Health insurance or Medicaid said no in Florida? Deadlines and free help

In Florida, state-regulated health plans are overseen by Florida Department of Financial Services (DFS), Division of Consumer Services, Florida Office of Insurance Regulation (OIR) and Florida Agency for Health Care Administration (AHCA).

Florida uses the federal process for independent review of denials. You have 4 months to ask for it.

External review means a doctor or reviewer outside your plan decides again. Internal appeal means your plan looks at its own decision again.

Pick your plan type

Which kind of coverage was denied? The plan type decides which rules and deadlines apply.

Insurance I bought or got through work

Your state insurance rules may apply. First appeal to your plan, then ask for an outside review.

My employer pays claims itself (self-funded)

Federal rules apply, and most state insurance laws do not. Free help comes from the U.S. Department of Labor.

Florida Medicaid

You ask the state for a fair hearing. In a Medicaid health plan, you usually appeal to the plan first.

Marketplace (HealthCare.gov) decision

A decision about whether you can buy a plan or get financial help is appealed to the Marketplace.

How long do I have?Urgent care: faster decisionWrite my appealFree help

Checked against official sources: October 30, 2026.

Appeal deadlines are strict. If you are near a deadline or your care is urgent, call free help today.

How long do I have in Florida?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
4 months (federal rule)
Hearing deadline
90 days — The date on the written notice (if the notice was mailed later than its date, from the mailing date).
Keeping your benefits during the appeal
For DCF Medicaid eligibility actions, your assistance continues at the current level until the hearing decision if you ask for a hearing (orally or in writing) within 10 days after the notice was mailed or handed to you.
Appeal to the plan first
60 days (federal rule)
Then a state hearing
120 days
Appeal deadline – HealthCare.gov
90 days (federal rule)

How long do I have? Deadline calculator

How do I know which plan type I have?

How to tell which agency regulates your plan

If you bought insurance yourself or have insurance from an employer that does business only in Florida, contact the Florida Department of Financial Services. If your coverage comes from a self-insured employer plan (often a large company or one in several states), contact the U.S. Department of Labor.

Step 1: Appeal to your plan in Florida

What it is called: Grievance (internal appeal); for HMOs, review by an internal review panel

Time to file

Florida HMOs must tell you that a grievance must be filed within 1 year after the action, and you have 30 days after the HMO's final adverse determination notice to ask for review by its internal review panel. Federal rules give at least 180 days for most plans. The deadline that applies to you is on your denial notice.

An HMO must decide an expedited review of an urgent grievance as fast as your condition requires and within 72 hours, and give written confirmation within 2 working days if it first told you by phone. For a review of an ongoing (concurrent) service, the service continues at no cost to you until you are told the decision. An HMO must resolve other grievances within 60 days (90 if information is needed from outside the service area), but federal claims rules, which Florida adopts for group plans, can require a faster decision. After the grievance process you may choose binding arbitration if your contract offers it, which may cost you money.

Law: Fla. Stat. 641.511(1), (3)(e), (4)-(6)

Step 2: Outside review in Florida

Program

Federal external review (HHS-administered process)

Who runs it
  • U.S. Department of Health and Human Services (HHS) federal external review process: Insured health plans in Florida (individual and job-based insurance policies and HMOs)
Deadline to ask

Federal rule: at least 4 months.

Florida uses the federal external review process. The federal deadlines and contacts apply.

Do I have to appeal to my plan first?

Federal rules apply.

Cost

Federal rules apply.

Federal rule: The HHS-administered federal process is free. A state program or a plan's contracted reviewer may charge a fee, but not more than $25.

Law: HealthCare.gov, External Review

What can be reviewed

Federal rules apply.

Is the decision final?

Federal rules apply.

How to ask

Use the federal external review process described on your final denial notice.

HHS-Administered Federal External Review Process (MAXIMUS)

Only for plans that use the HHS-administered process. Ask your plan, or check your denial notice, to find out.

maximusferp.my.site.com · 1-888-866-6205 · MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534

Urgent care in Florida: faster decisions

Outside review

Federal rules apply.

Medicaid

AHCA holds expedited fair hearings for Medicaid service decisions; in an expedited hearing your case file must be given to you within 24 hours of your request. Ask for an expedited hearing when you call or write the Medicaid Hearing Unit.

Law: Fla. Admin. Code R. 65-2.046, 65-2.048 (DCF); R. 59G-1.100 (AHCA Medicaid Fair Hearings)

An expedited appeal to your Medicaid health plan: 48 hours.

Complaints about your plan in Florida

For problems with an insurance company or HMO, contact the DFS Division of Consumer Services by phone at 1-877-693-5236 (out of state 850-413-3089, TDD 1-800-640-0886), by the online contact form, or by email at Consumer.Services@myfloridacfo.com. HMO members can also call AHCA's toll-free hotline about an unresolved grievance at any time; HMOs must give you AHCA's address and hotline number.

Law: Fla. Stat. 641.511(3)(b)-(c)

myfloridacfo.com

Medicaid (Florida Medicaid (Statewide Medicaid Managed Care, SMMC)) denials in Florida

Who holds the hearing: For denied, reduced or stopped services: AHCA Office of Fair Hearings (Medicaid Hearing Unit). For Medicaid eligibility decisions by DCF: DCF Office of Inspector General, Appeal Hearings Section.

Hearing deadline: 90 days

All the details →

Marketplace decisions in Florida

Florida uses HealthCare.gov. Appeals go to the federal Marketplace Appeals Center.

HealthCare.gov

1-855-231-1751

Other rights in Florida

Step therapy already completed on another plan

A Florida insurer may not make you go through step therapy again for a covered drug if another health plan already approved it after step therapy and you give documentation from that plan showing it paid for the drug in the 90 days before your request. Insurers must publish how to request a step-therapy exemption and how to appeal a denial, and a denial must explain the clinical reason.

Law: Fla. Stat. 627.42393(2)-(3)

Medicaid plan service decisions

Florida Medicaid health plans must make a service decision (adverse benefit determination) within 7 days and decide an expedited plan appeal within 48 hours.

Law: AHCA, SMMC Program Snapshot (12/4/2024)

How long do I have? Deadline calculator

Pick your plan type and enter the dates on your notice. We count from the rules in Florida and the federal rules.

Worked out in your browser. Nothing you enter here is saved or sent.

If you are not sure when it arrived, use the date printed on the notice. That date is never later than the day it arrived.

Choose what was decided and enter the date on your notice

We add the number of days or months from the law to your date. Nothing is saved.

Write my appeal: free letters

Free help in Florida

Good to know in Florida

  • Florida uses the federal external review process for insured plans instead of its own state program (CMS CCIIO, State External Appeals Review Processes).
  • Florida Medicaid splits fair hearings: AHCA hears service denials and cuts, and DCF hears Medicaid eligibility decisions.
  • A DCF fair hearing decision can be appealed to the District Court of Appeal within 30 days of the Final Order.

Changes in 2024–2026

In February 2025 AHCA moved to new Statewide Medicaid Managed Care contracts that keep the plan grievance and appeal system (48-hour expedited appeals, 120 days for a fair hearing after the plan decision).

Source: AHCA, SMMC Program Snapshot, 12/4/2024

Questions about appeals in Florida

How long do I have to appeal a health insurance denial in Florida?

Florida HMOs must tell you that a grievance must be filed within 1 year after the action, and you have 30 days after the HMO's final adverse determination notice to ask for review by its internal review panel. Federal rules give at least 180 days for most plans. You have at least 180 days (about 6 months) from when you receive the denial notice to file an internal appeal.

How do I get an outside (external) review in Florida?

Use the federal external review process described on your final denial notice.

Is outside review free in Florida?

Federal rules apply.

How long do I have to ask for a Medicaid fair hearing in Florida?

90 days. The date on the written notice (if the notice was mailed later than its date, from the mailing date).

Can I keep my Medicaid benefits while I appeal in Florida?

For DCF Medicaid eligibility actions, your assistance continues at the current level until the hearing decision if you ask for a hearing (orally or in writing) within 10 days after the notice was mailed or handed to you. For Medicaid plan service cuts, see the managed care rule.

Who regulates health insurance in Florida?

Florida Department of Financial Services (DFS), Division of Consumer Services, Florida Office of Insurance Regulation (OIR) and Florida Agency for Health Care Administration (AHCA). If you bought insurance yourself or have insurance from an employer that does business only in Florida, contact the Florida Department of Financial Services. If your coverage comes from a self-insured employer plan (often a large company or one in several states), contact the U.S. Department of Labor.

Not about a denied claim?

Nearby states

Sources

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