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Florida health insurance marketplace: history and news of the state’s exchange

Highest enrollment in the country; highest percentage of residents in the individual market. 44.7% average rate hike for 2018, mostly due to CSR uncertainty

Highlights and updates

Florida exchange overview

Florida uses the federally-run exchange, so residents enroll through HealthCare.gov. Florida has the highest exchange enrollment of any state in the country.

1,760,025 people enrolled in private plans through the Florida exchange during the 2017 open enrollment period. 90 percent of them are receiving premium subsidies that reduce average premiums from $442/month to $118/month. By March 2017, effectuated enrollment stood at 1,437,968, with 93 percent receiving premium subsidies (for comparison, 84 percent of exchange enrollees nationwide were receiving premium subsidies).

During the 2017 open enrollment period, 1,556,676 people enrolled in private plans in California — the state with the second-highest enrollment. But California has a state-run exchange; among states that use HealthCare.gov, Texas had the second-highest enrollment, and it was more than half a million lower than Florida’s.

Florida’s 2017 exchange enrollment is also 1 percent higher than it was in 2016, when 1,742,819 people enrolled. Across all states that use HealthCare.gov, there was an average enrollment decline of about 5 percent, but Florida bucked that trend and saw growing enrollment for 2017.

Individual market enrollment is particularly high in Florida. Charles Gaba of ACA Signups has calculated that nationwide, an average of 6.4 percent of the population is covered by individual market plans, including on and off-exchange policies. But in Florida, it’s double the national average, at 12.7 percent. And in South Florida, it’s nearly 20 percent.

For 2017, benchmark premiums (second-lowest-cost silver plan) increased by an average of 14 percent in Florida (lower than the national average of 22 percent). Premium subsidies are based on the cost of the benchmark plan relative to enrollees’ income, so subsidies are larger in 2017 than they were in 2016, assuming incomes remained fairly steady.

Open enrollment ends Dec.15, but special enrollment period triggered by hurricane will continue until Dec. 31

As is the case in every state that uses HealthCare.gov, open enrollment for 2018 coverage ends December 15 in Florida. But HHS announced in late September that residents of areas declared by FEMA as eligible for “individual assistance” or “public assistance” would have a special enrollment period to sign up for coverage. The special enrollment period continues through December 31, 2017.

The entire state of Florida was deemed eligible for individual assistance or public assistance or both, so all Florida residents are eligible for the SEP, as are people who now live elsewhere but who lived in Florida during Hurricane Irma.

2018 enrollment

1,021,576 people had enrolled in Florida’s exchange by December 9, which was about 16 percent higher than the enrollment as of December 10 the year before. As of December 9, six days remained in open enrollment for 2018 coverage, but as noted above, everyone in Florida actually has until December 31 to enroll in coverage, due to the hurricane-related special enrollment period.

2018: Humana exiting individual market, other insurers will remain in the exchange

Individual and small group market health insurance rate filings, for both on and off-exchange coverage, were due in Florida by June 21, 2017. Of the six insurers that offer coverage in Florida’s exchange in 2017 — seven if you count the two separate Florida Blue entities — only Humana will exit the exchange at the end of 2017 (this is true in every state where Humana still offers coverage). Human offered plans in seven of Florida’s 67 counties in 2017.

Although there were six insurers offering plans in the Florida exchange in 2017, most of them have limited coverage areas (2017 coverage areas for each insurer are listed here). Florida Blue is the only insurer offering plans in 67 counties in Florida, including most of the northern part of the state, so their commitment to remaining in the exchange for 2018 was particularly important.

Celtic and Health First expanding coverage areas

Centene/Celtic/Ambetter already offers plans in the Florida exchange in 2017, but they have expanded their coverage area for 2018. They offer plans in 17 counties in 2017, and that has increased to 22 counties for 2018. The counties where Centene/Celtic/Ambetter is expanding are Alachua, Lake, Marion, Orange, and St. Lucie.

Health First offers plans in four counties in 2017, but will cover five counties in 2018, with expansion into Seminole County (note that Health First’s website says that their individual market plans are only available in Brevard and Indian River counties, but Florida Office of Insurance Regulation (FLOIR) data indicates that Health First plans are also offered in Flagler and Volusia counties in 2017, and a quote search on HealthCare.gov confirms this).

2018 rate: State approved 44.7% average rate increases, mostly due to assumption that feds wouldn’t fund CSR

In June, FLOIR announced that six insurers planned to offer coverage in the Florida exchange for 2018, and that their combined proposed average rate increase was 17.8 percent. At that point, the rates that each insurer had filed were not yet publicly available, but it’s important to note that those initial filings were based on the assumption that cost-sharing reductions (CSRs) would continue to be funded by the federal government in 2018.

Rate filings became available on August 1 on ratereview.healthcare.gov. The actuarial memos with the Florida filings are much less comprehensive than the filings available in many other states, but one insurer’s filing memo noted that “due to the exit of Aetna/Coventry from the [off-exchange] ACA market, FLOIR has required all carriers to increase rates by 3% so that rates are adequate to accommodate the migrating members.”

The initial rates that insurers filed for 2018 were based on the assumption that funding will continue for CSRs. Insurers are obligated to provide CSRs regardless of whether the federal government funds them or not. If that funding is not forthcoming, insurers have to increase their prices to account for the lack of federal funding.

So Florida regulators asked insurers to file backup rates that would apply if CSR funding is eliminated, as rates need to be considerably higher in that case — and the backup rates are the ones that were ultimately approved by state regulators, as there had been no resolution to the CSR funding issue at the federal level by the time rates had to be finalized (in October, the Trump Administration eventually did officially cut off CSR funding, so it was fortunate that Florida regulators had already approved the rates based on the assumption that would happen).

Overall, the rates that Florida regulators approved represent an average increase of 44.7 percent (details below for each insurer). But FLOIR noted that 31 percentage points of that is “directly attributable” to on-exchange silver plans, which will bear the increased premiums necessary to cover the cost of CSRs. Not counting on-exchange silver plans, the average premium increase is 18 percent — still a significant increase, but not nearly as eye-popping as 44.7 percent.

People who have silver plans and who receive premium subsidies will not have to bear the burden of the CSR load on the silver plans, as premium subsidies are based on keeping the second-lowest-cost silver plan affordable, so they’ll grow to keep pace with the premium increases. 93 percent of Florida exchange enrollees are receiving premium subsidies (versus the nationwide average of 84 percent).

FLOIR notes that “consumers enrolled in a Silver on-Exchange plan that do not receive a premium subsidy will have the option of purchasing a similar off-Exchange Silver plan without this extra cost [of the added premium to pay for CSRs].” On- and off-exchange plans have to have the same premium if they’re identical, but if a slightly different off-exchange plan is offered, it wouldn’t have to have the same premium, and could thus avoid the CSR load.

To fill in the backstory, CSRs are part of the ACA, and they allow low-income enrollees to have coverage with lower out-of-pocket costs if they pick silver plans. 75 percent of Florida exchange enrollees are receiving CSRs in 2017 (versus 57 percent of exchange enrollees nationwide). But the ACA didn’t specifically allocate funding for them, and House Republicans sued the Obama Administration in 2014 over the funding issue. The court sided with House Republicans in 2016, but the Obama Administration appealed and the money has continued to flow to insurers ever since (to the tune of about $7 billion in fiscal year 2017). The case was pended throughout 2017, but President Trump repeatedly threatened to cut off funding for CSRs, and his threats took on new urgency when the Senate failed to pass any version of their ACA repeal/replace legislation in late July (Nicholas Bagley has written an excellent explainer of how this all works).

In early August, a group of 17 states (Florida is not among them) and DC were granted a motion to intervene in the lawsuit. And bipartisan legislation that was being considered in Congress in September could have allocated funding for CSRs, but there was a very tight deadline for getting it done, and the bill was tabled by Senate Republicans in favor of pursuing the Graham-Cassidy amendment to repeal the ACA. That bill was pulled on September 26, the day before insurers had to sign contracts with HealthCare.gov.

The bipartisan legislation might still come together, but until it does, CSR funding has officially ended due to Trump’s decision on October 12 to eliminate it. If Congress ends up allocating funding before premiums are finalized for 2019, rates would be able to drop back down to reflect the resumed federal funding. If not, insurers will have to continue to collect enough in additional premiums to cover the cost of CSR.

Rates and plans for 2018

Open enrollment for 2018 coverage began on November 1, 2017 and will continue until December 15, 2017 (and as noted above, residents in Florida actually have until December 31 to enroll, due to the hurricane-related special enrollment period).

The six insurers that are offering plans in the exchange for 2018 have a total of 170 plans available in the exchange, but insurer participation is localized and varies considerably from one part of the state to another. A list of the counties where each insuer is offering coverage for 2018 is available here42 of the state’s 67 counties have just one insurer offering plans in the exchange.

FLOIR approved the following average rate increases — keeping in mind that the bulk of these increases are attributable to silver plans, and the overall average rate increases would have been much lower if CSR funding had been committed for 2018 (the proposed rates, in parentheses, are what the insurers originally filed with the assumption that CSR funding would continue).

  • Florida Blue (BCBS of Florida): 38.1 percent (BCBS of Florida had originally proposed average rate increases of 9.3 percent to 24.7 percent, depending on the plan).
  • Florida Blue HMO (Health Options): 36 percent (Health Options had originally proposed average rate increases of 6.3 percent to 11.3 percent, depending on the plan).
  • Florida Health Care Plan Inc. (FHCP is a subsidiary of Florida Blue): 26.5 percent (FHCP had originally proposed average rate increases of 1.7 percent to 15.4 percent, depending on the plan)
  • Ambetter (Celtic): 46.1 percent (Celtic/Ambetter had originally proposed an average rate increase of 12.4 percent; Ambetter has 219,053 members in 2017, and will expand to a larger coverage area in 2018, described above).
  • Molina: 71.2 percent (Molina has 336,515 on-exchange members. The insurer had originally proposed a 37.5 percent average rate increase. Molina executives noted over the summer that their average rate increase across all states where they offer exchange plans would increase to 55 percent if cost-sharing reduction funding is eliminated; in Florida, their final rate increase was 33 percentage points higher—nearly double—than their original filing, due to the new assumption that CSR funding won’t continue in 2018).
  • Health First Health Plans: 39.3 percent (Health First offers plans in Brevard, Indian River, Flagler and Volusia counties in 2017; they will expand to also offer coverage in Seminole County in 2018. In 2017, they have 17,591 on-exchange members, plus 3,057 off-exchange. Filings don’t show up on ratereview.healthcare.gov, but FLOIR confirmed on August 7 that Health First has filed rates and plans for 2018, and has not withdrawn them. And Health First plans were included in the approved plans that FLOIR announced in late September.

Premium subsidies much larger for 2018, making after-subsidy rates lower for some enrollees

Because the cost of CSR has been added to silver plan premiums, premium subsidies are much larger in Florida than they were in previous years. Consider a family of four (parents are 45, kids are 15 and 13) living in Miami. If they earn $70,000, they can get a premium subsidy of $1,022 per month in 2018. After that subsidy is applied, the cheapest plan available to them in the exchange is just $21/month in total premiums for the family.

For the same scenario in 2017, the premium subsidy would have been $452 per month, and the cheapest plan available to them would have cost $447/month in after-subsidy premiums.

Premium subsidies are available to households with income up to 400 percent of the poverty level. And it’s important to understand what counts as income — don’t give up on eligibility for a subsidy until you talk with a tax adviser, because contributions to an HSA and/or retirement plans might bring your income into the subsidy-eligible range, even if it initially seems too high.

Unfortunately, Florida has a Medicaid coverage gap because the state has rejected federal funding to expand Medicaid. As a result, households with income below the poverty level are not automatically eligible for Medicaid (very low-income parents are eligible, but non-disabled childless adults are not, regardless of how low their income is). People with income below the poverty level are also ineligible for premium subsidies. Florida could fix the coverage gap at any time by accepting federal funding to expand Medicaid, but they have not yet done so.

Florida’s exchange and the Trump Administration

In December 2016, HHS reported that nearly 1.6 million people gained health insurance in Florida from 2010 to 2015, as a result of the ACA. This is despite the fact that Florida has refused to accept federal funds to expand Medicaid under the ACA. Lawmakers in Florida have shown no signs of moving forward with Medicaid expansion, despite the fact that two-thirds of Florida voters support Medicaid expansion.

House Republicans passed the American Health Care Act (ACHA) in May 2017, but Republican Senators failed to pass any of their versions of the legislation, and by late July the measure had been pended — with the option to put it back on the Senate calendar if and when it had enough support to pass. Senate Republicans took that option in September, attempting to pass the Graham-Cassidy-Heller-Johnson amendment. But the measure was pulled on September 26 when it became apparent that Republicans didn’t have enough support to pass the bill.

Ilena Ros-Lehtinen, a Republican who represents Florida’s 27th Congressional District (Miami-Dade County, where nearly 20 percent of the population has individual market coverage), was opposed to the AHCA, noting that it would result in many of her constituents losing coverage. Ros-Lehtinen opposes the ACA, but did not feel that the AHCA would be an adequate fix, and wants a bipartisan solution “without hurting the elderly and disadvantaged among us.” When the AHCA came up for a vote on the floor of the House in early May, Ros-Lehtinen was one of 20 Republican Representatives who voted against it.

But her fellow South Florida Republican representatives, Carlos Curbelo (26th District) and Mario Diaz-Balart (25th District), both voted in favor of the AHCA. Their districts have 18.9 percent and 17.8 percent of residents enrolled in individual market coverage, respectively.

In addition to legislation, there are things that the Trump Administration can do — or not do — that will stabilize or destabilize the individual market. Insurers wanted reassurance that the Trump Administration would continue to fund the ACA’s cost-sharing reductions, and they want to know that the Administration will continue to enforce the individual mandate penalty. But the Trump Administration instead cut off cost-sharing reduction funding altogether and has already taken a more lax approach to enforcing the individual mandate. These factors have played a significant role in the sharply higher rates in Florida’s individual market for 2018.

7 carriers offering plans in 2017; others exited at the end of 2016

UnitedHealthcare exited the individual market in Florida at the end of 2016, as was the case in many of the states where they offered exchange plans in 2016.

Aetna also left the exchange in Florida at the end of 2016, as was the case in all but four of the states where they offered exchange plans in 2016. Aetna is continuing to offer off-exchange coverage in Florida’s individual market, but will exit the entire individual market at the end of 2017.

Cigna was planning to re-enter the Flordia exchange after pulling out at the end of 2015 (details below), and they did file rates for on-exchange plans. But ultimately, they did not re-enter the exchange, and a Florida Office of Insurance Regulation (FLOIR) chart shows Cigna only offering two off-exchange plans in Florida for 2017. FLOIR also confirmed via email that Cigna does not have any on-exchange plans for 2017.

Humana scaled back their exchange participation across the country for 2017. They remained in the Florida exchange, but with a much smaller footprint. As of September 2016, Humana was planning to offer 16 plans in the Florida exchange, but no off-exchange plans. They exited 31 of the 38 counties where they offered plans in 2016, but are continuing to offer exchange plans in the other seven counties in 2017.

Humana will exit the individual market altogether, nationwide, at the end of 2017, however. Those seven counties in Florida will no longer have Humana coverage available in the exchange in 2018.

Harken Health – a subsidiary of UnitedHealthcare – had planned to enter the exchange for 2017, in the Miami and Fort Lauderdale areas. Harken began offering coverage in the Chicago and Atlanta areas in 2016, and their plan was to expand into Florida with the upcoming open enrollment period. But in early August, they reversed course, saying that they would not offer plans in Florida in 2017. But they left the door open for a future expansion into Florida, saying “Harken believes people in South Florida could benefit greatly from our innovative model, and we look forward to offering access to those services as part of future expansion.

2017 rate changes

There are seven carriers offering coverage in the Florida exchange for 2017, but plan availability varies considerably from one county to another. According to The Upshot, a significant portion of Florida (outside the Miami, Tampa, and Orlando metro areas) has just one or two carriers available in the exchange in 2017.

There are no PPO options available in the exchange in Florida for 2017, as is the case in numerous states. Most of Florida’s exchange carriers are offering HMOs; BCBS of Florida and Celtic are offering EPOs.

The carriers that are participating in the exchange implemented the following average rate increases (before subsidies are applied) for 2017:

  • Florida Blue (BCBS of Florida): 19 percent
  • Florida Blue HMO (Health Options): 18.9 percent
  • Florida Health Care Plan Inc.: 15.4 percent (FHCP is a subsidiary of Florida Blue)
  • Humana: 36.8 percent (will exit the market at the end of 2017)
  • Ambetter (Celtic): 20 percent
  • Molina: 17.4 percent
  • Health First Health Plans: 11.7 percent

The average rate increase overall was a little higher than the carriers had initially requested. This is the reverse of what happened in 2016, when most of the carriers in the individual market in Florida ended up with approved rate increases that were smaller than they had requested.

And although the average approved rate increase in Florida for 2016 was 9.5 percent, the after-subsidy premium increase in Florida for 2016 was just two dollars a month. In 2015, 93 percent of Florida exchange enrollees received a subsidy. Their average pre-subsidy premium was $376 per month, while their average after-subsidy premium was $82 per month. For 2016, more than 93 percent of Florida’s enrollees received subsidies, and while the average pre-subsidy premium (for people who enrolled during open enrollment) climbed by $10 (to $386 per month), their average after-subsidy premium was just $84 per month.

For 2017, however, average pre-subsidy premiums are $442/month, and average after-subsidy premiums are $118/month.

Grandmothered and grandfathered plans

Florida is one of the states that has allowed grandmothered/transitional health plans to remain in force through 2018. In October 2016, the Florida Office of Insurance Regulation (FLOIR) published a report showing how many people were enrolled in various types of coverage during the 2015 coverage year:

  • 236,701 people were enrolled in grandmothered individual market plans (including some in association plans that were governed by another state’s regulations)
  • 1,999 people were enrolled in grandmothered “group of one” sole proprietor plans (coverage for self-employed people in the small group market)

The continuation of grandmothered plans is one of the factors that results in a less healthy risk pool for the ACA-compliant market. This is because everyone on grandmothered plans passed medical underwriting between 2010 and 2013, meaning it’s a relatively healthy book of business. Since these individuals are allowed to remain on their medically underwritten (and thus less expensive) coverage, they don’t enter the ACA-compliant market, resulting in the latter being more skewed towards sicker, older enrollees.

Grandfathered plans can remain in force as long as the insurance company wants to continue to maintain them (some insurers have opted to terminate grandfathered plans, but they are not required to do so at any point, unlike grandmothered plans, which must terminate by the end of 2018).

  • 84,149 people were enrolled in grandfathered individual market plans in Florida in 2015, including those governed by another state’s regulations.
  • 620 people were enrolled in grandfathered sole proprietor group plans.

2016 enrollment

January 31, 2016, marked the end of the 2016 open enrollment period, and 1,742,819 people enrolled in private health insurance plans through the Florida exchange by February 1 — by far the highest of any state in the country, and also the highest per-capita enrollment rate in the country.

California and New York both have larger populations than Florida, but unlike Florida, they have both expanded Medicaid, which results in fewer enrollments in private plans through the exchange, and New York also debuted a Basic Health Program for 2016, which further reduces private plan enrollment. Texas also has a higher population than Florida and has not expanded Medicaid.

Florida’s enrollment for 2016 was about 9 percent higher than it was during the 2015 open enrollment period, despite the fact that the 2016 enrollment report already accounted for early attrition through February 1 (in prior years, HHS waited to begin subtracting cancelled and unpaid enrollments until after open enrollment had ended). Compared with in-force enrollment as of June 2015, the enrollment total as of February 1 was nearly 33 percent higher.

Effectuated enrollment as of March 31, 2016 stood at 1,531,714 in the Florida exchange. 93.3 percent of Florida’s enrollees are receiving premium subsidies – higher than the nearly 85 percent average across the country. Among people who had a plan in the Florida exchange in 2015 and still have coverage for this year, 38 percent picked a different plan, while 62 percent kept their existing coverage for 2016.

Now that open enrollment for 2016 had ended, enrollment in individual 2016 health insurance plans (including outside the exchange) will only be possible if you experience a qualifying event (Native Americans can enroll year-round, as can applicants who are eligible for Medicaid or CHIP). Open enrollment for 2017 will begin on November 1, 2016, for coverage effective January 1, 2017.

Increased outreach = increased enrollment

There is still plenty of room to expand health insurance coverage in the Sunshine State. According to US Census data, the uninsured rate in Florida was 20 percent in 2013, and 16.6 percent in 2014 – among the highest in the country both years. By mid-2015, a Gallup survey indicated that the uninsured rate had fallen to 15.2 percent – still significantly higher than the national average.

During the 2016 ACA open enrollment period, the South-Florida, Miami-Fort Lauderdale metro area (Broward, Palm Beach, and Miami-Dade counties) was targeted by HHS for increased outreach and enrollment activities. The area still had an uninsured rate of 19.4 percent in 2014 (US census data) – far higher than the 10.4 percent national average at that point.

By February 1, enrollment through Healthcare.gov in the Miami-Fort Lauderdale metro area had reached 643,911 – by far the highest enrollment of any of the Designated Market Areas HHS tracked during the 2016 open enrollment period.

Legislation to end surprise balance bills

On March 11, 2016, lawmakers in Florida passed House Bill 221, and Governor Scott signed it into law in April. HB221 bans the practice of balance billing in situations (including non-emergency care) where the patient uses an in-network hospital or urgent care facility and “does not have the ability or opportunity to choose a participating provider at the facility” (for emergency care, insurers are simply required to cover treatment at in-network rates, regardless of whether the providers are in-network, and there’s no requirement that the patient not have been able to pick a different provider). The new rules take effect July 1, 2016, and HB221 is being called a model for other states that want to implement similar consumer protections.

Florida already prohibits balance billing for HMO members who receive emergency care or treatment at an in-network facility, but HB221 would provide similar protections for insureds who have PPO and EPO plans. HB221 was sponsored by six Republicans and two Democrats. Rep. Carlos Trujillo, a Miami Republican and one of the bill’s sponsors, has said that their goal was to “remove the consumer from the middle” of the billing process when hospitals contract with providers who aren’t in the same networks as the hospital. Rep. Trujillo also noted that he “can’t imagine a scenario” in which Gov. Scott would veto HB221.

Balance billing has become increasingly common as health insurance plans offer narrower networks, and it puts patients in the often impossible situation of needing to verify that every provider who will be treating them is in-network. Without HB221, it’s not enough to verify that the facility and primary doctor are in-network; assistant surgeons, radiologists, anesthesiologists, and durable medical equipment suppliers may be out-of-network, and the patients may not even realize that those providers are treating them.

Not surprisingly, radiologists and anesthesiologists were among those fighting against HB221 in Florida, claiming that it would force them to accept whatever payment the insurance companies wanted to offer them, despite the fact that they don’t have a contract with the carrier in question. But the legislation passed with support from both the Florida Association of Health Plans and the Florida Medical Association.

HB221 also requires hospitals to post names and links for providers who are in-network, and explain that the patient should take steps to ensure that treatment is being provided by in-network providers in order to avoid balance billing (note that HB221’s ban on balance billing in non-emergency situations only applies when a patient is treated by a non-network provider at an in-network facility, AND the patient wasn’t able to choose an in-network provider instead).

Cigna pulled out of exchange for 2016, planned to re-enter for 2017 but didn’t; Time and Preferred Medical also exited

Two weeks before the start of the third open enrollment period, Cigna announced that they would not offer plans in the exchange in Florida in 2016. At that point, they had about 30,000 enrollees in the Florida exchange, all of whom had to select coverage from a different carrier if they wanted to continue to be insured in the exchange in 2016. Cigna is continuing to offer plans outside the exchange, but no subsidies are available outside the exchange.

In August, when Florida regulators announced the approved rates for carriers in the state, Cigna was listed among the off-exchange carriers. I contacted the Florida Office of Insurance Regulation to clear up the discrepancy – how could a carrier pull out of the exchange when they were already listed as only offering plans outside the exchange several weeks earlier?

FLOIR explained that in August 2015, when the rates were being finalized, Cigna had already expressed concerns about their on-exchange business, and were still in the process of determining whether they would offer on-exchange plans in 2016. Of all the Florida carriers whose rates were finalized in August, Cigna was the only one where there was still uncertainty about whether they would offer plans in the exchange. So FLOIR listed them among the off-exchange carriers at that point, since the off-exchange market was the only one for which they were certain Cigna would participate.

In the weeks leading up to the start of open enrollment, there were carriers in several states that announced they would not participate in the exchanges for 2016. In most cases, the risk corridor payment shortfall was cited as a reason, but Cigna’s justification for leaving the exchange was somewhat unique: the carrier cited fraudulent billing by substance abuse clinics and labs in Florida. Cigna has said they didn’t realize how significant the fraudulent claims were until after the deadline to submit plans for 2016. Once they determined the scope of the problem, they made their decision to pull out of the exchange market for a year.

Cigna planned to re-enter the Florida exchange in 2017 with a new suite of plans available. They filed rates in the spring of 2016, but ultimately withdrew their on-exchange plans, are only offering off-exchange plans in Florida for 2017, for the second year a in a row.

Time announced in June 2015 that they would exit the health insurance market nationwide and are not offering plans for 2016.

Preferred Medical Plan exited the Florida exchange at the end of 2016, due to the risk corridor shortfalls that were announced in October 2015. With the lower-than-anticipated payments that carriers received through the risk corridors program, Preferred Medical Plan’s was forced to pull out of the exchange. In December 2015, the carrier noted that “CMS has maintained its position that Preferred Medical Plan not be allowed to participate on the [ACA exchange] due to the funding shortfall created by CMS not paying the Risk Corridor payment.” Preferred Medical Plan had about 75,000 Obamacare enrollees in 2015 in Miami-Dade and Broward counties, but they had to select new coverage for 2016.

2016 rates, now with oversight

For 2014 and 2015, Florida’s Insurance Commissioner was powerless to regulate proposed health insurance premiums, due to legislation signed into law by Governor Scott in 2013. But in 2015, for the first time since ACA-compliant plans debuted, Insurance Commissioner Kevin McCarty had the ability to challenge rates proposed by health insurance carriers.

19 individual market carriers in Florida submitted proposed rates for 2016 ACA-compliant plans, although ten of them (including Cigna) only offer plans outside the exchange for 2016. FLOIR has searchable rate filing data available on its site, but most of the carriers submitted their proposed rate hikes as “trade secrets” which means that they were not disclosed to the public unless they were above ten percent (prior to the start of open enrollment, Healthcare.gov’s rate review tool also only displayed proposed rate hikes of ten percent or more).

But the details were revealed on August 26, when FLOIR released final rates – along with the original proposals – for all 19 carriers. Just three of them had final approved rates the same as what they originally proposed. Of the remaining 16 carriers, final rates were lower than proposed for ten of them, and higher than originally proposed for the other six.

Ultimately, the weighted average approved rate increase in the individual market in Florida came out to 9.5 percent for 2016. For plans in the exchange, rate changes for 2016 varied from a decrease of 9.7 percent (Florida Health Care Plan, Inc.) to an increase of 16.4 percent (UnitedHealthcare of Florida, Inc.).

HHS released a report in October 2015 that showed average benchmark premium changes for 2016 (note that the benchmark plan is the second-lowest-cost Silver plan in a given area; it’s not necessarily the same plan from one year to the next). While changes in the benchmark premium are useful in terms of seeing how much subsidies will change, they’re not particularly useful from an individual insured’s perspective. But for what it’s worth, the average benchmark premium across Florida increased by just 1.2 percent in 2016. In the Miami metro area, according to a Kaiser Family Foundation analysis, the average benchmark premium decreased by 4.4 percent in 2016.

The fact that the average benchmark premium increased by just 1.2 percent statewide means that subsidies are only slightly higher in 2016 than they were in 2015 (in areas where the benchmark premium decreased, subsidies decrease as well). But overall premiums are 9.5 percent higher. That means subsidies didn’t necessarily keep pace with the increase in premiums across the state, unless insureds shopped around during open enrollment.

2015 enrollment numbers

Florida’s uninsured rate dropped to 15.2 percent in the first half of 2015, down from 22.1 percent in 2013. That’s certainly an improvement, although it’s still significantly higher than the 8.9 percent average uninsured rate in states that established their own exchanges and expanded Medicaid (Florida did neither).

Between Nov. 15, 2014, and Feb. 15, 2015, 1,596,296 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.

Some enrollees didn’t pay their initial premiums however, and others opted to cancel their coverage early in 2015. By the end of June, effectuated enrollment in Florida stood at 1,314,890 people. And while attrition is a natural part of the individual health insurance market, plan selections continued throughout the year, due to qualifying events and the tax season special enrollment period that Healthcare.gov offered during the spring (that was a one-time special enrollment period; it wasn’t offered again in 2016).

From February 23 to June 30. 2016, Florida led the nation in enrollments, with 160,828 people signing up for private coverage through the exchange. Almost half of them qualified for a special enrollment period due to losing other health insurance coverage, but more than 30,000 Florida residents enrolled as a result of the tax season special enrollment period. That means that they were uninsured in 2014, and found out about the penalty when they filed their tax return. Thanks to the special enrollment period, they aren’t on the hook for the full 2015 penalty (which is significantly higher than it was in 2014) when they file their 2015 tax return.

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).

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), 1.2 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 805,000. But in June 2015, 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 was obviously good news for the 1.2 million people in Florida who were receiving subsidies in 2015, but it was 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 had 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 preserved subsidies for 1.2 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 2015, Florida 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 19 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 in 2015, but funding had long been scheduled to end on June 30, 2015.

Scott sued CMS because the agency refused to renew Florida’s LIP funding, and Scott’s administration saw 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 May 2015, CMS notified Scott’s administration that Florida could still qualify for $1 billion in LIP funding for the 2016 fiscal year, although the state had 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. And a 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.

On June 25, 2015, 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 by the time the 2017 fiscal year begins in mid-2016, Florida’s LIP funding will be just 25 percent of what it was in the 2015 fiscal year.

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 2016 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 567,000 people in the state with no access to Medicaid or premium subsidies. And Florida would need far less money to cover uncompensated care 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 2016 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 Affordability Exchange Program (FHIX).

In June 2015, the Senate approved FHIX (Senate Bill 2) with a 33 to 3 vote. But the House defeated it, with a 72 to 41 vote. FHIX would have used the state’s existing Florida Health Choices exchange (more details below) to provide heavily subsidized coverage for people with income between 22 percent and 133 percent of the poverty level, using Medicaid expansion funding.

A special legislative session to address the budget convened on June 1, 2015, and lawmakers showed a willingness to work togetherr 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.

No expansion, but Medicaid enrollment grows

Despite the fact that Florida has not expanded Medicaid under the ACA, enrollment in the program continues to grow. The state has estimated that for the 2016 fiscal year that began on July 1, 2015, Florida’s Medicaid program will cover 4 million people, which represents a 6.6 percent increase over the 2015 fiscal year. Enrollment stood at 2.2 million a decade ago, and was at nearly 3.6 million by December 2015.

Florida will miss out on $66 billion in federal funding from 2013 to 2022 if it continues to reject Medicaid expansion. For states that do expand Medicaid, the federal government will pay the full cost of expansion through the end of 2016, and the state’s portion will gradually increase to ten percent by 2020, remaining at that level going forward.

In January 2016, President Obama proposed a plan to allow for full federal funding of Medicaid expansion for the first three years in each state, regardless of what years those are (ie, a state could expand in 2017 and receive full federal funding through 2019). However, Congress would have to approve that plan, and it’s highly unlikely that they’ll do so. At this point, it’s also unlikely that Florida will have expanded Medicaid in place at any point in 2016, meaning that if and when they do expand coverage, the state will have to pay a small portion of the cost from the start.

Florida’s other exchange: 712 customers by 2016, may shut down due to vetoed state funding

Florida Health Choices is the state’s own version of an online marketplace, but it does not offer any premium subsidies. 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. The state’s pseudo-exchange was engaged in a legal battle with HHS over efforts to trademark “Healthchoices, The Health Insurance Marketplace.”

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 (by 2016, Florida Health Choices was no longer offering prescription discount plans, due to lack of consumer interest).

In early January 2015, Florida Health Choices began offering health plans that were compliant with the ACA and covered the ACA s ten essential health benefits. Policies from four insurers were available in 2015: Assurant, Cigna, Humana, and UnitedHealthCare. For 2016, Assurant exited the health insurance market nationwide, but Cigna, Humana, and UnitedHeathcare continue to offer plans through Florida Health Choices (Cigna exited the Healthcare.gov exchange for 2016, but continues to participate in Florida Health Choices, which is technically “off-exchange”).

For 2016, Assurant exited the health insurance market nationwide, but Cigna, Humana, and UnitedHeathcare continued to offer plans through Florida Health Choices (Cigna exited the Healthcare.gov exchange for 2016, but continued to participate in Florida Health Choices, which is technically “off-exchange”).

For 2017, UnitedHealthcare exited the individual market in Florida, and their plans are no longer available on or off-exchange. Humana remained in some counties in Florida on HealthCare.gov, but dropped out of the Florida off-exchange market altogether, which means their plans are no longer available via Florida Health Choices.

AvMed, CoventryOne, and Cigna are offering coverage in Florida Health Choices in 2017.

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. As of February 2016, 91 percent of Florida residents who had coverage through Healthcare.gov were receiving premium subsidies.

The Florida Health Choices board of directors approved an $852,000 budget for 2015. Heading into the year, 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. During his unsuccessful 2016 presidential campaign, Marco Rubio distanced himself somewhat from Florida Health Choices, not mentioning it in his plans for repealing and replacing Obamacare.

By August 2015, Florida Health Choices had enrolled 150 people, and was reaching out to Realtors and professionals licensed by the state of Florida, offering them coverage through dedicated private exchanges. Naff noted that Florida Health Choices is aimed at people who earn too much money to qualify for premium subsidies, since those can only be obtained through Healthcare.gov in Florida. But Naff explains that Florida Health Choices can also help people enroll in Healthcare.gov if their income makes them subsidy-eligible.

By mid-2016, Florida Health Choices had 712 customers, according to the Jacksonville Times Union. In order to be self-sustainable, they would need at least 3,000 customers, so they are still reliant on state funding. However, Governor Scott vetoed $250,000 in state funding for Florida Health Choices in the 2017-2018 budget, and Florida Health Choices may end up being dissolved as a result.

2015 premiums up 7 percent

A Commonwealth Fund analysis shows Florida marketplace premiums increased 7 percent on average compared to 2014 rates. Nationally, premiums were flat from 2014 to 2015; however, that average masked 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 were:

  • $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 offered policies through the marketplace for 2015. Four of the insurers were new to the marketplace for 2015, according to Health News Florida.

Participating marketplace insurers for 2015 included 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: 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.

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 also 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 wanted to serve as a navigator. The state requirements were 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)

More Florida coverage

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