Miami-Dade County

Obamacare enrollment begins Saturday

Willem Muller and Kettely Mesidor listen as a representative of Sunshine Life & Health Advisors explains choices of coverage last year at the Mall of the Americas.
Willem Muller and Kettely Mesidor listen as a representative of Sunshine Life & Health Advisors explains choices of coverage last year at the Mall of the Americas. Miami Herald Staff

When consumers start signing up for 2015 health coverage under the Affordable Care Act on Saturday, they may feel overwhelmed by the number of choices available on the exchange: Insurers are offering 278 different health plans across Florida, including about 90 each in Miami-Dade and Broward counties, and 24 in Monroe.

For those who enrolled last year, healthcare experts are stressing the importance of re-selecting a plan — something most consumers don’t do — in order to avoid higher insurance costs and ensure that the plan still provides access to preferred hospitals and trusted doctors.

And since the health law calls for increases in premium contribution amounts, out-of-pocket limits and tax penalties in 2015, consumers should consider updating their annual income and other information in order to avoid unpleasant surprises, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation, a nonprofit focusing on national health issues.

“It’s a good idea for consumers to check in, see what’s being offered and what it costs, and make an active decision about whether to keep their current plan or change,” Pollitz said.

One change certain to affect nearly all consumers receiving federal financial aid — about 85 percent, or 6 million of the estimated 7.1 million Americans on the ACA exchange — is the amount of their government subsidy.

The U.S. Supreme Court announced last week that it would hear a challenge to the legality of subsidies offered through the federally run exchanges in 36 states, including Florida. A decision is not expected until spring at the earliest.

Pollitz cited a number of reasons why consumers will see a difference in the amount of financial help they receive next year compared to 2014, among them an adjustment to the federal poverty level for 2015.

But the biggest reason, she said, is a change in the cost of the second-lowest-priced mid-range plan in each county — the so-called “benchmark plan” used to determine the amount of financial help each consumer receives.

In Miami, the price of the benchmark plan for a hypothetical 40-year-old non-smoker earning $30,000 per year is scheduled to increase by 1.8 percent, from $269 a month in 2014 to $274 in 2015, according to a Kaiser analysis.

In 2014, that consumer would have received a government subsidy of $60 a month toward his premiums. However, because the price of the second-lowest-priced mid-range plan increased in 2015, so will that consumer’s subsidy — to $66 a month.

But that consumer will receive the higher subsidy only by updating his or her application for financial aid through the ACA exchange, and by re-selecting the correct benchmark plan, which may change from one year to the next.

If consumers neglect to update their health plan by Dec. 15, Pollitz said, those in states using the federally-run exchange at will automatically receive the same tax credit as they did in 2014.

“In most cases,” Pollitz said, “that amount will be a little bit wrong — too high or too low.”

About 91 percent of Floridians who bought a plan on the ACA exchange for 2014 received financial aid from the government, according to the U.S. Department of Health and Human Services. The average premium in Florida was $68 a month.

In order to avoid potential pitfalls when re-enrolling, and to find the plan that best fits their needs, consumers should seek in-person assistance from a trained professional, said Jodi Ray, director of Florida Covering Kids & Families, a program of the University of South Florida, which received a $5.3 million grant from HHS to provide in-person assistance for consumers.

The USF program will have about 160 so-called “navigators” across Florida’s 67 counties, including Miami-Dade and Monroe, where the Health Council of South Florida will act as a partner.

“The navigator can walk you through not just the costs of the plan but also what the benefits are, what drugs are covered, which hospitals and doctors you can visit,” Ray said, adding that many navigators have backgrounds in community outreach or healthcare.

One important date for consumers to keep in mind is Dec. 15. First-time consumers must sign up by that date for coverage starting Jan. 1.

That’s also the date by which returning customers must select a plan — or else they will be automatically re-enrolled in the same plan, or a similar plan if theirs is no longer offered for 2015. Those consumers also will be automatically re-enrolled with the same subsidy they received for 2014.

But even if consumers are automatically re-enrolled, they can change their plan up until the end of open enrollment on Feb. 15.

Eligible Americans who do not sign up by that date will be hit with penalties — 2 percent of annual income, or $325 per uninsured adult and $162.50 per uninsured child, whichever is greater.

Sabrina Corlette, a senior research fellow at Georgetown University’s Center on Health Insurance Reform, said it’s imperative for consumers to comparison shop.

State regulators calculate that the average premium for all health plans in Florida’s individual market will rise by 13.2 percent next year. But some insurers have reduced premiums in 2015.

“If you’re enrolled in a plan that had a big premium hike,” Corlette said, “then in all likelihood there’s a more affordable plan available.”

However, consumers should not buy plans based on the monthly price alone, said Maura Shiffman of the Health Council of South Florida.

“Sometimes the bottom-line price looks wonderful,’’ she said, “but when you actually start utilizing the services, you realize the out-of-pocket costs are very high or a doctor or specialist you trust isn’t in the provider network.”

Shiffman said the majority of her group’s navigators are bilingual in Spanish or Creole, part of a push to enroll minorities. Hispanic enrollment lagged behind that of other groups last year.

One significant challenge for navigators, insurance agents and others helping to enroll consumers for subsidized plans on the ACA exchange will be a lack of awareness. According to a Kaiser poll conducted in October, about 89 percent of uninsured consumers from 18 to 64 years old did not know that open enrollment would begin in November.

Consumers who enrolled for 2014 should expect a letter from their insurer informing them of changes to their premiums or plan benefits.

The federal government estimates that 83 percent, or about 5.9 million of the current 7.1 million enrollees nationwide will renew their ACA coverage.

Karen Egozi, CEO of the Epilepsy Foundation of Florida, said she was concerned by the lack of interest from consumers so far.

“Last year people were calling months ahead of time [for information],” said Egozi, whose Doral-based group received an $871,000 grant from HHS and will hire 96 navigators. “I don’t understand why it’s been relatively quiet with enrollment so close.’’

Navigators are not the only resources consumers can go to for help. Insurance brokers also are promoting their services — on billboards, fliers and other advertisements.

Last spring, as the enrollment deadline loomed, consumers formed long lines outside of Sunshine Life & Health Advisors, an insurance agency in the Mall of the Americas, off West Flagler Street.

Navigators and agents are certified by the federal government to help consumers, but there’s an important difference: Navigators are not allowed to make recommendations about what plan a consumer should choose.

Cameron Girouard, chief compliance officer at the Health Benefits Center of Hollywood, an insurance agency, said that’s a disservice to consumers.

“That’s one of the reasons we’re telling consumers that they should choose us over a navigator,” she said. “We have the freedom to help the consumer figure out what’s in their best interest.”

Insurance agents also receive a commission from the company whose plans they sell, though — an incentive that navigators are quick to point out.

“There’s no financial gain for navigators to enroll consumers in any one plan,” said Ray of USF.

With dozens of plans offered in Miami-Dade and Broward, consumers will choose from different tiers or “metal levels” of plans.

There are a few important things consumers should keep in mind, including their total out-of-pocket costs, such as deductibles and co-payments, and their anticipated healthcare needs, said Carrie McLean, director of customer care for eHealth Insurance.

Typically, plans with higher monthly premiums offer lower out-of-pocket costs — providing better value for consumers with chronic health conditions or those who anticipate costly medical treatment.

Of the plans sold on the ACA exchange for 2014, the most popular type selected by Floridians was the silver or mid-range plan, which was selected by nearly three of four consumers.

Follow @MHhealth for health news from South Florida and around the nation.

This article was produced in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Need help signing up Saturday?

Latino Enrollment Event: Palmetto General Hospital, 2001 W. 68th St., Hialeah, 10 a.m. to 2 p.m.

Community Health of South Florida Event: Doris Ison Health Center, 10300 SW 216th St., Miami, 8:30 a.m. to 4 p.m.

Healthy Living Event: Raymond Oglesby Preserve, 3115 SW 52nd Ave, Pembroke Pines, 10 a.m. to 3 p.m.

Consumers can visit or call 800-318-2596 to find assistance in their area.

Important enrollment dates

Nov. 15: Open enrollment begins. Consumers can start signing up for coverage.

Dec. 15: Consumers must sign up by this date to receive coverage starting Jan. 1. They are also required to pay the first month’s premium before coverage begins.

Jan. 15: Consumers must sign up by this date to receive coverage starting Feb. 1.

Feb. 15: Open enrollment ends. Consumers must sign up by this date to receive coverage starting March 1. Eligible consumers who miss this deadline will face financial penalties.

Terms to know

Premium: The monthly price you pay for your insurance. It can be reduced with a tax credit from the government depending on your income.

Deductible: The amount you have to cover on your own before your insurer starts to pay. Your premiums do not count against your deductible. Some plans have a separate deductible for prescription drugs.

Network: A list of health providers (doctors, hospitals, clinics, etc.) approved to deliver services by your insurer. You will pay more to visit out-of-network providers.

Essential health benefits: The 10 services your insurer must provide. These include outpatient care, emergency room visits, preventative care such as vaccines and screenings, mental health and substance abuse services, and maternity and newborn care.

Out-of-pocket maximum: The Affordable Care Act caps the amount consumers must pay each year for their health costs at $6,600 for individuals and $13,200 for families. Your insurer must pay any costs above this limit. The out-of-pocket maximum does not include premiums, out-of-network costs or spending on non-essential health benefits.

Co-pay: A fixed amount you pay for covered services, such as a doctor’s visit or blood test, when you receive the service.

Co-insurance: The percentage of covered services you must pay for after you meet your deductible. Plans with lower monthly premiums tend to have higher rates of “cost sharing” like co-pays and co-insurance.

Cost-sharing reduction: If your annual income is between 100 and 250 percent of the federal poverty line (between $11,670 and $29,175), you may be eligible for significant reductions in your out-of-pocket maximum and cost-sharing responsibilities. This reduction is only available for silver-level plans.

Formulary: A list of prescription drugs covered by your health plan. Insurers often keep their drugs on different “tiers.” The higher the tier, the more expensive the drug. People taking prescription drugs should check what tier their medications are on before signing up for a plan.

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