Florida ACA ON Marketplace Health Plans

The process can be overwhelming for many consumers that do this just once a year.  But when you use an agent, they can make the process much easier.  Here is what you can expect:

1. Gather information to start research:  Ages of those to be covered, household size, zip code/county, projected household income for next year, a list of your doctors and medications.
2. Retrieve an estimate of your subsidy eligibility based on age, income, and household size.
3. Analyze health plans available in your county based on this new lower subsidized price and plan benefits.
4. Make sure your doctors and medications are IN THE NETWORK and on the respective drug formulary list.  Use links in the right column.  Or use a new doctor matching to network tool here at Plan Compass
5. Pick an application method:  You can choose to use a web broker, an insurance carrier, and the government website or phone center to complete your transaction.
6. Fill out your household and income information and receive a determination letter with your results of being awarded either subsidies or lower deductible plans, or both.
7. Select the amount of subsidy you want to use, and pick the plan you’ve already decided upon.
8. Healthcare.gov sends a file to the carrier and uploads into their system.  The carrier then generates a bill, that needs to be paid immediately upon receipt to “activate” your policy, and get a medical card in the mail.
9. Lastly, once all of that is in place, send in or upload any follow up documentation requested by the government within 90 days (if applicable).  Examples include proof of projected income and citizenship.
10. Stay on top of any communication from the carrier or the Marketplace with any changes or requests.

In short, if your income is low enough to qualify for financial assistance in the form of premium and deductible subsidies. If you qualify, you must buy your health plan “ON the Marketplace” in order to get these subsidies or advanced premium tax credits (APTC)  to lower your monthly health insurance premiums.  APTC is determined by your modified adjusted gross income (MAGI), your household size, and how that relates to the Federal Poverty Level (FPL) guidelines.  In Florida, if you’re between 100% – 400% of FPL, then you may be eligible for APTC.

In addition, if between 100% and 250% of FPL, you’re also eligible to buy a Cost Sharing Reduction (CSR) plan with reduced deductibles and out of pocket maximums.  In order to receive these additional benefits, you must buy a Silver Level plan.

First, you must not have access or coverage through other entities like you or your spouse’s employer group health plan, Medicare, Medicaid, or the VA.  Basically, you must be in a position that you need to buy your own health insurance.  Of course, there are exceptions to every rule. Examples of people who may be eligible for subsidized Marketplace coverage would inclue:  The self-employed, pre-retirees, employees of small companies who don’t offer group insurance, small business owners, and the temporarily unemployed.

Second, your income has to be above 100% FPL and below 400% FPL in Florida.

Third, other factors including your age(s), household size, county of residence, and what is called the Second Lowest Cost Silver Plan (SLCSP).  This SLCSP is the baseline for which all tax credits are calculated. You can quickly see if you’re eligible for subsidies using our web broker link, or the Kaiser Subsidy Calculator.

“Subsidies”, technically known as Advanced Premium Tax Credits (APTC), that you may be eligible for, are sent directly from the IRS to the insurance carrier that you choose, each month, which lowers your insurance premium.  You pay the additional amount each month to make up the difference for the full premium required.  The dollar amounts that people receive can range between $0 a month to over $1200 a month.  It all depends on your situation. The older you are, and the lower income you receive, creates a scenario for the highest amount of tax credits to offset the large premiums. How much you ultimately receive depends on:

1. The age(s) for everyone on the policy.
2. Number of people in your tax household.
3. The County where you reside in your state.
4. The Second Lowest Cost Silver Plan (SLCSP) in your county.
5. Your household projected income or Federal Poverty Level (FPL)>

All subsidies / tax credits (APTC) that you receive in advance are subject to a “claw-back” at the end of the year when you file your taxes, and you “reconcile” those tax credits.  If your income is higher than you initially projected, you could be subject to paying back some or ALL of that tax credit.  Be very careful not to go over 400% FPL, as there is no maximum on the amount that can be “clawed” back.  If income comes in lower, you may be eligible for an additional refund.  In fact, some people request for a lower amount of tax credits to be used each month than they were initially awarded. Instead, they pay a higher monthly premium, with the hopes of eventually getting the tax credit in the form of a refund when they reconcile and file their taxes.  Consumers who choose this method can afford the higher monthly cost, and typically have volatile or inconsistent income, or near the 400% subsidy claw-back cliff.

Many Florida health care consumers don’t realize or take advantage of the incredible benefits afforded to those with income between 100% and 250% of Federal Poverty Level (FPL).  In addition to receiving subsidies / tax credits (APTC) to lower the premium each month, you may also be eligible for a “free upgrade” to a Platinum or Gold actuarial valued plan and experience much lower deductibles, copays and out of pocket maximums.  These are called Cost Sharing Reduction (CSR) plans.

BUT, you must buy a Silver Plan to receive these benefits.  A Silver PLan typically represents a 70% Actuarial Value (AV) plan.  Gold is 80% and Platinum is 90%. The most comprehensive plan that anyone can buy is a 94% AV CSR Plan.

In Florida, if you are between 100% and 150% of FPL, then you are eligible for the richest upgrade to a 94% AV CSR Plan. I’ve seen out of pocket maximums on these plans as low as $500 to $1000 a year.  If you are between 150% and 200% of FPL, then you receive the second best upgrade to a 87% AV CSR plan, which is between a Gold and a Platinum AV Plan.  This is still an incredible plan at Silver Plan subsidized prices.  Out of pocket maximums that I’ve seen are between $1100 and $2500 a year. Lastly, if you are between 200% – 250% FPL, then you qualify for the 73% AV CSR plan.  Since the increase is just 3% above the typical 70% Silver Plan, this CSR plan does not make a large impact on plan benefits. As always, it’s best to call me for the best advice, as everyone is in a different situation.

A major hole in the law was exposed to consumers with household income under 100% of Federal Poverty Level (FPL) in Florida, after the Supreme Court ruled that individual states can not be forced into expanding Medicaid to childless adult residents between 0% and 138% FPL.   Florida was among about 20 states that elected NOT to expand Medicaid creating a void or Medicaid “hole” for many residents in this income range of 0% – 138% FPL.

BUT, the ACA law also contained verbiage that allows subsidies for those with income between 100% to 400% of FPL, sparing those between 100-138% of FPL, with massive financial assistance to buy private health insurance in Florida through the Health Insurance Marketplace.

Unfortunately, if the combined income for your household size is below 100% of FPL, then you are NOT eligible for financial assistance / subsidies, reduced deductible plans or Medicaid.  You are eligible to buy a health plan, but would have to pay the entire premium amount.  Not to worry, your income should be low enough to allow you to get an exemption from having to buy coverage or pay any penalties.

Yes, you can apply online yourself.  I get it, some people like to do things themselves (or, don’t want to talk to a perceived “salesperson”). But, you shouldn’t make it harder on yourself.  Leverage the technology provided to us by private entities (web brokers) who integrate with the government website healthcare.gov.

We appreciate your consideration in using our web broker link if you found this website useful.

Otherwise, you can go directly to healthcare.gov.