Pensacola, Florida
Monday April 23rd 2018


Navigating the Affordable Care Act

By Jessica Forbes & Sarah McCartan

“Despite Glitches, Could’ve Been Worse,” NPR
“Somebody Finally Got Fired For,” Washington Post
“Health Care Exchange Is Vastly Improved, Users Say,” The New York Times
“Warning: Ignore claims that 3.9 million people signed up for Medicaid because of Obamacare,” Washington Post

If you’ve so much as glanced at national media headlines in the last few months, you already know the marketplace has gone a little something like this:  Website crash, angst, public outcry, followed by public apologies and finally, an extended enrollment deadline.

When it comes to signing up for healthcare coverage under Obamacare—the moniker given to the Affordable Care Act [ACA] of 2010—despite the fact that is now reasonably functioning, the process has still proved confusing for many.

If you haven’t worked out your coverage and have been putting off sorting things out, you’re not alone. There is a multitude of information out there and it is hard to know where to begin.

If you are someone who has benefits offered through your employer, family member, or other beneficiary and have not been prompted to take action on an individual/family level, then this story will only provide additional perspective into the process. If you need coverage or more info on subsidies, exemptions, and penalties, then it is meant to help you out.  To do so we’ve narrowed it down to the essential facts, and spoken with individuals at insurance companies and non-profits trained to navigate individuals through the process.

The Basics

But first, let’s start with the basics. Like many a federal initiative and/or healthcare related-program, the ACA is awash in terminology. If you’ve yet to secure insurance coverage, at this point in time, the most important terms and concepts to note are those related to the open enrollment deadline, subsidy qualifications, penalty exemptions, and Medicaid expansion.

The Marketplace
The term the “marketplace” refers to the health insurance marketplace accessible through March 31 is the open enrollment cutoff for 2014, meaning you can shop the marketplace and enroll in a plan through that date and avoid facing the penalty.

If a person is uninsured after March 31, they will be unable to purchase an insurance plan through the marketplace until the next open enrollment period, which is expected to begin in November 2014. There are exceptions to that rule as well; a person may qualify for a special enrollment period between open enrollment dates if they experience a “qualifying life event,” which includes marrying, divorcing, having a child, or moving to a new state, for example. Also, small business owners may begin offering coverage to employees at any time, and persons eligible for Medicaid or the Children’s Health Insurance Program (CHIP) may enroll in those programs at any time.

While some may believe that the federal government’s role in establishing the marketplace indicates that the government is operating the plans available through the site, that is a misconception; the marketplace allows individuals to register, provide income and other relevant information, and then be presented with plan options from private insurance companies. If a person is eligible for Medicaid based on the information they enter, the marketplace will connect them to their state’s Medicaid portal.

The marketplace is essentially the federal government’s attempt at making compliance with the ACA somewhat easier—at least, that is the intent.

Metal Levels
Once a person has entered all of the basics and income information for themselves and any dependents and/or fellow household members, and are determined ineligible for Medicaid, the marketplace generates a list of insurance plans from which that person may choose. The plans are presented in categories:  Bronze, Silver, Gold, and Platinum. Catastrophic care plans, which have lower premiums but protect mainly from very high medical costs, are available only to those under 30 or those who qualify for hardship exemptions.

The category names correspond to the total average cost of healthcare that a plan will cover in ascending order:  Bronze plans cover up to 60 percent of total average healthcare costs, Silver plans cover up to 70 percent, Gold plans up to 80 percent, and Platinum plans up to 90 percent. As insurance has always been, the lower the premium, the higher the deductible—and, correspondingly, the higher the out of pocket costs are in the event you need care. The prices of monthly premiums are higher according to the quality of the plan, as always, too.

Advance Premium Tax Credits
No matter the metal level of the plan, however, all health insurance plans offered through the marketplace must include “essential health benefits” within 10 categories, which include emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, laboratory services, and preventive and wellness services among them.

The good news is you may qualify for a subsidy (also known as Advance Premium Tax Credits in ACA-speak) that will reduce your monthly premium cost. Eligibility for tax credits is based on household income as it relates to the Federal Poverty Level (FPL), which the U.S. Department of Health and Human Services determines, and publishes each January.

The 2013 federal poverty guideline for a household of one was $11,490 for example, and for a family of four the guideline was set at $23,550.

To qualify for an ACA subsidy a total household income must be less than 400 percent of the FPL. For a household of one in 2013, the cut off is $45,960, for four persons is $94,200 etc. Meaning if that a family of four earns over $94,200 a year, they will pay full price for their insurance premiums; if they earn less than that amount, they are likely eligible for a subsidy/tax break.

Medicaid (Non-) Expansion
As far as Medicaid expansion goes, Florida (along with neighboring Georgia and Alabama) are among the states that refused to accept expansions of Medicaid under the ACA. Typically, funding Medicaid is a joint effort between states and the federal government; under the ACA expansion, the federal government would have covered the cost of Medicaid expansion in full for the first three years, and 90 percent of the cost after that.

Currently, Medicaid eligibility in Florida is determined by considering a family’s income related to the FPL and their total assets, and requires that a person be pregnant, a parent, blind, or have a disability among the stipulations. Medicaid expansion would “expand” eligibility for the program to nearly all adults making 133 percent of the FPL or less—that’s an annual income of $15,856 or less for a single adult.

Without the Medicaid expansion in Florida, there are an estimated 763,000 Floridians whose income does not qualify them for Medicaid and also may not be enough for them to afford the cost of insurance premiums, even with a subsidy. They, along with all others who remain uninsured, will have to pay a penalty—also called “the individual shared responsibility payment”— unless they meet one of the many exemption requirements.

Paying a Penalty
If you do not have some form of healthcare plan—Medicaid, Medicare, a plan through your employer, or an individual policy—after March 31, you may be subject to a financial penalty when you file taxes for 2014, due in April 2015.

The penalty amount for being uninsured in 2014 will be $95 per adult or one percent of total household income, whichever amount is higher; the penalty for each uninsured child is $47.50. Each year, the flat penalty and percentage will increase. Although it may not seem substantial now in year one, from 2016 forward the penalty for being uninsured will rise to $695 per adult or 2.5 percent of household income, whichever amount is higher.

Penalty Exemptions
Exemptions from penalties are available in several specific situations, including being uninsured for less than 3 months of the year, or instances in which the lowest price of coverage available to someone costs more than 8 percent of their household income, for example.

Another category of exemptions, called “hardship exemptions” include being homeless, having filed bankruptcy in the last 6 months, or having medical expenses you couldn’t pay within the last 24 months, also among several others.

If you’ve resigned yourself to paying a penalty without exploring the options, you may want to consider either logging onto yourself, or perhaps consulting one of the numerous health care and insurance professionals trained to navigate the system with you and explain just what your options for coverage may be.

Whether it’s Medicaid, a subsidy/tax break, or an exemption from the penalty, people trained and working with the system regularly can guide you through discovering what you are eligible for.

Navigating the System

Many professionals working in healthcare and related services completed training and are certified to help people register and navigate the various options available, hence the term “navigator.”

If the thought of delving into and trying to understand the options on your own doesn’t sound appealing, several area organizations offer assistance navigating the Affordable Care Act Marketplace.

Mary Ann Andrews, an outreach and enrollment specialist with Escambia Community Clinic, Inc., is one such professional. As a federally qualified health center, the clinic focuses on providing care to economically disadvantaged persons, with a sliding fee schedule for services that typically ranges from $5 to $114. In addition to ACA assistance, Andrews also regularly works with patients in filing for Medicaid, Social Security benefits, ADA Transportation documents, and Medicare among others.

Andrews estimates that she and the other three Outreach and Enrollment Specialists on staff at the clinic counsel eight to 12 people a day regarding ACA issues. During the visits, the specialists help individuals establish a profile in the website, enter necessary contact and income information for themselves and their household members, and review the list of plan options from a variety of insurance companies that the site presents. Pricing and individual plan information is available for comparison. If a person is ready to select a plan immediately, information on where to send payments and/or set up bank drafts is also immediately available.

“I’ve seen maybe a couple of people who were afraid of the penalty,” Andrews said of common worries she’s heard. Once individuals sit down and take a look at the website with Andrews’ assistance, she stated they usually find a solution, whether it’s an affordable plan or perhaps a hardship exemption. “There are several different hardships and exemptions, and most of our patients that come here, they qualify.”

Amy Wells, a case manager with the Epilepsy Foundation of Florida (EFOF), is also one of the health professionals certified to assist people with ACA enrollment. Like Andrews, through her work with EFOF, Wells regularly assists patients and families in filing for Medicaid and other programs to facilitate healthcare. While her focus is normally on services for individuals with epilepsy, EFOF’s ACA navigation is open to anyone under 65, the minimum age for Medicare.

“It’s for anyone out there. We thought since we are serving a population at risk medically, often times they are at risk financially, too,” said Wells, emphasizing that while navigation compliments the services offered for EFOF’s clients, the navigators welcome anyone to visit. “It’s the law, so we’re helping people to comply with that. We’re not pro, con, for, against—we are here to help people follow the law. We’re neutral. We’re Switzerland.”

There are 18 certified navigators with EFOF throughout the state and Wells is one of two located in Pensacola. For several months, EFOF was available for consultations at the downtown library, but are now offering ACA navigation assistance at their office/Epilepsy Resource Center on Fairfield Avenue.

Navigators can explain plan details, but cannot suggest which plans to purchase. If an individual needs more time to consider the options, the navigators encourage people to make a return visit if they want assistance actually enrolling and paying for a plan. If an individual has access to a computer, it is also possible for them to log back on, peruse the plans at their leisure, and enroll in one on their own, if they feel comfortable doing so.

Both Andrews and Wells reported that despite the initial hiccups, for the most part has been running smoothly as of late. Still, the process can be slightly time consuming, so Andrews recommends reserving a couple of hours for initial registration as a rule of thumb.

“For each person that we put in, we need the name, date of birth, Social Security number, income, and if it’s mom, dad and five kids, we’ve got to put all of that information in. So I always tell them to be prepared to stay at least two hours,” said Andrews.

And if a person neither qualifies for Medicaid nor cannot afford a plan even with a subsidy, “That’s where a lot of the community clinics are stepping up,” said Andrews. “They can come here, become a patient, and still receive primary care. That’s been a really big help to a lot of people.” Still, without an exemption and without an insurance plan, penalties will still apply.

Insurance Assurance

Of course, there is the option of speaking directly with an insurance agent, trained to educate you regarding the available options through their respective company. If you currently are insured and are concerned about changes in your current coverage, or have some familiarity with a company from having been previously insured, working directly with an insurance agent is a viable place to start. With the changes in healthcare, it’s become an agent’s priority to assist their customers through the entirety of the process.

Since the moment the marketplace opened up, Barnes Insurance and Financial Services of Northwest Florida has been working diligently in helping individuals select a plan that best suits individual needs.

“Our agency embraced the law since it was passed and we have spent a great deal of time training our staff to help clients as each part of the law has been implemented,” said Vice President Glenn Little.

Barnes insurance is a Florida Blue (BlueCross BlueShield of Florida) Contracted General Agency, meaning they sell Florida Blue individual products on and of the exchange/marketplace.

“Specifically for the individual open enrollment, our staff was trained and ready to enroll individuals the day open enrollment began. Obviously, there were some issues, but as soon as the system issues were corrected, we worked very hard to enroll clients needing a January 1 effective date,” he said.

An agent educated on the reform changes who is familiar with the ins and outs of plan levels and options, cannot only help you filter your options, but can answer detailed questions about deductible considerations, medications, provider selections, and co-pays, along with any hypothetical situations you may have that are specific to you, your health and your lifestyle, that the marketplace doesn’t take into account.
“There are many factors clients need to consider when choosing a plan such as cost, plan design and network coverage that includes their health care providers. Our trained agents are very familiar with the products and have helped many clients with plan selections, who are in need of subsidized coverage,” encouraged Little.

As with working with another healthcare navigator, the perk of having an agent also includes speaking to a real person, and allows you this same face-to-face contact after you are signed up and ready to go.

“Selecting a plan can be a little overwhelming if you are not familiar with insurance products, but trained insurance agents can easily help a client choose a plan that fits their needs. There is no extra cost to purchase an individual plan via an agent. After the purchase the agent can continue to help a client with future questions and issues,” said Little.

Still, despite the added assistance, in the end it all comes down to the numbers, and affordability—or lack thereof—pushing some to take the penalty.

Is It Actually Affordable?

Some of the individuals electing to take the penalty fall in what is being referred to as the “Young Invincibles” group, those between 18 and 34 years of age.

A twenty-something recent college graduate, Nicole Ponder found herself ready to sign up for an affordable healthcare plan through the marketplace. Like many, her expectations did not match up to reality. It wasn’t the process that Ponder found difficult, but rather the options that were presented to her. Based on her income, the options still proved far from affordable.

“It wasn’t a painful process at all,” said Ponder. “I had my tax information from the last few years by my side and did not feel confused by any of the questions. I was feeling good until I was close to the last section.”

After imputing her annual salary information as well as expected income for 2014, Ponder was presented with a handful of options, none of which, taking into account her low level of income, were considered affordable.

According to Ponder, these options ranged from $189 monthly premiums to over $350.

“For the time being I am going to stick with paying the fee,” said Ponder.

Do pre-existing conditions matter?
Like Ponder, self-employed freelance writer Grant Hutchinson faced his own predicaments. While pre-existing conditions may not matter for the sake of signing up through the marketplace, they certainly come into play considering the amount of coverage an individual needs for his/her continued wellbeing in certain cases, and in turn, can affect affordability.

Hutchinson’s previous plan was $427 dollars a month (including medical, dental and prescriptions). With a medical premium that was scheduled to increase in 2014, the cost was expected to jump to $570 month. Hutchinson made the decision to reapply for different coverage, signing up through the marketplace.

“The site was a complete nightmare for the first month. Once they fixed all the glitches though, it was great. You can filter all the available plans by all sorts of different criteria, and you can compare your chosen plans side-by-side to really get a sense of which one is right for you. It’s a great resource,” said Hutchinson.

Although preexisting conditions were not a factor in the plans that were available, he had to keep this in mind when deciding the amount of coverage he had to have, with the cheaper catastrophic policies being out of the question. Likewise, he is a smoker (a question that is asked during the signup process), and the amount of income he made bumped him out of the range to receive a subsidy. Still, despite his added expenses, Hutchinson ended up with a plan more affordable than his existing.

“The plan I found was cheaper than what I have now, and also offers better coverage. Unfortunately, there was an additional $4000 deductible just for prescription drugs hidden in the fine print that I doubt a lawyer could’ve found. So my prescription costs have gone up, but overall I’m still paying less money. My current plan is now $374 (including medical, dental and prescriptions),” he said.

Medications and More…
Prior to Dec. 1, AshleeAnne Palmer began inquiring about healthcare through the Marketplace website.

“I was trying to figure out if anyone could tell me how much anything would cost, how coverage would work, etc.,” said Palmer. “Every person I spoke with just kept saying—Dec. 1—that’s the day we will all know.”

Like many, after battling site glitches, around Dec. 15 Palmer was able to log in and select a plan with Humana.

“I did not choose the ‘catastrophe’ plan, as it was the cheapest, but I chose the Silver plan at 185 a month. I did not qualify for any subsidy, and I was not able to get any Medicaid benefits because Florida, of course, opted out of that coverage. My coverage is a deductible of 5k and my primary care visits are covered up to 5 a year. My copay is around $35 for visits—and things like blood work are not covered.”

Still, for Palmer, there was a medication consideration, one that adds up to an extra monthly $80 expenditure. On the upside, since becoming insured, Palmer has been able to continue visiting her current physician, who has provided her samples of the medication to prevent her from having to take on this added monthly cost, at least in the immediate.

The Deciding Factor
If you are uninsured and wondering where to begin, whether you utilize on your own or schedule an appointment for assistance, learning what you are eligible for—plans, subsidies, exemptions, or maybe even Medicaid—would at least define your options and the specific avenues toward obtaining insurance (or not) you could choose.

Plainly stated, the options for all who are currently uninsured are purchasing a plan, paying a penalty, or, if you qualify, filing for an exemption which will allow you to remain uninsured without being subject to a penalty—at least for 2014.

While no one can tell you specifically what to do, guidance and help spelling out the options is available. Your overall health as well as how often you typically visit doctors, your current prescription medication requirements, and other existing healthcare needs should factor into your decision when choosing a plan.

“You should just pick the one that’s best for you and your family, what’s going to fit your needs both from a healthcare perspective and a financial perspective, also,” Andrews said of her advice to those visiting the clinic to enroll. Discovering, then weighing the options and choosing a plan may seem like a slight headache, but it is one that will pass quickly and be a benefit in the long run.


Escambia Community Clinics, Inc.
2200 N. Palafox (Main Site)
8 a.m.-5 p.m. Monday – Friday (possible weekend hours coming soon)

Epilepsy Foundation of Florida
916 E. Fairfield Drive
9 a.m.-1 p.m., Monday – Friday

Barnes Insurance & Financial Services
1582 Airport Blvd.
8 a.m. – 5 p.m., Monday – Friday

For a list of local organizations currently registered as offering application assistance, visit

The open enrollment period for coverage for 2014 closes on March 31.

ACA:  Youth Matters

According to ACA enrollment numbers the Obama administration released earlier in Jan. 2014, 24 percent of those who have purchased insurance plans during open enrollment are between the ages of 18 and 34 years old, the so-called “Young Invincibles.”

As people in that demographic are typically healthier and incur lower healthcare costs, having young adults enroll and purchase plans boosts the money in the pot, so to speak, thereby offsetting the cost of payouts insurance companies make for older Americans, or those utilizing more healthcare services.

The administration had previously estimated that of the 7 million people expected to buy insurance plans under the ACA, approximately 40 percent would need to be in the 18 to 34 year old range for the insurance boat not to rock very dramatically.

Factors such as being a generally healthier segment of the population, or generally less in need of regular medical services and therefore being able to put off enrolling, as well as just run of the mill procrastination may be behind the lag in youth purchasing plans, or at least being late jumping on the bandwagon.

The Washington Post reported that in Massachusetts in 2006, a similar delayed pace occurred among “young invincibles” when that state’s health care reform law was enacted, with a steady growth in enrollment numbers in the first year the law was in place.

In December, approximately 140,000 Floridians purchased health care plans, and approximately 20 percent of those were in the 18 to 34 demographic. The total number of Floridians with new plans as of December was just over 158,000.