When a health plan stalls an ABA authorization, ignores your calls, misses a deadline or seems to break its own rules, a complaint to a regulator can get the company's attention. The catch is that Florida has several regulators, and the right one depends on what kind of plan your child has. Filing in the wrong place mostly costs you time.
This guide routes each type of plan to the right office, with phone numbers taken from the agencies' own pages, explains what a complaint can and cannot do, and gives you a short template. A complaint runs alongside your appeal rights; it does not replace them. For the appeal itself, see how to appeal an ABA denial.
Which regulator handles my child's plan?
Start by finding out whether your plan is fully insured or self-funded; your Summary Plan Description or HR can tell you. See fully insured vs self-funded plans. Then use this table.
| Your plan | Who handles complaints | How to reach them |
|---|---|---|
| Fully insured plan or HMO issued in Florida (employer or individual, including Marketplace plans) | Florida Department of Financial Services (DFS), Division of Consumer Services | 1-877-693-5236 (1-877-MY-FL-CFO); out of state (850) 413-3089; online Consumer Assistance Portal |
| Self-funded private employer plan (for example, plans run through UMR or Personify Health) | U.S. Department of Labor, Employee Benefits Security Administration (EBSA) | 1-866-444-3272; online through Ask EBSA |
| Employer plan issued outside Florida | DFS points to EBSA for employer plans headquartered out of state; for out-of-state policies, the insurance department of the state where the policy was bought | EBSA 1-866-444-3272 |
| Self-funded city, county or school district plan | Your local plan officials first, then the federal Department of Health and Human Services | Email phig@cms.hhs.gov (per DFS) |
| State of Florida employee plans | Division of State Group Insurance | (850) 921-4600 or 1-800-226-3734 (per DFS) |
| Federal employee plans (FEHB) | The carrier first, then the U.S. Office of Personnel Management | Follow your plan brochure's disputed claims section |
| TRICARE | TRICARE East Region (Humana Military) | 1-800-444-5445 |
| Florida Medicaid managed care | Your plan first, then the Agency for Health Care Administration | Medicaid Helpline 1-877-254-1055; online complaint form |
| Medicare or Medicare Advantage | Centers for Medicare and Medicaid Services | 1-800-633-4227 (1-800-MEDICARE) |
DFS says plainly what it does not cover. Its autism coverage page states that the department "does not have authority over self-insured plans under ... ERISA, employer group health plans issued outside the State of Florida, Medicaid, Medicare, Tricare, or any other governmental health plan."
How do I file a complaint with Florida DFS?
DFS lists four steps. Here they are, with what each means for an ABA problem.
- Contact the insurer first. DFS asks you to "contact the insurance company and allow them the opportunity to resolve your issue," and notes that most issues can be resolved within 30 days. Call member services, ask for a reference number, and put your request in writing.
- Confirm DFS can help. DFS handles policies issued in Florida, including health insurance. If your plan is self-funded or governmental, use the table above instead.
- Know what DFS can and cannot do (below).
- Gather documents and submit through the DFS Consumer Assistance Portal, or call the helpline. The helpline runs 8:00 AM to 5:00 PM ET, Monday through Friday. Relay users can dial 711.
What to have ready
- the exact name of the insurance company and your policy or member ID number;
- the front and back of the insurance card;
- any claim or authorization reference numbers;
- a short, dated description of the problem;
- copies of letters, denial notices, emails and notes of phone calls (date, time, name, reference number); and
- supporting documents, such as the treatment plan submission date from your provider.
DFS says incomplete submissions cause delays. You can also write to the Division of Consumer Services, 200 East Gaines Street, Tallahassee, FL 32399-0322.
What can a DFS complaint achieve, and what can it not?
According to DFS, once you file it will ask the company to explain its actions. DFS says companies have 14 days by statute to respond, and it aims to resolve concerns within 30 days. It reviews the response for compliance with Florida law and rules, helps you understand your policy, and points you to other resources if it lacks authority.
DFS also lists what it cannot do. It cannot:
- give legal advice;
- make medical judgments or decide questions of fact;
- set claim values or act as your adjuster; or
- force payment or other action "when the company has not violated a law, rule, or policy provision."
In practice, a complaint is most useful when the plan is not following the rules: missing decision deadlines, losing paperwork repeatedly, refusing to give you the criteria it used, or ignoring Florida's autism mandate in a plan it applies to. A disagreement about medical necessity is usually better handled by internal appeal and then external review, because an independent reviewer can overrule the plan on medical judgment and DFS cannot.
What about self-funded plans and EBSA?
Self-funded private employer plans are governed by federal ERISA rules, so the U.S. Department of Labor's EBSA is the place to go. EBSA says its "Benefits Advisors are available to assist you," by phone at 1-866-444-3272 or through an online form for health plan questions. DFS also lists EBSA's regional office at 1000 S. Pine Island Road, Suite 100, Plantation, FL 33324.
Questions EBSA is well placed to help with include a plan refusing to give you plan documents or claim files, missed claim decision deadlines, and parity concerns, such as stricter rules for ABA than for comparable medical care. See mental health parity and ABA denials.
A short complaint you can adapt
Keep it factual and brief. Attach the documents rather than retelling them.
My child, [name], member ID [number], is covered by [plan name], a [fully insured / self-funded] plan through [employer]. On [date], our ABA provider submitted a prior authorization request for applied behavior analysis for autism spectrum disorder. [Describe the problem: for example, "As of [date], the plan has not issued a decision, although we have called on [dates], reference numbers [numbers]."] [If relevant: "We have asked in writing for the medical necessity criteria used and have not received them."] We ask the department to review whether the plan has complied with its obligations and to help us obtain a decision. Copies of the request, call log and letters are attached. [Your name, phone, email]
Tips that make a complaint more effective
- Keep a call log from the first day. Date, time, the representative's name and the reference number. A complaint with a clear timeline is easier to act on.
- Ask for things in writing. Decisions, reasons, criteria and deadlines.
- Do not let a complaint stop the appeal clock. Appeal deadlines keep running while a regulator looks at your complaint. File your appeal on time either way.
- Bring in your provider. Your BCBA's office can confirm submission dates and peer-to-peer requests.
- Think about a lawyer when the stakes are high. For self-funded plans, a Florida attorney who handles ERISA benefit claims can explain options beyond appeals.
How Hope Center helps when a plan will not respond
For children we serve, Hope Center for Behavior Change tracks each authorization and follows up with the plan. When a plan stalls, we give you the submission dates, reference numbers and copies you need for an appeal or a complaint, and our BCBAs request peer-to-peer reviews where they can help. If you are still deciding where to start, we offer a free benefits check, which also tells you whether your plan is fully insured or self-funded. Visit insurance at Hope Center, contact us or call 561-337-8865.