When a Florida Government Health Plan Says “We’re Only the Administrator” …

Once again dear readers, I’ve been moved to write one of my infrequent blog posts.  Frankly, I’d much rather, when I have the occasional time and impulse to do so, personally write about an issue that we regularly encounter. 

Hopefully you’ll agree that even an infrequent post that I personally write is much better than to have a 3rd party “professional blogger” or AI dishing up weak soup you can get anywhere.

With that said….

After 44 years representing people in serious disputes with health insurers, I have seen nearly every version of a coverage fight: denied claims, cancelled policies, pre-existing-condition disputes, experimental-treatment denials, underwriting problems, fraudulent sales practices, and the increasingly common demand that a patient “try and fail” one treatment before the plan will approve the treatment the doctor actually prescribed.

This post is about a problem we are seeing more often from Florida public employees and their families. A county employee, municipal employee, firefighter, police officer, teacher, or dependent receives health coverage through a Florida governmental employer. Care is denied. The denial letter looks like it came from a familiar national health insurer. The family calls the number on the card. Then comes the answer that leaves people feeling stuck: “We are not the insurer. We are only the administrator.”

So, what now? How do you fight back when the company making the decision says it is merely administering someone else’s plan?

The answer starts with understanding the structure. Florida law allows local governmental units to provide group health coverage and to self-insure certain health, accident, and hospitalization plans, subject to approval by the Florida Office of Insurance Regulation based on actuarial soundness. In practical terms, the governmental entity may be financially responsible for the plan, while a familiar health insurance company or professional administrator drafts plan documents, processes claims, issues explanations of benefits, handles appeals, and communicates denials.

That structure can be confusing by design. To the patient, the administrator looks and acts like an insurer. But when challenged, the administrator may try to distance itself by saying it is not the ultimate risk-bearer. That statement may be partly true as a matter of plan financing, but it should not end the analysis.

Governmental health plans are also different from many private employer health plans. A private employer’s self-funded health plan is often governed by ERISA. Governmental plans generally are not. That matters because if ERISA does not govern the plan, Florida state law may supply important rights, standards, and remedies that should not be ignored.

Florida law does more than merely allow a governmental employer to self-fund coverage. A plan of self-insurance providing health coverage benefits to Florida residents must comply with certain Florida statutory requirements relating to individual rights to specified benefits and coverages. In other words, “self-funded” does not mean “free from statutory requirements,” and “administrator only” does not mean “no one has to answer for the denial.”

One common example is step therapy. If a plan denies a medication, procedure, surgery, or course of treatment because the patient supposedly must try something else first, Florida has a statute that addresses step-therapy protocols, protocol-exemption requests, appeal procedures, and the explanation required when an exemption is denied. That statute expressly includes a governmental entity providing a plan of self-insurance within the definition of a health coverage plan.

If you or a family member receives one of these denials, do not assume the administrator’s first answer is the final answer. Ask for the complete governing plan document, the summary of benefits, the denial letter, the appeal procedure, the specific plan language relied upon, and the statutory or clinical basis for the denial. If the issue involves step therapy, ask for the protocol-exemption form and the procedure for appealing a denial of that exemption. Preserve every deadline.

It may also be useful to confirm whether the governmental entity has an approved self-funded plan filing with the Florida Office of Insurance Regulation and to review publicly available filings maintained by Florida regulators. Those filings may help identify the plan sponsor, administrator, actuarial submissions, and the structure of the plan.

The bottom line is simple: if your Florida governmental health plan denies needed care, do not let “we are only the administrator” be the end of the conversation. You may have rights under the plan document and under Florida law. The denial should be tested against both.

Here is a link to one of our ongoing cases involving these issues.