Two parents work for two large Florida employers. Both have insurance cards with the same well-known company name. One gets ABA approved for her son without much trouble. The other is told the plan "excludes ABA." The difference is usually not the insurance company. It is how each employer pays for its health plan. This guide explains the difference between fully insured and self-funded plans, why it decides whether Florida's autism law protects your child, and how to find out which one you have in a few minutes.
What does "fully insured" mean?
In a fully insured plan, your employer buys a group insurance policy from an insurance company or HMO and pays it a premium. The insurer takes on the risk: if claims cost more than expected, the insurer pays the difference. Because the insurer sells insurance in Florida, it is regulated by the state, and the policy must follow Florida insurance law.
That includes the Steven A. Geller Autism Coverage Act (s. 627.6686 for insurers and s. 641.31098 for HMOs). The Act applies to group plans from insurers "licensed to engage in the business of insurance in this state," and excludes individual-market plans and plans "provided to a small employer," which Florida defines as 1 to 50 eligible employees. So a fully insured plan from a Florida-licensed insurer, for an employer with 51 or more employees, must cover ABA for eligible children with autism or Down syndrome. The details are in Florida's autism insurance law explained.
What does "self-funded" mean?
In a self-funded (also called self-insured) plan, the employer pays employees' medical claims from its own funds. It usually hires an outside company to run the plan: process claims, build the provider network, handle prior authorization and answer member calls. That company is called a third-party administrator (TPA), or the arrangement is called "administrative services only" (ASO). Large insurers do this work for many employers, and some companies, such as UMR, exist mainly to administer self-funded plans. UMR's own ABA form describes it as "a Third-Party Administrator (TPA) representing all self-insured groups."
Self-funded private employer plans are governed by a federal law, the Employee Retirement Income Security Act of 1974 (ERISA). ERISA generally keeps state insurance mandates from applying to them. The Florida Department of Financial Services (DFS) says it "does not have authority over self-insured plans under the Employee Retirement Income Security Act of 1974, employer group health plans issued outside the State of Florida, Medicaid, Medicare, Tricare, or any other governmental health plan."
The result: Florida's autism mandate does not apply to a self-funded plan, even if the employer is in Florida and has thousands of employees.
Does self-funded mean ABA is not covered?
No. This is a common misunderstanding. Many large self-funded employers choose to cover ABA. Some do it to attract and keep staff, some because their administrator's standard plan includes it, and some because of federal mental health parity rules. Under the federal Mental Health Parity and Addiction Equity Act, a plan that covers mental health benefits generally cannot apply stricter limits, prior authorization or exclusions to those benefits than to comparable medical benefits. In a September 2026 bulletin, the Department of Labor said plans "in general ... cannot apply blanket exclusions of treatments for covered MH/SUD conditions" when similar medical treatments are covered. Whether that reaches a particular ABA exclusion depends on the plan, and the bulletin does not mention ABA by name.
Two other points matter:
- Parity law has a small-employer exemption: self-funded plans of employers with 50 or fewer employees are generally exempt.
- In a self-funded plan, the plan document is the rulebook. The administrator's medical policy guides medical necessity review, but if the plan document excludes ABA, the administrator applies the exclusion.
How can I tell which kind of plan I have?
You usually cannot tell from the card. Here are four ways that work.
- Ask HR or your benefits office directly. Use these words: "Is our medical plan fully insured or self-funded? If it is insured, which company issued the policy, and in which state?" HR staff hear this question often.
- Read the Summary Plan Description (SPD). Your employer must give you one. Look for phrases such as "self-funded," "self-insured," "administrative services only," "ASO," "claims administrator" or "administered by." For example, the State of Florida's PPO booklet says it "is a self-insured plan" and names Florida Blue as administrator. A fully insured plan usually says benefits are "insured by" or "underwritten by" a named company and comes with a certificate of coverage.
- Look at who pays the claims on your Explanation of Benefits. An EOB that says the claim was "administered" or "processed on behalf of" your employer's plan points to self-funding.
- Call member services. Ask: "Is this plan fully insured or self-funded, and is it subject to Florida's autism mandate, section 627.6686?" Write down the answer and a reference number.
Also check the size of the employer and where the policy was issued. A fully insured plan for a company with 40 employees, or one issued in Georgia, is outside the Florida mandate too.
| Question | Fully insured (51+ employees, Florida-issued) | Self-funded |
|---|---|---|
| Who pays claims? | The insurer or HMO | The employer |
| Does Florida's autism mandate apply? | Yes | No |
| Can ABA be excluded? | Not for eligible children with autism or Down syndrome | Possibly, subject to federal parity rules |
| Main rulebook | Florida law plus the certificate of coverage | The plan document (SPD) plus ERISA and parity |
| Who handles complaints? | Florida DFS, 1-877-693-5236 | U.S. Department of Labor, EBSA, 1-866-444-3272 |
| External review after a denial | Federal HHS-administered process or an independent review organization | An independent review organization under federal rules |
Where do I go for help in each case?
Fully insured plans
Call the DFS Insurance Consumer Helpline at 1-877-693-5236, or file a complaint online through MyFloridaCFO.com. DFS can contact the insurer on your behalf when you believe the plan is not following Florida law. See how to file a DFS complaint.
Self-funded private employer plans
DFS refers these families to the U.S. Department of Labor's Employee Benefits Security Administration (EBSA). DFS lists EBSA's Florida office at 1000 S. Pine Island Road, Suite 100, Plantation, FL 33324, toll-free 1-866-444-3272, direct (954) 424-4022. EBSA benefits advisors can help you get plan documents and understand your appeal rights under ERISA.
Self-funded government plans
Some cities, counties and school districts self-fund too. ERISA does not cover government plans. DFS advises contacting your local plan officials first, then the federal Department of Health and Human Services at phig@cms.hhs.gov.
What can I do if my self-funded plan excludes ABA?
- Get the exclusion in writing, with the exact plan language.
- Request the plan's documents. Under ERISA you can ask the plan administrator in writing for the SPD and the full plan document. For mental health benefits you can also ask for the medical necessity criteria and the plan's parity comparative analysis.
- Appeal the denial. Even in a self-funded plan, you have internal appeal rights and, in many cases, external review. See appealing an ABA denial.
- Ask your employer to add ABA. Self-funded employers can change their plans, often at renewal. Our guide on asking your employer to add ABA includes a sample letter.
- Compare options at open enrollment, including a spouse's plan.
For a specific legal dispute, a Florida attorney who handles ERISA benefit claims can tell you what applies to your plan.
How Hope Center can help
We check plan type as part of every free benefits check. Many of the families we serve have self-funded plans, including plans administered by UMR and Personify Health, and many of those plans do cover ABA. We will tell you what your plan says, what authorization it needs and what your share is likely to be. Costs depend on your plan, and self-pay with a sliding scale is available. Start with insurance at Hope Center or request your free benefits check, or call 561-337-8865. If your plan is administered by UMR, see does UMR cover ABA.