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What you need to know about Florida’s health insurance before you buy.

If you’re seeking affordable health insurance in Florida, let us show you the different factors influencing health care in your state and what you need to know when shopping for a plan. We’ll also examine the impact of the Affordable Care Act (ACA) on the state of Florida and tell you what you need to know about the law before moving forward with your decision.

Before we begin, here’s a glimpse of the overall climate of health in Florida:

  • In the 2015 America’s Health Ratings, the Sunshine State came in 33rd place in overall health. A prevalence of Salmonella along with a high percentage of uninsured adults contributed to Florida’s position on the list. Florida has not been in the top 25 at any point since the annual study began in 1990. 
  • The Commonwealth Fund’s Scorecard on State Health System Performance found that 24 percent of Florida adults ages 19-64 were uninsured, above the national average of 15 percent, placing Florida at a 50th-place ranking. 
  • Florida’s uninsured rate has dropped since the ACA’s individual mandate was passed.

While the drop in uninsured rates is promising in Florida, the uninsured rate is still above national average, and plenty of residents remain without insurance. If you’re among these residents, or looking to change your plan, you have plenty of options. So, where do you start?

Where to Buy Health Insurance in Florida

If you do not have health insurance benefits through an employer, you have options for health coverage:             

  1. Through a public or private marketplace
  2. Through a licensed agent in person or over the phone 
  3. Directly from an insurance company

You may also be eligible for assistance through Federal or state based programs, such as Florida KidCare for children. 

Buying Insurance on the Marketplace in Florida

Thirteen states have their very own Health Insurance Exchange (including the District of Columbia), or “marketplace.” Florida, however, is among the 38 states that does not have its own state exchange and instead partners with the federal government to offer health insurance through a marketplace. The marketplace is just like its name implies; it’s a place where anyone is free to shop for an insurance plan that meets their unique needs.

The marketplace works like this:

  1. Every Fall there is an open enrollment period, which typically lasts around 90 days. Prior to this time, customers are free to browse the marketplace and explore all of the different plan options offered by insurance companies. However, customers must wait until the first day of the open enrollment period to actually purchase any health plans.  
  2. Open enrollment is the only time of year that most Americans are able to purchase health insurance or make a switch from their current plan. In some cases, you may qualify for a Special Enrollment Period.
  3. All insurance supplied through the marketplace satisfies the requirements of “minimum essential coverage” as mandated by the ACA.

There are four main levels of plans available in the marketplace—platinum, gold, silver and bronze. These plan levels, often called “metal levels” vary based on their actuarial value. Actuarial value affects the amount you are responsible for paying in out-of-pocket expenses versus what your plan will pay (on average). While plans with lower actuarial values will often sport lower premiums, they are usually paired with higher out-of-pocket expenses (like copays and deductibles). When choosing a plan, it’s important to understand how deductibles will impact your premiums.

It’s equally important to ensure you are buying a Florida plan that is ACA compliant, meets your medical needs, and fits in your budget. If it all starts to get a bit confusing, don’t worry. We’re here to help.

Off-Exchange Insurance in Florida

There are some key differences between an off-exchange plan and a plan bought from the exchange.

  1. In addition to meeting the basic requirements set forth by the ACA, marketplace (or on-exchange) plans must also be considered qualified health plans (QHP), which must comply with an additional set of standards. These standards may exceed those of the ACA. Off-exchange plans must meet the ACA requirements but are not required to be qualified health plans. However, many insurance companies are choosing to offer certified QHPs both on and off exchange. In fact, many companies offer their most robust and coverage rich plans off-exchange.
  2. Unlike marketplace plans, off-exchange plans are not eligible for premium or cost-sharing subsidies. 
  3. The same policies that are sold both in the marketplace and off-exchange will be sold at the same price. However, not all plans sold in the marketplace will be available off-exchange and vice versa. Some insurance companies do not participate in the marketplace and only offer plans off-exchange. Insurance agencies that have a private marketplace, like HealthMarkets, includes both on- and off-exchange plans.

In some states, plans are cheaper off exchange, and in others, they are cheaper on exchange. Either way, an agent who is licensed to sell exchange policies should be able to help determine whether an on or off-exchange policy best meets your needs. 

Whether you choose to purchase your insurance on or off-exchange, the ACA has expanded options and improved quality of coverage (through mandates like guaranteed issue). Take your time to find the policy that makes the most sense for your unique needs. 

If you do qualify for a subsidy, it probably makes more sense to stick with the exchange since off-exchange plans aren’t eligible for subsidies. But what should you know about subsidies before moving forward?

Subsidies in Florida and Other Ways to Receive Help with the Cost of Health Insurance

Low to middle income individuals and families looking for coverage in the marketplace may be eligible for premium tax credits or cost-sharing reductions. These subsidies help reduce monthly payments as well as out-of-pocket expenses, like copays and deductibles. Below are some common questions asked by individuals looking for help with the cost of their health care. 

Do I have to wait until the end of the tax year to receive my premium tax credit?

No. A tax credit may be paid to the insurer in advance or as a lump sum when filing taxes in order to lower monthly payments on premiums for the customer. These subsidies are based on income level and are made available to those making between 100 percent and 400 percent of the Federal Poverty Level. The tax credit caps the cost of monthly premiums at no more than 9.5 percent of total household Modified Adjusted Gross Income.  

What’s the difference between a cost-sharing reduction and a premium tax credit?

While tax credits reduce the cost of health insurance premiums, cost sharing reductions do the same for out-of-pocket expenses like coinsurance, co-payments, and deductibles. These reductions are available to customers with Silver plans who make between 100 percent and 250 percent of the Federal Poverty Level.

Cost-sharing reductions are only available to individuals enrolled in a silver plan through the health insurance marketplace, while premium tax credits may be applied to any plan in the exchange or marketplace (aside from catastrophic plans). Because of this, premium tax credits are considered to be more flexible than cost-sharing reductions.

Can I still receive premium tax credits if I qualify for Medicaid?

Individuals with incomes between 100 and 138 percent of the poverty line who are eligible for Medicaid are not eligible for premium tax credits. They could qualify for premium tax credits if they are not eligible for Medicaid because their state hasn’t expanded Medicaid. Some limited Medicaid coverage is not considered “minimum essential coverage” and thus would not disqualify that individual from receiving premium tax credits.

How do I determine if I’m eligible for Medicaid in Florida?

Florida Medicaid provides health coverage for:

  1. Children up to 1 year old with a family income up to 206 percent of the federal poverty level (FPL)
  2. Children 1-5 with family income up to 140 percent of FPL
  3. Children 6-18 with family income up to 133 percent of FPL
  4. Pregnant women with family income up to 191 percent of FPL
  5. Young adults 19-20 with family income up to 30 percent of FPL
  6. People who qualify for Supplemental Security Income
  7. Adults with dependents with a family income up to 30 percent of FPL

The Affordable Care Act initially included a withholding of government funds to states’ existing Medicaid programs who did not expand Medicaid to cover adults with a household income of up to 138 percent of FPL. In 2012, the U.S. Supreme Court ruled that the decision to expand Medicaid should be left open to individual states and that the withholding of funds was unconstitutional. While Medicaid coverage has expanded in many states, Florida remains one of only a handful of states without expanded coverage under the ACA.

The Basics of the Affordable Care Act 

No matter which state you live in, you’re probably at least somewhat familiar with the Affordable Care Act, which is more commonly referred to by its nickname, “Obamacare.” The law was passed in March of 2010 and was seen as the largest overhaul to the American healthcare system in more than 40 years. 

What is Obamacare?

In short, the law requires the majority of Americans to have health insurance that qualifies as “minimum essential coverage.” This is defined by two factors:

  • Value. The plan must pay for at least 60 percent of medical expenses on average for a standard population.  
  • Affordability. Each employee’s premium contribution to the plan cannot exceed 9.5 percent of their household income.  

In addition to ensuring that all Americans have health insurance that is both affordable and valuable, there are a few additional benefits of the law:

  1. Americans now have access to a number of new benefits, rights, and protections.
  2. Individuals and families can no longer be denied coverage or required to pay more for plans based on gender, age, race, or health status.
  3. The ACA is expected to slow the growth of healthcare spending in the U.S. and reduce the deficit by more than $100 billion over the next 10 years.

What are the penalties for not enrolling in health insurance? 

Obamacare has an individual mandate that imposes a tax penalty on most people not enrolled in health insurance. Depending on things like income and family size, this penalty may come in the form of a flat fee or a percentage of income. The penalty is capped at the average price of the most affordable plan and only applies to full months without health coverage.

For example, a single person with no dependents in 2014 who makes $35,000 per year may face a penalty of $249 per month during their first year without coverage. The penalty would be paid when filing taxes and would increase each year thereafter.

Is anybody exempt from paying the penalty?

There are several exemptions to the penalty, including anyone who:

  1. Went fewer than three months without health insurance
  2. Has an income below the tax filing threshold and therefore does not have to file taxes
  3. Makes a household income in which any insurance coverage would cost more than 8 percent 
  4. Suffered a hardship that deems him or her unable to obtain coverage for financial or other reasons
  5. Has a recognized religious reason for not having health insurance
  6. Is a member of a recognized health care sharing ministry
  7. Is not lawfully present, such as an undocumented immigrant 
  8. Is incarcerated
  9. Is a member of a federally recognized Indian or Alaska Native tribe

People who experience a qualifying event can also enroll in a health insurance plan outside of the open enrollment period, a time known as a special enrollment period. Qualifying events include:

  1. Moving to a new state (or service area)
  2. Job loss
  3. Change in family size (marriage, divorce, death, birth of a child)
  4. Gaining membership in a federally-recognized tribe

Florida and The Affordable Care Act

The law has been especially impactful in Florida. Despite ranking fourth in population, Florida experienced the highest number of residents to sign up for health insurance through the marketplace during the 2015 open enrollment period. Between Nov. 14, 2014 and Feb. 15, 2015, about 1.6 million Floridians acquired insurance through the federal exchange, well over the one million that had been projected.

Florida’s population of uninsured residents measured 16.6 percent during 2014, a marked improvement from the 20 percent uninsured rate in 2013. Despite the progress, Florida remains one of the least insured states in the country.

Health Insurance for Florida’s Children

There are programs available to children that provide low-cost and even no-cost healthcare coverage for children in Florida. One is Medicaid and the other is CHIP, or the Children’s Health Insurance Program. 

In addition, there are state programs that operate through Florida KidCare that also provide affordable health insurance for kids. If you’re looking for help with your children’s healthcare, you do have options. However, you might be confused about which option is the best fit and whether or not you qualify.

What’s the difference between Medicaid, CHIP, and Florida KidCare?

CHIP and Medicaid cover things like checkups, immunizations, prescriptions, emergency services, and more. They are both public insurance programs that cover children and are jointly funded by state and federal money. 

CHIP is for uninsured children, ages 0-19, who have a family income too high for Medicaid. These income restrictions vary from state to state. 

Children ages 0-6 with a family income up to 133 percent of the federal poverty level (FPL), or children ages 6-19 with a family income up to 100 percent of the FPL, are eligible for Medicaid coverage.

Florida KidCare

Florida KidCare is a low-cost, high-quality health insurance program for children. With its four partners, it offers coverage for children ranging from birth to age 18 that meet certain eligibility requirements surrounding household income and citizenship. 

Health Insurance for Business Owners in Florida

If you’re a business owner in Florida, you know that compliance with the law is critical. And, failure to comply with the laws put in place by the ACA may result in penalties for many businesses. For business owners with less than 49 employees, it is not required by law for health insurance to be supplied by the employer.

Businesses with 50 or more full-time employees fall under Obamacare’s Employer Mandate. The mandate requires such employers to provide coverage to at least 95 percent of full-time employees and dependents up to age 26 or pay a penalty. 

If you’re self-employed, you must have basic health insurance coverage or pay a fee when filing your federal income tax return. You may qualify for an exemption for several reasons, including if coverage is unaffordable or against your religious beliefs.

What about coverage for dental and vision in Florida?

It is not required for health insurance companies in the marketplace to include dental or vision insurance, although you will find plans that do. And, employers are not required to offer such insurance either, with one exception. 

Basic pediatric vision and dental care is required on all plans that qualify as minimum essential coverage under the ACA.

Health Insurance and You

Health insurance is an investment of more than just a monetary value. You’re investing in your health and your future—making the right choice is critical. Under the new law, you have more options, and with more options come more decisions. Let us help you make the best one.

If you’d like to learn more, just pick up the phone and call HealthMarkets today at (800) 360-1402. We’ll walk you through the enrollment process to find the right plan for you. 


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