Frequently Asked Questions

What is the Subscriber Assistance Program?
The program is a State of Florida program (we are State Employees) made up of two (2) parts. One part is the "program staff", the other is the "Panel" which hears your grievance. It is the program staff's function to gather all the important documents, prepare the case for review, schedule the hearing, and generally provide administrative support to the panel. It is the panel's responsibility to hear your case, and make a recommendation to either the Agency for Health Care Administration or the Office of Insurance Regulation.

Who can use the program?
The program can hear grievances of subscribers of Health Maintenance Organizations (commercial and Medicaid ), Prepaid Health Clinics and Exclusive Provider Organizations. But you must have completed the internal grievance process of the managed care organization (except in emergency cases).

Who cannot use the program?

• Those persons who have "traditional" health insurance, including Preferred Provider Organizations (PPOs) or other "gatekeeper" products sold by insurance companies.
• Employees or dependents whose health benefit is provided by an employer that "self insures" that health benefit program. If you are unsure of what type of coverage you have from your employer or your spouses employer, contact the personnel office of the employer and they should be able to tell you.

What are my chances of getting the health plan's decision reversed?
The subscriber has prevailed in approximately 50% of the cases heard.

Diagram of Outcomes

How long does it take?
State law requires us to complete the grievance process within 165 days after you file your grievance with us. Currently for non-emergency cases, if your case goes to hearing, the average time it takes is 90 days.
The Procedure

What if it is an emergency?
If your case is determined to be an emergency, the program has 24 hours from the date of notification to the managed care entity to hold a hearing. Call us to talk to one of our Registered Nurses.

Where and how are the hearings held?
The hearings are conducted via telephone-conferencing connection. The panel is located in Tallahassee.

Do I need an attorney?
This process is meant to be an informal one, so there is no requirement that you have an attorney. However if you would like to have one present, that is certainly your right. The cost of the attorney will be your expense. Some managed care entities have their attorney present, and as with you, they bear the cost of their attorney.

Can I bring someone with me?
Yes. This is your hearing, bring anyone you wish. Just remember that your hearing time is limited and your entire presentation to the panel is limited to 15 minutes and 5 minutes of rebuttal if necessary, regardless of the number of persons present.

Do you have an interpreter?
Generally no, however if you need one and cannot find one on your own, we will make every effort to secure one for use during your hearing.

What information do you want?
You should provide to the program all information relavent to your grievance. Please keep in mind that your health plan will be providing us with copies of your contract, handbook, etc. If you submitted documentation to the health plan during your grievance hearings, the health plan will also send us copies of that documentation used for your appeal process. All information you provide to the program is confidential, and will be given only to those people you have authorized.

What can I do if I lose?
You can seek legal advice to determine whether or not you have any other remedies available to you.

How long do I have to file a grievance with the program?
You have 365 days from the time you are notified by the managed care organization of the final outcome of your grievance to file with the program.

Who is on the panel that will be hearing my case?
The panel is comprised of the Insurance Consumer Advocate, or designee; at least two members employed by Agency for Health Care Administration and two employed by the Department of Financial Services; a physician appointed by the Governor; and a consumer representative appointed by the Governor; and, if necessary, physicians who have expertise relevant to the case to be heard.

What happens after the Final Determination?
You will be notified of the Final Determination by U.S. Mail. If the ruling is in the Subscriber's favor, the Managed Health Care Orgainzation has 30 days from receiving their notice to comply with the Final Determination. However, pursuant to section 408.7056 (14), Florida Statutes, the Health Plan has the right to request a summary hearing to contest the agency's decision in the matter in accordance with section 120.574, Florida Statutes.

What are the types of issues usually heard by the panel?
The most frequent issue involves "Excluded Benefits." This is followed by "Medical Necessity", "Non-Authorization for Service", and "Out of Network Services."

If you have a question that we have not answered or if you need further information, please write us, call us, or e-mail us.
Contact Information.