Health Options, Inc. (Florida) in-network claim denial rate: 25.3%

In the CMS Transparency in Coverage file for plan year 2025, Health Options, Inc. reported denying 9,940,136 of 39,268,216 in-network claims (25.3%) in Florida, from 2023 claims. 38.5% of internal appeals were overturned (1,130 of 2,937). That is the 5th highest reported rate of 13 ranked issuers in Florida; the state median is 20.4%.

Denial rate

25.3%

9,940,136 of 39,268,216 claims

Appeals overturned

38.5%

1,130 of 2,937 filed

External review overturned

26.6%

21 of 79 filed

Prior file (plan year 2024, 2022 claims): denial rate 14.2% (4,109,571 of 28,872,821); appeal overturn rate 48.3%.

Compared with Florida and the national median

Measure	Health Options, Inc.	Florida median	National median
In-network denial rate	25.3%	20.4%	18.3%
In-network claims received	39,268,216	—	—
Internal appeals filed	2,937	—	—
Internal appeal overturn rate	38.5%	38.1%	41.7%
External reviews filed	79	—	—
External review overturn rate	26.6%	26.6%	0.0%
Out-of-network denial rate	6.7%	—	—

Medians are across issuers with at least 1,000 in-network claims received in the same file (Florida: 13 issuers; national: 176 issuers in 32 states). Plan year 2025 file, 2023 claims.

Read these numbers carefully

Reporting lag: the CMS public-use file for a plan year reports claims from two plan years earlier (the PY2025 file carries 2023 claims). These are not this year's figures.
In-network only: the denial rate is in-network claims denied divided by in-network claims received. Out-of-network claims are shown separately where the issuer reported them.
"Denied" is broad: CMS counts every denial, including administrative denials, duplicate submissions, ineligibility, incorrect billing and partial denials, not only medical-necessity decisions.
Issuer level: CMS reports the counts once per issuer per state and repeats them on every plan row; plan-level counts, where present, list denials only, so no per-plan rate is computed.
Coverage: only issuers on the federally facilitated marketplace (HealthCare.gov states) report to this file. Employer plans, Medicare and Medicaid are not included.
No inference of intent: a higher rate can reflect the issuer's mix of claims, its billing rules or its membership as much as its coverage decisions. Compare with the state median and read the N.

Source: CMS Transparency in Coverage Public Use File (Health Insurance Exchange PUFs), plan year 2025; data dictionary. Issuer's own claims-payment policy page: https://www.floridablue.com/members/tools-resources/transparency.

If Health Options, Inc. denied your claim

A denial is a decision you can contest. Marketplace plans must give you at least 180 days to file an internal appeal and offer independent external review after it (45 CFR 147.136). The letter states your deadline.

Plans in this filing (76)

Where CMS lists plan-level denial counts they are shown; no plan-level rate is computed because the file does not give plan-level claims received.

Plan ID	Type	Metal	Plan-level denials (in-network)
30252FL0070001	HMO	Bronze	244,410
30252FL0070009	HMO	Gold	41,363
30252FL0070022	HMO	Silver	664,421
30252FL0070023	HMO	Gold	5,617
30252FL0070025	HMO	Bronze	17,025
30252FL0070027	HMO	Platinum	5,962
30252FL0070028	HMO	Gold	9,581
30252FL0070031	HMO	Bronze	562,615
30252FL0070033	HMO	Bronze	156,451
30252FL0070035	HMO	Silver	1,226,186
30252FL0070036	HMO	Bronze	63,806
30252FL0070039	HMO	Bronze	345,815
30252FL0070041	HMO	Bronze	29,442
30252FL0070044	HMO	Bronze	50,686
30252FL0070045	HMO	Bronze	9,634
30252FL0070046	HMO	Bronze	358,489
30252FL0070053	HMO	Silver	35,784
30252FL0070054	HMO	Silver	6,274
30252FL0070055	HMO	Gold	9,477
30252FL0070056	HMO	Gold	2,687
30252FL0070058	HMO	Platinum	2,966
30252FL0070070	HMO	Silver	n/a
30252FL0070074	HMO	Gold	n/a
30252FL0070075	HMO	Platinum	n/a
30252FL0070076	HMO	Silver	n/a
30252FL0070078	HMO	Silver	n/a
30252FL0070100	HMO	Platinum	n/a
30252FL0070101	HMO	Silver	n/a
30252FL0070102	HMO	Silver	n/a
30252FL0070103	HMO	Silver	n/a
30252FL0140002	POS	Silver	n/a
30252FL0140003	POS	Bronze	n/a
30252FL0140004	POS	Platinum	n/a
30252FL0140005	POS	Bronze	n/a
30252FL0140006	POS	Silver	n/a
30252FL0140007	POS	Platinum	n/a
30252FL0140008	POS	Gold	n/a
30252FL0140009	POS	Bronze	n/a
30252FL0140010	POS	Gold	n/a
30252FL0140015	POS	Platinum	n/a
30252FL0140017	POS	Bronze	n/a
30252FL0140018	POS	Bronze	n/a
30252FL0140020	POS	Gold	n/a
30252FL0140021	POS	Silver	n/a
30252FL0140023	POS	Bronze	n/a
30252FL0140025	POS	Bronze	n/a
30252FL0140026	POS	Bronze	n/a
30252FL0140027	POS	Silver	n/a
30252FL0140028	POS	Gold	n/a
30252FL0140029	POS	Platinum	n/a
30252FL0140031	POS	Bronze	n/a
30252FL0140032	POS	Silver	n/a
30252FL0140033	POS	Gold	n/a
30252FL0140034	POS	Platinum	n/a
30252FL0190003	HMO	Silver	n/a
30252FL0190009	HMO	Bronze	n/a
30252FL0190010	HMO	Bronze	n/a
30252FL0190011	HMO	Silver	n/a
30252FL0190018	HMO	Bronze	n/a
30252FL0190025	HMO	Silver	n/a

Showing 60 of 76 plans; all rows are in the CSV download.

Questions

What counts as a "denied" claim in Health Options, Inc.'s 25.3% rate?

Every in-network claim the issuer reported as denied in the 2023 claims year, including administrative denials, duplicates, ineligibility, incorrect billing and partial denials, not only medical-necessity decisions. The figure is in-network claims denied divided by in-network claims received, exactly as reported to CMS.

Why is the data from 2023 when the file is for plan year 2025?

CMS's Transparency in Coverage public use file for a plan year reports claims data from two plan years earlier. This is the most recent issuer-level denial data CMS publishes for marketplace plans.

Does this predict whether my Health Options, Inc. claim will be denied?

No. It is an aggregate across all of the issuer's marketplace plans in Florida. Your own claim depends on your plan, the service and the documentation. Compare the rate with the Florida median (20.4%) and read the N before drawing conclusions.

How do I appeal a Health Options, Inc. denial?

Read the denial letter for the reason and the deadline, request the criteria and the claim file in writing, and file an internal appeal (at least 180 days on marketplace plans under 45 CFR 147.136). In the reporting year, 38.5% of internal appeals to this issuer were overturned (1,130 of 2,937). If the internal appeal fails, independent external review is available.

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Cite: Apellica Insurer Denial Report Cards, Health Options, Inc. (Florida), plan year 2025, from the CMS Transparency in Coverage PUF. CC BY 4.0. Download the full table as CSV or read the methodology. Corrections: editorial@apellica.com.