not your child's health plan ¹⁰. By law AHCA pays the center directly, even for children in a Medicaid health plan ⁹. The letter tells you which path and which deadline apply to your child.

What is a reconsideration?

A reconsideration is a second review of the denial by a different doctor at the review contractor ¹¹. A parent, the ordering doctor, or a hospital discharge planner can ask by phone, fax or mail ¹¹. The contractor's manual gives 30 calendar days from the date on the denial letter ¹¹. Your letter states the deadline.

Send new or clearer information with the request: an updated doctor's letter, recent records, and the plan of care ¹¹. The reviewer can uphold the denial, approve part of it, or reverse it ¹¹. If the denial stands, you can still ask for a fair hearing ¹¹. Your child's doctor can also ask for an optional "peer-to-peer" call with the reviewing doctor ¹¹.

How do we ask for a Medicaid fair hearing?

Ask the Agency for Health Care Administration (AHCA), which holds Medicaid hearings under Florida law, by phone, email, fax or mail ⁶¹⁵. A fair hearing is a fresh review by a hearing officer who had no part in the first decision ². For a PPEC decision from Florida Medicaid, your request must reach AHCA within 90 days of the date the notice was sent ².

How to ask ⁶:

• Call the Medicaid Helpline at 1-877-254-1055 (TDD 1-866-467-4970).
• Email MedicaidHearingUnit@ahca.myflorida.com, or fax (239) 338-2642.
• Mail: Agency for Health Care Administration, Medicaid Hearing Unit, P.O. Box 7237, Tallahassee, FL 32314-7237.
• Give your name, phone, address, your child's name and Medicaid ID, and what was denied or cut.

If your child's Medicaid health plan sent the letter, you must finish the plan's appeal first ²⁶. You have 60 calendar days from the letter date to appeal to the plan ³. The plan must answer a standard appeal within 30 calendar days ³. Then you have 120 days from the plan's decision to ask AHCA for a hearing ².

What happens next: AHCA confirms your request in writing ⁶. You get the hearing date at least 14 days ahead, by phone ². You can ask for your child's whole file, free, within 7 days ². You can speak for yourself, bring a helper, or have a lawyer ². A final order comes within 90 days ².

For a new denial, the family must show the care is needed. For a cut to care already approved, the state or the plan must show why ².

Can the care continue while we appeal?

Sometimes, if you ask in time. When approved care is being cut or stopped, the state must send the notice at least 10 days before the change date ¹. If you request a hearing before that date, the care continues until the hearing is decided ⁴.

Plan members ask the plan for an appeal and for continued benefits within 10 calendar days of the notice ⁵. If the change date is later, that date is the deadline ⁵.

Two limits. Continued care applies to approved services being cut, not to a first request that was never approved ⁴⁵. And if you lose, Medicaid or the plan may ask you to repay the cost of care given only because you appealed ⁴⁵.

What should we bring from the doctor?

Ask your child's doctor for records that show both tests in the PPEC rule ⁸. A checklist:

• A current physician referral for PPEC, with the hours and days requested. Florida's rule calls it a prescription from your child's attending doctor ⁸.
• The plan of care, updated within the last 180 days and signed by the center's registered nurse and the doctor ⁸.
• A short letter in plain words: which nursing tasks your child needs each day, how often, what happens if they are missed, and why a center is safe for your child.
• Recent records: hospital stays, emergency visits, the medicine and treatment schedule, and equipment such as a feeding tube, oxygen or a tracheostomy tube.
• Anything the denial letter said was missing. Answer its stated reason point by point.

What can we do this week?

Start with the letter, then the doctor, then the requests.

1. Read the letter today. Note the date sent, the reason, the rule it cites, and the deadlines ¹.
2. Call your child's doctor's office. Ask for the records above, and for a peer-to-peer call if the doctor wants one ¹¹.
3. Ask for a reconsideration right away, with the new records ¹¹.
4. Ask AHCA for a fair hearing too. The rule counts the 90 days from the first notice, so do not wait for the reconsideration answer ².
5. If care is being cut, ask for continued benefits before the change date ⁴⁵.
6. Get free legal help. Legal Aid Society of Palm Beach County: 561-655-8944 or legalaidpbc.org/onlineintake, in English, Spanish and Haitian Creole ¹². Statewide: Florida Health Justice Project ¹³ and FloridaLawHelp.org ¹⁴.

At Superhero Kids PPEC, we work with your child's doctor on the referral, the plan of care and the paperwork. If your child was denied or your hours were cut, call us. Call (561) 877-2152. Open Monday to Saturday, 7 am to 7 pm. We return calls within 15 minutes during those hours.

Questions parents ask

Who decides on PPEC, the state or my child's health plan?

The state. Florida Medicaid, through AHCA and its review contractor, approves PPEC and pays the center directly ⁹¹⁰. Children in any Florida Medicaid plan can attend; call to ask about yours.

Do we need a lawyer for a fair hearing?

No. Parents can speak for themselves or bring a helper ². Free legal help is available in Palm Beach County and statewide ¹²¹³. The hearing is by phone and is recorded ².

What if we miss the deadline?

Ask anyway, and explain why. AHCA may waive the 90-day limit when it failed to send a timely notice or failed to act on a request ². Otherwise a late request can be dismissed ².

Can the center ask for the hearing for us?

Yes, with your written permission. A provider can request a hearing for a child, but must file an authorization signed by the parent or guardian ².

Keep reading

• Does Florida Medicaid pay for PPEC?
• PPEC eligibility requirements: who qualifies in Florida?
• How to enroll in PPEC, step by step

Sources

1. Code of Federal Regulations, Title 42, sections 431.210 (what the notice must contain) and 431.211 (notice at least 10 days before the action). Read October 19, 2026. https://www.ecfr.gov/current/title-42/section-431.210 and https://www.ecfr.gov/current/title-42/section-431.211
2. Florida Administrative Code, Rule 59G-1.100, Medicaid Fair Hearings (effective September 24, 2018): 90-day and 120-day request deadlines, plan appeal first, 14-day hearing notice, phone hearings, the file within 7 days, burden of proof, representation, final order within 90 days. Read October 19, 2026. https://www.flrules.org/gateway/RuleNo.asp?ID=59G-1.100
3. Code of Federal Regulations, Title 42, sections 438.402 (60 calendar days to appeal to the plan) and 438.408 (plan decides a standard appeal within 30 calendar days). Read October 19, 2026. https://www.ecfr.gov/current/title-42/section-438.402 and https://www.ecfr.gov/current/title-42/section-438.408
4. Code of Federal Regulations, Title 42, section 431.230, Maintaining services (care continues when a hearing is requested before the date of action; repayment if the decision goes against you). Read October 19, 2026. https://www.ecfr.gov/current/title-42/section-431.230
5. Code of Federal Regulations, Title 42, section 438.420, Continuation of benefits while the plan appeal and the state fair hearing are pending. Read October 19, 2026. https://www.ecfr.gov/current/title-42/section-438.420
6. Agency for Health Care Administration, Medicaid Fair Hearings (how to ask, what to include, plan appeal first). Read October 19, 2026. https://ahca.myflorida.com/medicaid/florida-medicaid-complaints/medicaid-fair-hearings.html
7. Florida Medicaid Definitions Policy, May 2024, section 2.83 "Medically Necessary or Medical Necessity", adopted in Rule 59G-1.010. Read October 19, 2026. https://ahca.myflorida.com/content/download/24713/file/59G-1.010%20Definitions%20Policy.pdf
8. Florida Medicaid, Prescribed Pediatric Extended Care Services Coverage Policy, February 2018, adopted in Rule 59G-4.260 (who can receive, plan of care every 180 days, authorization). Read October 19, 2026. https://www.flrules.org/gateway/RuleNo.asp?ID=59G-4.260
9. Florida Statutes, section 409.968(3) (AHCA pays the PPEC provider on a fee-for-service basis for children in a managed care plan). Read October 19, 2026. https://www.flsenate.gov/Laws/Statutes/2025/409.968
10. Agency for Health Care Administration, Prescribed Pediatric Extended Care (PPEC): the agency's contract for prior authorization of PPEC services. Read October 19, 2026. https://ahca.myflorida.com/medicaid/child-health-services/prescribed-pediatric-extended-care-ppec.html
11. AHCA's Florida Medicaid review contractor, Care Coordination Services Provider Manual (PPEC, PDN and PCS): reconsideration within 30 calendar days, who may ask, physician review, peer-to-peer, fair hearing after reconsideration. Read October 19, 2026. https://fl.acentra.com/wp-content/uploads/sites/14/2024/05/8.2023-Care-Coordination-Provider-Manual.pdf
12. Legal Aid Society of Palm Beach County, free civil legal services, online intake in English, Spanish and Haitian Creole. Read October 19, 2026. https://legalaidpbc.org/
13. Florida Health Justice Project, Medicaid resources and legal help. Read October 19, 2026. https://www.floridahealthjustice.org/
14. FloridaLawHelp.org, Find a Provider (free legal aid by location and topic). Read October 19, 2026. https://www.floridalawhelp.org/find-provider
15. Florida Statutes, section 409.285, Opportunity for hearing and appeal (AHCA conducts Medicaid hearings). Read October 19, 2026. https://www.flsenate.gov/Laws/Statutes/2025/409.285