New to helping someone in Florida?
Start with three things from the patient or family:
- Insurance card — shows the carrier and plan name
- Denial letter or explanation of benefits (EOB) — lists appeal rights and deadlines
- Summary of Benefits and Coverage (SBC) — if available
Your first job is to learn what kind of plan this is (Marketplace, job-based, Medicaid, Medicare) and what deadline the letter gives you.
For steps that work in every state, use these general guides first, then return here for Florida rules:
What is different in Florida?
- Federal Marketplace: Florida uses HealthCare.gov (not a state-run exchange). Major issuers include Florida Blue, Oscar, Molina, Ambetter/Centene, and others.
- Limited state PA statute: Florida requires standardized two-page PA forms when carriers lack electronic PA (F.S. § 627.42392)—but does not have a broad modern PA deadline law like many states. ACA plans still follow federal UR timelines.
- HMO grievances: HMOs must offer internal panel review within 30 days of a final adverse determination and decide urgent grievances within 72 hours (F.S. § 641.511).
- Federal external review: Florida uses the HHS-administered external review process for many health plans—not a Florida OIR independent review program. See Florida external review.
- Florida Medicaid: MCO appeal, then AHCA fair hearing—different from commercial insurer rules.
Who is in charge of your plan?
- Florida Office of Insurance Regulation (OIR) / DFS Consumer Services: Fully insured health plans, complaints — myfloridacfo.com — consumers. Help: 877-693-5236 (in FL) or 850-413-3089.
- U.S. Department of Labor: Many self-funded employer plans.
- AHCA: Medicaid fair hearings — ahca.myflorida.com.
- CMS: Medicare and Medicare Advantage.
For complaints after appeals, see Regulator complaints.