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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. 5.2% average rate hike for 2019, and Oscar has joined the exchange

Highlights and updates

Florida exchange overview

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

1,786,679 people enrolled in plans through the Florida exchange during the open enrollment period for 2019 coverage — by far the highest enrollment of any state in the country. Florida’s 2019 enrollment was an increase of about 4 percent over the prior year, when 1,715,227 people enrolled. Florida is one of just nine states where enrollment during the open enrollment period for 2019 plans was higher than it had been for 2018 plans.

Florida has had the highest exchange enrollment in the nation ever since the exchanges debuted in the fall of 2013. About 11.7 million people enrolled in exchange plans nationwide during open enrollment for 2018 plans, and 1.7 million of them (14.6 percent) were in Florida .

Individual market enrollment is particularly high in Florida. Charles Gaba of ACA Signups calculated that nationwide, an average of 6.4 percent of the population was covered by individual market plans, including on and off-exchange policies, in 2017. But in Florida, it was double the national average, at 12.7 percent. And in South Florida, it was nearly 20 percent.

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 starting in 2016, which further reduces private plan enrollment. Texas also has a higher population than Florida and has not expanded Medicaid, but exchange enrollment in Florida is far higher than in Texas.

Starting in 2018, premium subsidies in the Florida exchange are much larger than they were in 2017, making coverage for many enrollees more affordable than it was in the past. That’s because the cost of cost-sharing reductions (CSR) is now added to silver plan premiums in Florida, and the subsidies are based on keeping the after-subsidy cost of the second-lowest-cost silver plan affordable. This is described in more detail below.

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.

Open enrollment ended December 15, but residents in the panhandle who were affected by Hurricane Michael have until February 16 to enroll in a plan for 2019, and some insurers have extended off-exchange enrollment until December 31

Open enrollment for 2019 plans ended December 15 in Florida and all other states that use But there are 18 counties in the Florida panhandle that were deemed eligible for FEMA assistance as a result of Hurricane Michael, which hit the area in October 2018. CMS had initially granted affected residents in those counties a special enrollment period that continued until December 18 (so just three extra days after open enrollment ended). But the agency later issued additional guidance that allows affected residents in those counties another 60 days to enroll in a health plan for 2019.

In order to take advantage of the special enrollment period, affected individuals must call the exchange at 1-800-318-2596 or TTY at 1-855-889-4325.

Outside the exchange, insurers have the option to extend open enrollment as they see fit. In Florida, some insurers have chosen to do so for 2019 coverage. AvMed, Florida Blue, Health First, and Florida Health Care Plans have all extended open enrollment until December 31, 2018.

Oscar joined the Florida exchange for 2019; average rate increase across Florida’s individual market = 5.2%

Florida insurers that plan to offer coverage in 2019, both on and off-exchange, had to submit their rate and plan filings to the Florida Office of Insurance Regulation by June 20, 2018.

A few days later, the Florida Office of Insurance Regulation (FLOIR) published a list of the insurers that had filed to participate in 2019, and noted that the average proposed rate increase for 2019 was 8.8 percent. But after the rate approval process was completed, FLOIR announced that the final average rate increase would be just 5.2 percent. Blue Cross Blue Shield of Florida offers plans statewide, but all of the other insurers have localized coverage areas (this chart shows where each insurer’s plans are available).

  • Blue Cross Blue Shield of Florida (Florida Blue): 2.4 percent increase (the proposed average rate increase was 10.5 percent)
  • Florida Blue HMO (Health Options): 7.2 percent increase (the proposed average rate increase was 9.5 percent)
  • Florida Health Care Plan Inc. (FHCP is a subsidiary of Florida Blue): 5.6 percent increase (approved as proposed)
  • Ambetter (Celtic): 5.9 percent increase (slightly higher than the proposed 5.8 percent increase)
  • Molina: 1.5 percent DECREASE (Molina had proposed a 9.5 percent average increase)
  • Health First Health Plans: 9.8 percent increase (approved as proposed)
  • Oscar Health: New for 2019, so no applicable rate increase

A 5.2 percent average rate increase is far smaller than the average rate hikes that applied for 2018, but it’s also worth noting that the average increase would be even smaller — or perhaps even a decrease — if the Trump Administration and GOP lawmakers hadn’t acted to destabilize the individual insurance markets (ie, if the individual mandate penalty wasn’t being eliminated, and if regulations hadn’t been finalized to expand access to short-term plans and association health plans; these changes will result in fewer healthy people in the ACA-compliant risk pools and premiums that will be higher than they would otherwise have been).

The basic details of the rate filings are available on the federal rate review site and on FLOIR’s rate filing search system. But essentially all of the pertinent documents for each rate filing (ie, details about the rate changes and what’s driving them, as well as enrollment numbers and coverage areas) are marked “trade secret” in Florida, and not available to view.

Six insurers offered plans in the Florida exchange for 2018 (details below). One of them, Molina, was considering whether to continue to offer coverage in the exchange in 2019, after losing a bid to renew their Medicaid managed care contract in Florida. Molina submitted plans for 2019 individual market coverage and simultaneously appealed the state’s decision on the Medicaid contract. In June, the state granted Molina a continued Medicaid contract in two regions of the state, in response to the insurer’s appeal. And Molina’s individual market plans continue to be available both on- and off-exchange coverage in 2019.

So for 2019, there are seven insurers in the Florida exchange, with the addition of Oscar Health. Oscar is significantly increasing its exchange footprint in 2019, including an expansion into Florida, Arizona, and Michigan, as well as coverage area expansions in some of its existing states.

The 5.2 percent overall average rate increase for 2019 is calculated before premium subsidies are applied. Subsidies will grow to keep pace with premiums (specifically, to keep pace with the premium of the second-lowest-cost silver plan in each area), so subsidized enrollees are generally protected from premium increases, although plan changes are sometimes necessary to avoid a rate increase (all enrollees have the opportunity to switch plans during open enrollment, which runs from November 1 to December 15, with coverage changes effective January 1).

Cigna and Avmed are continuing to only offer plans outside the exchange in Florida. The approved rate increases for both insurers were lower than they had initially proposed — Cigna’s by quite a bit (10 percent, down from 30.2 percent).

Enrollment still by far the nation’s highest; declined in 2018, but increased to a record high for 2019

Open enrollment for 2019 health plans ended on December 15, 2018, although as noted above, residents in much of the panhandle can still enroll until February 16 if they were affected by Hurricane Michael in October.

1,786,679 people enrolled in plans through the Florida exchange during the open enrollment period for 2019 coverage — the highest enrollment the states has had since the exchanges debuted in the fall of 2013. Florida’s enrollment was by far the highest of any state in the country, and was an increase of about 4 percent over 2018’s enrollment, when 1,715,227 people signed up for coverage. Florida is one of just nine states where enrollment during the open enrollment period for 2019 plans was higher than it had been for 2018 plans, and one of just five states that saw record-high enrollment numbers for 2019.

2018 enrollment in Florida’s exchange was a drop of about 2.5 percent from 2017, when 1,760,025 people enrolled in private plans through the Florida exchange.

Nationwide, across all states that use, there was an average enrollment drop of about 5 percent in 2017, and roughly the same average drop again in 2018. But in Florida, 2017 exchange enrollment was 1 percent higher than it was in 2016, when 1,742,819 people enrolled. And although enrollment dropped in Florida in 2018, the decrease was smaller than the average across other states. And it rebounded for 2019 to the highest level it’s ever been.

The enrollment decline in 2018 (and in 2017, in most states) was attributed to confusion about the status of the ACA after a year of GOP repeal efforts, a much shorter open enrollment period (just over six weeks, instead of three months), and the Trump Administration’s decision to drastically reduce funding for exchange marketing and enrollment assistance in the weeks leading up to open enrollment. All of that continued to exist for 2019 — with the individual mandate officially eliminated after the end of 2018, a further reduction in federal funding for outreach and enrollment assistance, and the Trump Administration’s new rules that expand access to short-term plans and association health plans as alternatives to ACA-compliant coverage for healthy enrollees. And yet Florida’s exchange enrollment reached a record high for 2019.

91 percent of the Florida residents who enrolled in coverage during open enrollment for 2018 were receiving premium subsidies. For comparison, 83 percent of exchange enrollees nationwide were receiving premium subsidies.

Humana exited individual market at the end of 2017, other insurers remained in the exchange

Of the six insurers that offered coverage in Florida’s exchange in 2017 — seven if you count the two separate Florida Blue entities — only Humana opted to exit the exchange at the end of 2017 (this was true in every state where Humana still offered coverage in 2017). But Human only 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 had limited coverage areas (2017 coverage areas for each insurer are listed here). Florida Blue was 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 expanded coverage areas for 2018; Celtic expanded again for 2019 but Health First dropped back to four counties for 2019

Centene/Celtic/Ambetter already offered plans in the Florida exchange in 2017, but they expanded their coverage area for 2018. They offered plans in 17 counties in 2017, and that increased to 22 counties for 2018, with expansion into Alachua, Lake, Marion, Orange, and St. Lucie counties. And for 2019, Celtic is offering plans in 26 counties.

Health First offered plans in four counties in 2017, but covered five counties in 2018, with expansion into Seminole County. For 2019, they are back to four counties, offering coverage in Brevard, Flagler, Seminole, and Volusia counties (but no longer in Indian River County).

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

In June 2017, 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 The actuarial memos with the Florida filings were 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 would 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 needed to be considerably higher in that case. 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 represented an average increase of 44.7 percent (details below for each insurer). But FLOIR noted that 31 percentage points of that was “directly attributable” to on-exchange silver plans, which bear the increased premiums necessary to cover the cost of CSR. Not counting on-exchange silver plans, the average premium increase was 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 do 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 grew in 2018 to keep pace with the premium increases. 91 percent of Florida exchange enrollees are receiving premium subsidies (versus the nationwide average of 83 percent).

FLOIR noted 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 CSR].” 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. 64 percent of Florida exchange enrollees are receiving CSRs in 2018 (versus 54 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 continued to flow to insurers until late 2017 (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).

Ultimately, the Trump Administration cut off CSR funding in October 2017. Insurers in most states, including Florida, added the cost of CSR to premiums (in most cases, only to silver plan premiums, as was the case in Florida). The result is larger premium subsidies for the 91 percent of Florida exchange enrollees who qualify for premium subsidies. For the 9 percent who aren’t eligible for premium subsidies, the added cost of CSR could be avoided by selecting a non-silver plan for 2018.

Rates and plans for 2018

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

Open enrollment has ended, but plan changes and enrollments can still be completed by people who experience a qualifying event.

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 insurer 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 had 219,053 members in 2017, and expanded 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 offered plans in Brevard, Indian River, Flagler and Volusia counties in 2017; they expanded to also offer coverage in Seminole County in 2018. In 2017, they had 17,591 on-exchange members, plus 3,057 off-exchange. Filings didn’t show up on, but Health First plans were included in the approved plans that FLOIR announced in late September.

Premium subsidies became much larger in 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 (starting in 2018) 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 $1,051 per month in 2019. After that subsidy is applied, the cheapest plan available to them in the exchange is $116/moth 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 (it’s worth noting, however, that the lowest-cost plan would have been just $21/month for this family in 2018; although the premium subsidy amount is slightly larger for 2019 than it was for 2018, the lowest-cost plan is more expensive (pre-subsidies) than it was in 2018).

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 GOP efforts to repeal the ACA

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. The only part of the ACA that was repealed in 2017 was the individual mandate penalty (as part of the GOP tax bill that was enacted in December 2017), but the elimination of the individual mandate penalty doesn’t take effect until 2019.

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 wanted 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. Ros-Lehtinen announced her impending retirement in 2017 and did not run for re-election in 2018. Her successor, Dr. Donna Shalala, served as Secretary of Health and Human Services during the Clinton Administration.

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

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 continued to offer off-exchange coverage in Florida’s individual market in 2017, but exited 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 did not have any on-exchange plans for 2017. Cigna continues to only offer plans outside the exchange as of 2019.

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 continues to offer exchange plans in the other seven counties in 2017. Humana exited the individual market altogether, nationwide, at the end of 2017, however. Those seven counties in Florida no longer had 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 for 2017. In August 2016 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 2019. 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 2019).

  • 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.

Florida’s enrollment for 2016 was about 9 percent higher than it was during the 2015 open enrollment period. 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 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.

Effectuated enrollment as of March 31, 2016, stood at 1,531,714 in the Florida exchange.

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 took effect July 1, 2016, and HB221 is being called a model for other states that want to implement similar consumer protections.

Florida already prohibited balance billing for HMO members who receive emergency care or treatment at an in-network facility, but HB221 provides 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, 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.

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 have since only offered plans outside the exchange in Florida.

Time announced in June 2015 that they would exit the health insurance market nationwide and did not offer plans for 2016 or any subsequent years.

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.

State began overseeing rate changes in 2015

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 offered 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,’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 were only slightly higher in 2016 than they were in 2015 (in areas where the benchmark premium decreased, subsidies decrease as well). But overall premiums were 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.

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 offered during the spring (that was a one-time special enrollment period; it wasn’t offered again in 2016).

Florida’s high enrollment has been 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’s other exchange: 712 customers by 2016, no longer state-funded by 2017

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 continued to offer plans through Florida Health Choices (Cigna exited the 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, but dropped out of the Florida off-exchange market altogether, which means their plans were no longer available via Florida Health Choices.

Consumers who shop on Florida Health Choices can NOT obtain subsidies to help them pay for coverage. Those subsidies are available only through, the federally facilitated marketplace. As of 2018, 91 percent of Florida residents who had coverage through 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 in Florida. But Naff explains that Florida Health Choices can also help people enroll in 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 were 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 is no longer supported by state funding. The state was working to sell the domain name in 2017, and it’s still up as of 2018, with Florida Blue plans available.

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

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

Florida had the highest 2014 enrollment among states using 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 open enrollment period for 2014 plans.

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)

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.