January 31, 2016 marked the end of the 2016 open enrollment period, and 1,742,819 people 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 included some early attrition (in prior years, HHS waited to begin subtracting cancelled and unpaid enrollments until after open enrollment had ended, resulting in a relatively sharp drop-off in enrollment during the months following open enrollment). Compared with in-force enrollment as of June 2015, the enrollment total as of February 1 was nearly 33 percent higher.
91 percent of Florida’s enrollees are receiving premium subsidies – higher than the 85 percent average across the 34 states that use the federally-facilitated marketplace. 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. If signed into law by Governor Rick Scott, HB221 would ban the practice of balance billing in situations (including nonemergency 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 would 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.
If signed into law, HB221 will also require 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 pulls out of exchange
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 (FLOIR) 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 plans to re-enter the Florida exchange in 2017 with a new suite of plans available.
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, 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 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 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.
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
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 is 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.
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 has exited the health insurance market nationwide, but Cigna, Humana, and UnitedHeathcare continue to offer plans through Florida Health Choices (Cigna has exited the Healthcare.gov exchange, but will continue to participate in Florida Health Choices, which is technically “off-exchange”).
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.
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 now-defunct 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 notes 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.
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. Time announced in June 2015 that they would exit the health insurance market nationwide and are not offering plans for 2016. Cigna also announced in October 2015 that they would not offer plans in the Florida exchange in 2016.
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)