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State guide

Florida

Pick the kind of plan you have to see who to call first. Florida can only help with plans it regulates.

On this page 8

Which plan do you have? Who to call first, by coverage

  • Your employer pays claims itself

    Florida usually cannot help with these plans. Call the Employee Benefits Security Administration.

    Call 1-866-444-3272

  • Insurance you buy, or an employer plan bought from an insurer

    Call Florida Department of Financial Services, Division of Consumer Services. See the at-a-glance box.

    Call 1-877-693-5236

  • Medicaid or children's coverage

    Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Florida.

    Medicaid in Florida

  • Medicare

    SHINE (Serving Health Insurance Needs of Elders), Florida Department of Elder Affairs gives free counseling. Or call 1-800-MEDICARE.

    Call 1-800-963-5337 1-800-633-4227

The short version for Florida

Florida does not run its own external review program, so an independent review of a denial goes through the federal process (or a review organization your insurer hires). The state's Division of Consumer Services runs a free helpline and will press an insurer to explain itself, but it says it cannot make medical judgments or force a company to pay a claim. Florida has its own laws on surprise bills and step therapy for plans issued in the state.

At a glance: independent review for plans Florida regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator
Florida Department of Financial Services, Division of Consumer Services · 1-877-MY-FL-CFO (1-877-693-5236); out of state (850) 413-3089
Independent review
The federal process run for the Department of Health and Human Services (External review (federal process))
Deadline to request it
4 months after the date you receive the notice or final determination that your claim was denied
Cost
None under the HHS-administered process; if your insurer uses its own review organization, no more than $25 per review
Decision time
As soon as possible, and no later than 45 days after the request is received; fast track: No later than 72 hours, or less, depending on how urgent the medical situation is

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

Florida does not give an insurance-card tip. Its Division of Consumer Services says the state does not have jurisdiction over all health plans and sorts them this way: an individual or group policy issued in Florida goes to the Division; a self-insured employer plan goes to the employer first, then the U.S. Department of Labor at 1-866-444-3272; a self-insured city, county or state plan goes to that government's human resources office; a policy issued outside Florida goes to the insurance department of the state where it was issued; Medicare goes to 1-800-633-4227; Medicaid goes to the Agency for Health Care Administration at 1-877-254-1055.

Independent (external) review

Process
The federal process run for the Department of Health and Human Services. Run by MAXIMUS Federal Services, for the U.S. Department of Health and Human Services (HHS), or an accredited independent review organization hired by your insurer.
Where you file
federal
How
Read your final denial letter first: it must say who handles your external review. If your plan uses the HHS-administered process, file online through the MAXIMUS secure website, or call 1-888-866-6205 for a form and fax it to 1-888-866-6190 or mail it to MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534. If your insurer uses its own review organization, send the request the way the letter says.
Which denials qualify
Any denial that involves medical judgment where you or your provider disagree with the plan, any denial that calls a treatment experimental or investigational, and a cancellation of coverage based on the insurer's claim that you gave false or incomplete information
Appeal to the plan first?
Yes. Florida's Division of Consumer Services says you need to exhaust the insurer's internal appeal before applying for an external review. The official pages loaded did not list the exceptions for urgent cases.

Official page Request form

General rules and what to send: how external review works, how to request it.

Free help in Florida

Medicare and Medicaid in Florida

Medicare counseling
SHINE (Serving Health Insurance Needs of Elders), Florida Department of Elder Affairs · 1-800-96-ELDER (1-800-963-5337) . Free help with Medicare appeals.
Medicaid agency
Florida Agency for Health Care Administration (Florida Medicaid)
Fair hearing deadline
If you are in a Medicaid health plan: the Agency must receive your request within 120 days of the date the plan's notice of plan appeal resolution is sent. For other Medicaid decisions: within 90 days of the date the notice of action is sent (Florida Administrative Code Rule 59G-1.100). Your notice states the deadline that applies to you.
Good to know
If you are in a Medicaid health plan you must finish the plan's own appeal first, or your hearing request may be turned down. Ask for a hearing by calling the Medicaid Helpline at 1-877-254-1055 (TDD 1-866-467-4970), by email to MedicaidHearingUnit@ahca.myflorida.com, by fax to (239) 338-2642, or by mail to the Agency for Health Care Administration, Medicaid Hearing Unit, P.O. Box 7237, Tallahassee, Florida 32314-7237.

Medicaid appeals page How Medicaid appeals work

State laws that can help

  • Step therapy. A health insurer may not make you repeat a step-therapy protocol for a covered drug if you already completed it under another health plan and can show that plan paid for the drug in the 90 days before your request; insurers must also publish a way to ask for an exemption and explain any denial in writing.

    Florida Statutes section 627.42393

  • Surprise billing. For covered emergency care, and for certain non-emergency care at an in-network facility when you had no real chance to choose an in-network provider, the insurer alone owes the out-of-network provider, and that provider may not collect more from you than your usual copays, coinsurance and deductible.

    Florida Statutes section 627.64194

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on . Phone numbers and deadlines change; check the official page before you rely on one.

  1. Affordable Care Act: Working with States to Protect Consumers (State External Appeals Review Processes), Centers for Medicare & Medicaid Services
  2. External review, HealthCare.gov
  3. Florida Consumer Assistance, Centers for Medicare & Medicaid Services
  4. Health Insurance FAQs, Florida Division of Consumer Services
  5. Contact Us, Florida Division of Consumer Services
  6. Get Insurance Help, Florida Division of Consumer Services
  7. Organization and Operation, Florida Office of Insurance Regulation
  8. Contact Us, Florida Office of Insurance Regulation
  9. Medicaid Fair Hearings, Florida Agency for Health Care Administration
  10. Rule 59G-1.100 Medicaid Fair Hearings, Florida Administrative Code
  11. SHINE, Florida Department of Elder Affairs
  12. Florida Statutes section 627.42393, Step-therapy protocol
  13. Florida Statutes section 627.64194, Coverage requirements for services provided by nonparticipating providers
Not confirmed (7)
  • The independent review request form. the MAXIMUS portal address is the one HealthCare.gov lists and the one the old federal address redirects to, but the portal page itself was not loaded
  • Whether you must appeal to the plan first. the rule comes from the Florida Division of Consumer Services; the exceptions for urgent cases were not stated on the official pages loaded
  • Where to file for independent review. Florida insurers may use either the HHS-administered process or their own contracted review organization, so some residents file with the insurer; the denial letter controls
  • A searchable list of past decisions. no searchable decisions found for the federal process
  • Published results of independent review. no officially published overturn rate found
  • The Medicaid fair hearing deadline. the deadlines come from the hearing rule (59G-1.100); the Agency's consumer page does not state them
  • The state regulators. the TDD line (1-800-640-0886) appears on the Office of Insurance Regulation site but not on the Division's own contact page, which points to Florida Relay 711

Sources last checked . Found a mistake? Report it.