Florida the biggest winner in King v. Burwell
A lot was at stake in Florida in King v. Burwell. The plaintiffs argued that subsidies could only be provided by state-run exchanges, and since Florida uses the federally-run exchange (Healthcare.gov), 1.28 million people would have lost their subsidies in Florida if the Supreme Court had agreed with the plaintiffs. That’s more than any other state, by far – Texas has the second-highest number of subsidies on the line, at 883,000. But on June 25, in a 6 – 3 ruling, the Court upheld the legality of the subsidies in every state, regardless of whether the state runs its own exchange.
That’s obviously good news for the 1.28 million people in Florida who are receiving subsidies, but it’s also good news for people who buy their own insurance without subsidies, since they would have seen rate increases of about 55 percent – in addition to regular annual rate increases – if subsidies and been eliminated. The entire individual insurance market would have been destabilized, and the Urban Institute estimated that the number of people covered by individual insurance would have dropped by 70 percent. Not only would that have been bad news for the insureds themselves, but it would also have been devastating to the insurers and medical providers in the state.
Unsurprisingly, Florida’s political leadership was mostly split along party lines in terms of their reactions to the Supreme Court’s ruling. But Senate President Andy Gardiner, a Republican from Orlando, expressed satisfaction with the outcome, noting that it preserves subsidies for 1.3 million people in Florida. He also used the ruling as an opportunity to remind people that hundreds of thousands of Florida residents are still caught in the coverage gap because the state hasn’t expanded Medicaid.
Florida Governor sues CMS
In April, Floria Governor Rick Scott announced that his administration was suing CMS over funding for the state’s Low Income Pool (LIP) program. Florida is one of 21 states that has not yet expanded Medicaid, and had the fifth-highest uninsured rate in the country in 2014. The LIP program got about $2.1 billion in federal dollars this year, but funding has long been scheduled to end on June 30, 2015.
Scott sued CMS because the agency refuses to renew Florida’s LIP funding, and Scott’s administration sees this as coercion to try to get them to expand Medicaid (Scott famously flip-flopped on the issue of Medicaid expansion).
Florida wins the battle, temporarily
In late May, CMS notified Scott’s administration that Florida could still qualify for $1 billion in LIP funding for the 2016 fiscal year, although the state will need to resubmit its proposal and budget for 2016 in order to obtain the funding. The letter from CMS included a warning that for the 2017 fiscal year, LIP funding will drop to $600 million, and that there is no provision for funding starting in June 2017.
On June 25, Gov. Scott announced that he was withdrawing his lawsuit against CMS. But for the work that was already done, the suit cost Florida taxpayers $175,000. Earlier in the week, Scott had reached an agreement with CMS to accept the $1 billion in LIP funding for the 2016 fiscal year, but lawmakers will need to revisit the issue of LIP funding when they reconvene again, as the funding will decrease in mid-2016. One condition in the CMS agreement to provide continued LIP funding is that it cannot be used for expenses that would have otherwise been covered if Florida had agreed to accept $50 billion for Medicaid expansion.
As part of the agreement over the LIP funding, Florida will use $400 million in state funds to increase Medicaid provider reimbursement rates, and that generates an additional $600 million in federal matching funds from CMS. Combined with the $1 billion in LIP funding for the upcoming fiscal year, the total pool of money to fund hospital indigent care is still at about $2 billion, the same as it was during the 2015 fiscal year.
Until Florida expands Medicaid, there will still be nearly 670,000 people in Florida with no access to Medicaid or premium subsidies. And in theory, Florida would need far less money for the LIP program if they were to expand Medicaid, as Medicaid expansion would mean fewer uninsured residents and thus less uncompensated care at Florida’s hospitals. This is the reason that Disproportionate Share Hospital (DSH) payments are also being phased out.
Lawmakers went into overtime to work out a budget
The issue of Medicaid expansion and LIP funding made the 2015 legislative session extremely contentious in Florida, and the session ended with no agreement on a budget for the upcoming fiscal year. The House is opposed to Medicaid expansion and supported Scott’s lawsuit against CMS, while the Senate has offered an alternative to Medicaid expansion known as the Florida Health Insurance Exchange Program (FHIX).
A special legislative session to address the budget convened on June 1, and lawmakers showed a willingness to work together during the special session. The legislature needed to pass a budget by July 1 in order to keep the government running, and they came to an agreement after a few weeks of work. Gov. Scott signed the budget on June 23.
2015 enrollment numbers
Between Nov. 15, 2014, and Feb. 15, more than 1.6 million Florida residents selected a private health plan in the exchange. Florida had more people sign up for health insurance through its marketplace than any other state during 2015 open enrollment. Florida ranks fourth in population, behind California, Texas, and New York.
In just the first month of open enrollment, Florida exceeded projections for new enrollees in 2015. Officials last fall estimated that more than 1 million residents would sign up to have health insurance in 2015, including 206,000 people who were expected to enroll for the first time. Two months into open enrollment, about 546,000 new consumers had already enrolled.
Florida’s enrollment success is attributed to well-coordinated outreach, a competitive insurance market in key population centers, and the state’s decision against Medicaid expansion. In states that did expand Medicaid, those with income up to 138 percent of the federal poverty level (FPL) can enroll in Medicaid. Without that option in Florida, low-income residents (with incomes between 100 percent and 138 percent of poverty) are turning to the marketplace for coverage (those with incomes below 100 percent of the poverty level are in the coverage gap – they don’t qualify for Medicaid, nor do they qualify for subsidies in the exchange).
Open enrollment will begin again in November
Open enrollment for 2015 is over. That includes the regular open enrollment period as well as a special enrollment period (SEP) that ran from March 15 through April 30 and applied to people who were previously unaware of the ACA’s penalty for being uninsured. The penalty-related SEP was available to anyone who didn’t know about the requirement to have health insurance until filing 2014 taxes. Penalties for 2014 will still apply, but people who enrolled during the tax season special enrollment period will have prorated penalty amounts for 2015.
Enrollment is still available for 2015 for people who get married, lose current coverage, or have another qualifying life event that triggers a special enrollment period. But without a qualifying event, no policies are available for purchase until November 1 when the next open enrollment period begins. That enrollment period will run from November 1 to January 31, and the earliest possible coverage date will be January 1, 2016.
Navigators and insurance agents are available to help consumers enroll both during open enrollment as well as throughout the year when people experience qualifying events. Both can help consumers evaluate the available options, but navigators cannot recommend one health plan over another. Agents receive commission from the insurance company for each person they sign up (although premiums are the same regardless of whether an agent is used); navigators do not. Use HealthCare.gov to search for a navigator by ZIP code, or see a list on Florida’s insurance website.
Florida’s other exchange
Florida Health Choices is the state’s own version of an online marketplace. While Florida Health Choices was established by 2008 legislation sponsored by Florida House Speaker Marco Rubio, it faced many delays and did not go live until March 2014.
Florida Health Choices initially offered “discount only” plans for some health services, such as dental services and prescription drugs. These plans were not true health insurance, and consumers largely ignored the state-sponsored exchange. Just 49 people purchased plans through Florida Health Choice during 2014.
In early January 2015, Florida Health Choices began offering health plans that comply with the ACA and cover the ACA’s ten essential health benefits. Policies from four insurers are available: Assurant, Cigna, Humana, and UnitedHealthCare.
Consumers who shop on Florida Health Choices can NOT obtain subsidies to help them pay for coverage. Those subsidies are available only through HealthCare.gov, the federally facilitated marketplace. Two months into 2015 open enrollment 93 percent of Florida residents who purchased coverage qualified for financial assistance.
The Florida Health Choices board of directors approved an $852,000 budget for 2015. Florida Health Choices has not announced official enrollment projections, but Naff was quoted in the Miami Herald saying, “I’d be tickled pink if we got 1,000 people.”
During the 2015 open enrollment period, 42 people bought health insurance plans through Florida Health Choices. By mid-April, it had 80 paying customers. In his newly-minted presidential campaign, Marco Rubio has distanced himself somewhat from Florida Health Choices, not mentioning it in his current plans for repealing and replacing Obamacare.
2015 premiums up 7 percent
A Commonwealth Fund analysis shows Florida marketplace premiums are up 7 percent on average compared to 2014 rates. Nationally, premiums were flat from 2014 to 2015; however, that average masks double-digit increases in some states and double-digit declines in others.
The same analysis found average monthly premiums for a 40-year old nonsmoker in Florida for 2015 are:
- $303 for bronze plans
- $369 for silver plans
- $419 for gold plans
- $487 for platinum plans
Florida officials and the Obama administration argued over the trend for 2015 premiums during the summer of 2014. Florida insurance regulators said 2015 premiums for individual and family coverage would rise 13.2 percent on average. That figure was a weighted average based on projected enrollment in the various plans. In contrast, the Obama administration projected average premiums would drop four percent. The decrease was based on an evaluation of the second-lowest silver-level health plan, which is the benchmark for premium subsidies.
2015 participating insurers
Florida residents have an extensive number of health insurers to choose from on the federal marketplace. In total, 14 companies are offering policies through the marketplace for 2015. Four of the insurers are new to the marketplace for 2015, according to Health News Florida.
Participating marketplace insurers for 2015 include Aetna, Blue Cross Blue Shield of Florida, Cigna, Coventry Health Care of FL, Florida Health Care Plan, Health First Health Plans, Health First Insurance, Health Options, Humana, Molina Healthcare of Florida, Preferred Medical Plan, Sunshine State Health Plan, Time Insurance Company, and UnitedHealthCare of Florida.
2014 results: highest enrollment for states using HealthCare.gov
Florida had the highest 2014 enrollment among states using HealthCare.gov and the fourth highest percentage of eligible individuals using the marketplace to purchase affordable health insurance. With 983,775 people signing up for coverage, Florida lagged only California in the number of individuals selecting a qualified health plan (QHP) during the 2014 open enrollment period.
While these are hopeful figures, there is still plenty of room to expand health insurance coverage in the Sunshine State. Although the figures vary among sources, Florida’s uninsured rates in 2013 and mid-2014 are among the highest in the U.S. The Gallup-Healthways Well-Being Index puts the figures at 22.1 percent in 2013 and 18.3 percent in 2014. A survey by the Commonwealth Fund shows the rates as 30 percent in 2013 and 26 percent in mid-2014.
Florida exchange background
Florida staunchly opposed the Affordable Care Act and the development of an ACA-compliant health insurance marketplace. Florida legislators not only failed to approve legislation to create an exchange in Florida, they returned a $1 million federal planning grant awarded in 2010. And right after the Supreme Court ruling that upheld most of the Affordable Care Act in June 2012, Republican Gov. Rick Scott announced that Florida would not establish a state-based health insurance exchange.
Florida has made it more difficult for navigators to assist consumers in using the marketplace. In 2013, Florida passed a law requiring fingerprinting and background checks for anyone who wants to serve as a navigator. The state requirements are in addition to federal requirements for 20 hours of training and a qualification test. Also in 2013, the Florida Department of Health (DOH) banned navigators from all county public health facilities. Florida DOH officials said the move was consistent with its policy of blocking outside groups not doing state business. They have also said the ban helps protects consumers from privacy concerns stemming from the collection of personal information for inclusion in a federal database. The Obama administration strongly criticized the ban on navigators, labeling the order “obstructionist” and “plain absurdity.”
Florida health insurance exchange links
State Exchange Profile: Florida
The Henry J. Kaiser Family Foundation overview of Florida’s progress toward creating a state health insurance exchange.
Florida Health Choices
State exchange established independent of the Affordable Care Act
Florida Office of Insurance Regulation
Assists consumers who have purchased insurance on the individual market or who have insurance through an employer who only does business in Florida.
(1-877-693-5236) / Out of State: (850) 413-3089
Subscriber Assistance Program – Agency for Health Care Administration
Serves residents enrolled in managed care; helps resolve grievance between managed care entities and their subscribers.
1-888-419-3456 (toll-free nationwide)