Making Sense Of The Health Insurance Exchange: Florida Blue

Oct 23, 2013

With health insurance exchanges now open across the country, including here in Florida, there are still questions as to if and how people can get and maintain coverage using the exchanges.

WJCT asked local health care experts for their advice given four potential scenarios for people who may be eligible for coverage under the Affordable Care Act.

Florida Blue, Florida’s Blue Cross and Blue Shield company, has approximately 4 million health care members and covers 15.5 million people in 16 states through its affiliated companies.

Florida Blue is a not-for-profit, policyholder-owned, tax-paying mutual company. Headquartered in Jacksonville, it is the only company offering health plans in the state's online health exchange in all 67 Florida counties.

We asked Florida Blue what they would tell the following four people about enrolling using the state's health exchange given their current health coverage and other factors.

1) "Julie"

  • 43-year-old woman
  • Currently has insurance through her employer
  • Taxable income of $55,000
  • Married, with two children
  • Lives in Jacksonville, Duval County

Florida Blue: For Julie’s coverage through her employer, nothing much is changing. They will still be offering her health insurance that includes family coverage. Since her employer offers her health coverage, she most likely isn’t eligible for help from the government, such as a premium tax credit (also called a subsidy) or a cost sharing reduction for medical care costs.

New employer health plans must now include things like:

  • Pediatric dental and vision care for kids up to age 19
  • Plans include ‘essential health benefits’ like hospital stays, prescription drugs and lab tests • No preexisting condition exclusions
  • Maximum 90 day waiting period for coverage to be effective for new employees • No dollar lifetime maximums or annual dollar limits for essential health benefits
  • Out-of-pocket maximums limited to $6,350 for an individual and $12,700 for a family each year

Julie will be able to contribute up to $2,500 for Flexible Spending Account contributions, to help pay for things like braces and doctor visits. Plus her family will be able to take advantage of routine physicals, immunizations, and well-child visits at no cost, which can really help them stay healthy and help the family budget.

2) "John"

  • 25-year-old man
  • No health insurance
  • Taxable income of $30,000
  • Lives in Miami, Miami-Dade County

Florida Blue: John’s taxable income from his IT job is $30,000 a year. For a single person, if their income falls within $11,490 to $45,960, they’ll qualify for premium tax credits to apply toward their health plan premiums in 2014. The exact amount of the tax credit (or subsidy) will depend on the estimated household income, family size and ages, the county where they live, and the premium cost for the second-lowest cost Silver plan in his county. Due to his tax credit, John will be able to save money on a health plan that is offered through the Marketplace – whether he works one-on-one with an agent to buy a plan or goes directly to the Marketplace.

Some things that might make John a little more interested in getting a health plan are:

  • Preventive care like routine physicals, including blood work, and immunizations are provided at no cost, so it is easier for him to stay healthy and active
  • "Essential health benefits" like hospital stays, prescription drugs and lab tests that come with every new health plan, no matter which one he chooses
  • No dollar lifetime maximums or annual dollar limits on essential health benefits – so he is protected from high medical costs if he breaks a leg surfing

Another option for John is to purchase a ‘catastrophic’ health plan through the Marketplace—a type of health plan that is available to him since he is under age 30. While the catastrophic plan’s monthly premium cost is generally lower than other qualified health plans, they do not qualify for the premium tax credit so he will have to pay the full monthly premium himself. 

Although these plans offer coverage for preventive services and three primary care visits per year, they also have a very high deductible that needs to be met before any other benefits kick in. So John would pay all of his medical costs up to $6,350 for his in-network medical costs. (Out-of-network is higher).

3) "Maria"

  • 32-year-old woman with 32-year-old spouse
  • They have an individual health insurance company
  • Taxable income $55,000
  • Has a child with another child on the way
  • Lives in Orlando, Orange County

Florida Blue: The new government premium tax credit (or subsidy) will help them save money on their monthly health plan premium. Based on their taxable income of $55,000, which falls within the $23,550 to $94,200 range for a family of four, they’ll qualify for premium tax credits to apply toward their health plan premiums in 2014. The exact amount of this tax credit will depend on things like the family’s estimated household income, family size and ages, the county where they live, and the premium cost for the second-lowest cost Silver plan in their county.

In addition to saving money on their monthly premium through a tax credit, since their household income is under $58,875 they can also save money with the “cost-sharing reductions” that are available with certain Silver qualified health plans. These plans can reduce the family’s out-of-pocket costs for covered services since these plans pay a larger share of the medical costs. The lower the income for qualified individuals and families, the richer the plan benefits.

Due to their tax credit, they will be able to save money on a health plan that is offered through the Marketplace – whether they work one-on-one with an agent to purchase a plan or go directly to the Marketplace. By purchasing a new plan, they can take advantage of some of the additional "essential health benefits" now included in all health plans, such as no exclusions for preexisting conditions, hospital stays, prescription drugs and lab tests. They will also get:

  • Preventive care like routine physicals for the entire family, including blood work and immunizations, and well-child care visits are at no cost. That’s really helpful for this active, growing family.
  • No cost well-child care visits, including lab tests and blood work • Also coverage for eye exams, lenses and more for children under 19
  • No limit on lifetime maximums or annual dollar limits for essential health benefits
  • Maternity and newborn care

4) "Adam"

  • 56-year-old man with 52-year-old spouse
  • Currently has insurance through his employer, but employer is dropping coverage
  • Taxable income of $85,000
  • No children

Florida Blue: Their taxable family income of $85,000 is above the government’s $62,040 income limit for a two person household to qualify for the new government tax credit (or subsidy) to help pay for their insurance premium. However, they could still go online to the Marketplace and answer more in-depth questions to see if they may qualify for any special situation. If they don’t qualify, then they will pay the full monthly premium for the health plan they decide to buy.

The couple has choices for getting health care coverage. They can still go online to the Marketplace and shop for plans (without the incentive of a tax credit) or contact an insurance agent who can work with them one-on-one to explain their options. Because Adam's diabetes needs continued care and control, he will be able to take advantage of the new "essential health benefits" now included in qualified health plans, including:

  • No exclusions for preexisting conditions
  • Preventive care like routine physicals, including blood work and immunizations, are at no cost
  • No limit on lifetime maximums or annual dollar limits for essential health benefits

In addition, some health plans offer special health programs, with personal support for diabetics, and generic drugs for diabetes all at no cost. And depending on the plan they decide to purchase, it could include vision and dental coverage to help round out their coverage.

You can follow Patrick on Twitter @patrickhdonges.