Florida exchange overview

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

Open enrollment for 2021 health plans will begin November 1, 2020 and continue through December 15, 2020. But Florida residents with qualifying events can still enroll or make changes to their coverage for 2020. Especially in light of the COVID-19 pandemic that is causing so many people to lose their jobs — and their job-sponsored health insurance — it’s important to understand that losing the health plans you had at work counts as a qualifying event. This is true regardless of whether you’re offered an option to continue your plan with COBRA (and it’s true even if you accept the COBRA offer; you still have the full 60 days to select a plan in the individual market if you prefer that option).

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 — despite the fact that two-thirds of Florida voters support Medicaid expansion.

Florida’s exchange enrollment each year is by far the highest of any state in the country — almost 17 percent of the entire country’s exchange enrollees are in Florida. 1,913,975 people enrolled in plans through the Florida exchange during the open enrollment period for 2020 coverage. That was more than a 7 percent increase over the year before; Florida was one of only 11 states that use HealthCare.gov that saw higher enrollment for 2020 than they’d had for 2019. And Florida was one of just nine states where enrollment during the open enrollment period for 2019 plans was higher than it had been for 2018 plans.

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.

Florida’s individual market is actually larger than both the small group and large group commercial insurance markets in Florida, although some small group and a significant portion of large groups (including a large majority of very large groups) self-insure, so their numbers are not counted among commercial insurance enrollment totals.

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 became 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.



2020 rates and plans: Overall average rates unchanged in the individual market

Florida already had a fairly robust individual insurance market, and it got more robust in 2020. Bright Health joined the Florida exchange for the first time as of 2020, and Cigna rejoined the exchange in some areas of the state, after exiting the exchange at the end of 2015.

The Florida Office of Insurance Regulation announced in June 2019 that insurers in the state’s individual market had proposed an overall average rate increase of 1.2 percent for 2020, but without details for each insurer. And although the state has a rate filing database, nearly all of the pertinent documents are considered trade secrets in Florida, and are thus not available to the public.

As of mid-August, rate filings were only available on the federal rate review site for four of Florida’s individual market insurers. But the following week, the Florida Office of Insurance Regulation announced that the final approved average rate change in the individual market would be 0 percent for 2020. There’s significant variation from one plan to another however; some saw modest increases while others saw modest decreases:

Ambetter (Celtic): 1.9 percent increase (plans available in 30 counties for 2020, including expansion into four new counties

Molina: 2.9 percent DECREASE (the second year in a row with decreasing premiums for Molina)

(the second year in a row with decreasing premiums for Molina) Health First Health Plans: 8.8 percent DECREASE

Oscar Health: 2.9 percent increase expanded into Daytona, Miami, Ocala, and Tampa for 2020)

Blue Cross Blue Shield of Florida (Florida Blue): 2 percent DECREASE

2 percent DECREASE Bright Health Insurance Company: (New to Florida for 2020, so no applicable rate change)

(New to Florida for 2020, so no applicable rate change) Cigna: 8.4 percent DECREASE (rejoined the Florida exchange for 2020, after switching to off-exchange-only plans starting in 2016)

8.4 percent DECREASE (rejoined the Florida exchange for 2020, after switching to off-exchange-only plans starting in 2016) Florida Blue HMO (Health Options): 0.5 percent increase

0.5 percent increase Florida Health Care Plan Inc: 4.2 percent increase (FHCP is a subsidiary of Florida Blue)

Avmed Inc. only sells plans outside the exchange. Their average rate change for 2020 was a 15 percent decrease.

Enrollment still by far the nation’s highest; increased to a record high for 2020

A record number of people — 1,913,975 — enrolled in plans through the Florida exchange during the open enrollment period for 2020 coverage. Florida’s enrollment was by far the highest of any state in the country, and was an increase of more than 7 percent over 2019’s enrollment.

Nationwide, across all states that use HealthCare.gov, 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. And although enrollment dropped in Florida in 2018, the decrease was smaller than the average across other HealthCare.gov states. It rebounded for 2019 to the highest level it had ever been, and then grew again, substantially, for 2020.

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, and again for 2020.

Florida’s exchange has led the nation in enrollment numbers ever since the exchanges began operation. Florida enrollment during previous open enrollment periods was as follows:

2014 coverage: 983,775 people enrolled

2015 coverage: 1,596,296 people enrolled

2016 coverage: 1,742,819 people enrolled

2017 coverage: 1,742,819 people enrolled

2018 coverage: 1,760,025 people enrolled

2019 coverage: 1,786,679 people enrolled

2020 coverage: 1,913,975 people enrolled

2019 legislation: Weak pre-existing condition protections (in case Florida is successful in overturning the ACA) and the elimination of Florida’s modest restrictions on short-term plans

In 2019, Florida enacted legislation (S.322) that initially began as an effort to ensure that people with pre-existing conditions would have access to at least some health plans in the state’s individual market if the ACA were to be repealed or overturned. But it was amended to include a provision that removed the state’s existing (but fairly weak) limitations on short-term health plans.

And it also directed the state to consider whether it should modify its benchmark plan for essential health benefits under the flexibility that CMS now allows (all essential health benefits are still required to be covered; only two states, Illinois and South Dakota, have thus far made modifications to their benchmark plans under the new rules). The Florida Office of the Insurance Commissioner analyzed the benchmark plans in other states compared with Florida’s and ultimately recommended that no changes be made to Florida’s benchmark plan.

Although S.322 does include a modest guaranteed-issue requirement that would take effect if the ACA is repealed or overturned by the Supreme Court. But it only requires each insurer to offer at least one guaranteed-issue plan, and there are no restrictions in terms of how much insurers could charge for that plan.

It’s also noteworthy that Florida is one of the states that is actively working to get the ACA overturned in the Texas v. U.S. lawsuit. Together with 17 other GOP-led states, Florida is arguing that the ACA should be invalidated, and a judge agreed with them in late 2018. The case was appealed in 2019, with oral arguments heard by the U.S. Court of Appeals for the 5th Circuit. A ruling was issued in late 2019, but it essentially amounted to a delay, as the case was sent back to the lower court.

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

Florida insurers that planned 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)

: 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)

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)

(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)

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)

1.5 percent DECREASE (Molina had proposed a 9.5 percent average increase) Health First Health Plans: 9.8 percent increase (approved as proposed)

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 hadn’t been eliminated as of 2019, and if regulations hadn’t been finalized to expand access to short-term plans and association health plans; over time, 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 2018, 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 significantly increased its exchange footprint in 2019, including an expansion into Florida, Arizona, and Michigan, as well as coverage area expansions in some of the states where coverage was already being offered.

The 5.2 percent overall average rate increase for 2019 was calculated before premium subsidies are applied. Subsidies grew 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.

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)..

Historically, Florida’s individual market has experienced the following average rate changes each year:

2018: Average increase of 44.8 percent, mostly due to the assumption (which was correct) that cost-sharing reduction funding would end. This is described in more detail below.

2017: Average increase of 19.1 percent.

2016: Average increase of 9.5 percent

2015: Average increase of 13.2 percent (although a Commonwealth Fund analysis shows Florida marketplace premiums increased 7 percent on average compared to 2014 rates).

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. Since then, Florida’s Insurance Commissioner has continued to regulate premiums in the state.

Florida Blue requires agents to be captive. Oscar sued to prevent this, and a judge dismissed the case. Oscar has appealed the decision.

Oscar entered Florida’s individual market in Orlando in 2019, and expanded to several other cities in 2020. Soon after the start of open enrollment for 2019 coverage, Oscar filed a lawsuit in an effort to eliminate Florida Blue’s exclusive agent clause. In most markets, licensed insurance producers can be appointed with numerous insurers, offering their clients an array of plan options and helping them determine which one best fits their needs. But Florida Blue’s contract with insurance agents requires them to be captive—they cannot sell other insurers’ policies, and must only represent Florida Blue. And after Oscar entered the market in Orlando, Florida Blue required agents to sign new exclusivity contracts.

In describing this tactic, Oscar noted that “Florida Blue is using its monopoly power to make sure consumers do what’s best for Florida Blue” (as opposed to doing what’s best for the consumer).

Florida Blue acknowledged that they do indeed have an exclusive agent clause in their contracts, but defended it as a legitimate marketing strategy. Florida Blue claims that exclusive agent contracts are common, while Oscar says this “anti-consumer, anti-competitive” requirement is “exceedingly rare.” For what it’s worth, we’re not aware of other big-name on-exchange insurers with captive agent clauses.

In April 2019, the US Department of Justice officially sided with Oscar. But although a captive agent clause is clearly at odds with the ACA’s one-stop-shopping approach to individual market health insurance, HealthCare.gov’s insurer contracts do not prohibit insurers from having captive agent clauses, and the website notes that while brokers represent multiple insurers, “agents may work for a single health insurance company,” and both can provide assistance with enrollments through HealthCare.gov.

In September 2019, US District Judge Paul Byron dismissed Oscar’s lawsuit (after ruling earlier in the year that Florida Blue could continue to use agents to sell policies while the case made its way through the legal system). Byron ruled that Florida Blue’s exclusivity contract with agents is lawful and not coercive (Oscar and the Department of Justice had argued that it is coercive, as agents risk losing commissions and the ability to sell any of Florida Blue’s lines of business statewide if they sell other insurers’ plans in any areas of the state).

Oscar filed an appeal in mid-October, so the case could still result in an eventual change to Florida Blue’s captive agent rule. But for now, Florida Blue can continue to require its agents to only sell Florida Blue plans; these agents are not allowed to present their clients with any other plan options, even if another plan would be a better fit for the client’s situation.

People in Florida can use an enrollment assister or a broker (HealthCare.gov’s “find local help” tool can be used to show all brokers/agents and assisters who are certified with the exchange), but should be aware that if a broker is showing them Florida Blue plans, they might be missing out on seeing other options. And conversely, if a broker is showing them other options but not Florida Blue, they might need to contact a different broker or assister in order to see the Florida Blue plans.

Oscar enrolled 31,000 people in Orlando in 2019, and expanded into Daytona, Miami, Ocala, and Tampa for 2020. Florida Blue has more than a million enrollees in ACA-compliant individual market plans.



2018 rates: Florida 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.

Florida regulators asked insurers to file backup rates that would apply if CSR funding were to be 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).

In addition, one Florida 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.”

Overall, the rates that Florida regulators approved represented an average increase of 44.7 percent. 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 were receiving premium subsidies in 2018, 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 were 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.



How insurer participation in Florida’s exchange has changed over time

As is the case in most states, insurer participation in Florida’s exchange has changed considerably over time. Here’s a summary:

Cigna exited at the end of 2015 (but plans to rejoin for 2020)

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 continued to offer plans outside the exchange (and that’s still the case as of 2019), but no subsidies are available outside the exchange.

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 had 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. But as noted above, they have indicated plans to rejoin the exchange for 2020, although the exact coverage area has not yet been specified.

Time/Assurant exited at the end of 2015

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

PMP was not allowed to offer plans as of 2016, due to financial concerns stemming from risk corridor shortfall

Preferred Medical Plan also exited the Florida exchange at the end of 2015, 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

UnitedHealthcare 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 exited at the end of 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.

Humana reduced coverage area for 2017, exited entire individual market at the end of 2017

Humana scaled back their exchange participation across the country for 2017, and left the individual market as of 2018. They remained in the Florida exchange in 2017, 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 continued to offer exchange plans in the other seven counties in 2017. However, Humana exited the individual market altogether, nationwide, at the end of 2017.

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).

Insurer participation grew in 2020

For 2020, Bright Health joined the exchange in Florida, and Cigna rejoined the exchange. The trend towards increased insurer participation in 2019 and 2020 mirrors a national trend, as the individual market has once again become profitable, after significant financial losses in the early years of ACA implementation

Grandmothered and grandfathered plans

Florida is one of the states that has allowed grandmothered/transitional health plans to remain in force through 2020. In October 2018, the Florida Office of Insurance Regulation (FLOIR) published a report indicating that there were still 151,605 people with transitional individual market coverage in the state—down from 236,701 in 2015.

Florida has also noted that more than half of the 523,000 people enrolled in small group plans in the state are covered under transitional small group plans. So the termination of transitional plans (if it’s ever required to happen) would be more disruptive in the small group market than in the individual market (where the vast majority of enrollees are already covered under ACA-compliant plans).

But 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 less robust (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, unless the federal government allows another extension). 58,192 people were enrolled in grandfathered individual market plans in Florida as of 2017.

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).

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 Marco Rubio, who was the Florida House Speaker at that point, 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 Healthcare.gov exchange for 2016, but continued to participate in Florida Health Choices, which is technically “off-exchange”).

For 2017, UnitedHealthcare exited the individual market in Florida, and their plans are no longer available on or off-exchange. Humana remained in some counties in Florida on HealthCare.gov, but dropped out of the Florida off-exchange market altogether, which means their plans 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 HealthCare.gov, the federally facilitated marketplace. As of 2018, 91 percent of Florida residents who had coverage through Healthcare.gov were receiving premium subsidies.

The Florida Health Choices board of directors approved an $852,000 budget for 2015. Heading into the year, Naff was quoted in the Miami Herald saying, “I’d be tickled pink if we got 1,000 people.”

During the 2015 open enrollment period, 42 people bought health insurance plans through Florida Health Choices. By mid-April, it had 80 paying customers. During his unsuccessful 2016 presidential campaign, Marco Rubio distanced himself somewhat from Florida Health Choices, not mentioning it in his plans for repealing and replacing Obamacare.

By August 2015, Florida Health Choices had enrolled 150 people, and was reaching out to Realtors and professionals licensed by the state of Florida, offering them coverage through dedicated private exchanges. Naff noted that Florida Health Choices was 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 explained that Florida Health Choices could also help people enroll in Healthcare.gov if their income made 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 needed 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, but it was still up as of 2018, with Florida Blue plans available. By 2019, the website was still up, but no plans appeared to be directly for sale through it.

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

HealthCare.gov

800-318-2596

Covering Florida

Navigator organization providing outreach and free enrollment assistance throughout the state

(1-877-813-9115)

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 healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.