SWFL Insurance

The Affordable Care Act (ACA), or “Obamacare,” is a law that has dramatically changed how health insurance works in America. Millions upon millions of people now have access to health insurance coverage as a result of the ACA. Additionally, the ACA has changed the affordability of health insurance for Americans. Overview Many Florida residents are feeling the impact of rising health care costs—especially adults under 65 who buy their coverage through the Affordable Care Act (ACA) marketplace. Premiums, deductibles, and out-of-pocket costs have increased steadily, and those who don’t qualify for subsidies often feel priced out altogether. This guide breaks down why ACA plans in Florida have become so expensive, who is most affected, and how to evaluate alternative coverage options, including private plans that may offer more predictable costs depending on your situation. Why Florida ACA Premiums Keep Rising ACA premiums rise due to several key factors—some national and some unique to Florida. 1. Medical Costs Continue to Increase Like the rest of the country, Florida faces higher medical costs due to: Rising hospital and provider prices Increased demand for care Higher prescription drug and medication costs More chronic conditions in the population, with many individuals requiring ongoing medications, which contributes to higher costs When healthcare costs rise, premiums follow. 2. Florida’s Demographics Drive Higher Utilization Compared to other states, Florida has a higher percentage of its population who are older or retired before age 65. This group typically uses: Use more medical services on average compared to younger populations. Require more specialist visits. Face more chronic health issues. The average healthcare costs and utilization for these individuals are higher than for other age groups. Higher utilization → higher claims → higher premiums for ACA insurers. 3. A Large Portion of Floridians Are Uninsured Many Floridians have a household income just above the subsidy cliff or experience income fluctuations that cause them to lose eligibility for subsidies. These individuals pay: Full price for premiums Full deductibles Higher out-of-pocket expenses For this group, ACA plans can become cost-prohibitive. 4. Narrow Networks Can Limit Value for Some Buyers To control costs, many ACA insurers introduce limited networks: Fewer doctors Fewer hospitals More HMO-style plans For people whose providers aren’t included, the perceived value drops—even as premiums rise. 5. Plan Structures Have Trended Toward Higher Deductibles It’s common to see: $9,000+ deductibles High out-of-pocket maximums Specialist visit restrictions Tiered drug formularies These designs help control premiums, but they also shift more of the cost burden to consumers. In many cases, high-deductible plans can still come with a significant monthly premium, further increasing the overall cost burden. Who Is Most Impacted by Rising ACA Costs Not everyone feels the premium increases equally. Some groups experience much bigger price shocks. 1. People Who Don’t Qualify for Subsidies If your income is: Above ~400% of the Federal Poverty Level Irregular (self-employed, commission-based) Not calculated correctly using marketplace rules …you may get little or no financial assistance, which means: Monthly premiums may be high, especially if you lose eligibility for a tax credit Deductibles may be difficult to meet Budgeting becomes unpredictable These individuals often explore alternative health insurance options. 2. Adults Ages 50 to 64 ACA pricing allows age-rating—meaning premiums rise as you get older. A 62-year-old often pays: 2–3× more than a 25-year-old on the same plan Even more if unsubsidized, with expected higher costs for adults ages 50 to 64 if ACA tax credits expire For many in this age group, ACA costs feel especially heavy. 3. Self-Employed Floridians People who are self-employed frequently: Earn variable income. Fall in and out of eligibility for subsidies. Face large tax-time adjustments when income doesn’t match estimates. Rely on tax deductions for health insurance premiums, but unpredictable income can complicate these deductions. This makes ACA budgeting extremely difficult year-round. 4. Early Retirees Under 65 Until they become eligible for Medicare at 65, retirees must find their own coverage. Those who do not qualify for Medicaid may face particularly high ACA premiums until they become eligible for Medicare. Without subsidies, ACA options can be one of their biggest expenses. When an ACA Plan Is Still the Best Fit Despite rising costs, ACA plans remain the right choice for many Florida residents. You may want to stay with an ACA plan if: You qualify for significant subsidies. You have chronic health conditions requiring broad health coverage. You need access to specific providers only in ACA networks. You expect high medical usage and want to ensure continuous health coverage. You prefer standardized protections (pre-existing conditions, essential benefits, etc.) ACA plans are especially valuable for: Lower-income households Individuals with ongoing medical needs who cannot risk gaps in health coverage Families with children and maternity needs When It Makes Sense to Explore Private Health Insurance Options There could be other individuals that live in Florida that might choose to obtain their private health insurance plan as an alternative (this option might provide them with a better mix between premium costs, benefits, and provider selections), while many employers will also provide hefty employer-subsidized health insurance benefits (which often means lower premiums for the employee and/or greater coverage because of the employer’s contribution and tax benefits associated with it). To better understand the importance of the role an employer plays in obtaining health insurance, individuals who do not receive employer-sponsored health insurance should consider purchasing a private plan, enrolling through the ACA, or both. Private plans may be worth comparing if: If you are not eligible for ACA subsidies. If you would like a monthly cost that is easier to estimate. If you want a more PPO-type of access to providers. If you want wider access to healthcare providers, i.e., greater access to hospitals. You want options outside the ACA open enrollment period. You’re relatively healthy and want coverage for larger medical events, not day-to-day usage. Important Note Private plans vary widely in structure and eligibility. They are not ACA plans and do not replace ACA protections. A licensed agent can explain

When shopping for health insurance in Florida, many people start with the Affordable Care Act (ACA) marketplace. What fewer people realize is that private health insurance plans—sometimes called off-exchange or non-marketplace plans—also exist and can be an option for certain individuals depending on income, health needs, and eligibility. Private health insurance can also be obtained through employers, making it accessible to many people as part of their employee benefits. This guide explains what private health insurance is, how it differs from ACA plans, when it may make sense to compare options, and what to consider before choosing a plan. What Is Private Health Insurance? Private health insurance refers to a type of health plan that provides medical coverage purchased outside the ACA marketplace directly through insurance carriers or with the help of a licensed agent. These plans: Are not subsidized by the federal government Are available year-round (not limited to Open Enrollment) May offer different network structures and benefit designs Eligibility for private health insurance may depend on the service area, which is the geographic region where coverage is available and enrollment is permitted. Private health insurance does not replace ACA plans, but it can serve as an alternative in specific situations. Florida Health Insurance Plans Florida’s health insurance market offers a range of plans, including family or single plans and varying levels of coverage. When selecting a plan, be sure to look for the minimum level of essential benefits offered by each plan, including prescription medications, hospital admissions, preventive health care, and physician visits. The Affordable Care Act mandates that all plans sold on the health insurance exchanges must include essential benefits, therefore providing access to adequate care for yourself and your family. With the Florida health insurance marketplace, you have the ability to review multiple insurance plan options side-by-side and see which plan best meets your health care and budget needs. If you are eligible to receive tax credits due to your household income being between 100% and 400% of the federal poverty level, you will be able to take advantage of these tax credits to reduce your monthly premium payment if you purchase your health coverage through the marketplace. Purchasing private insurance, either directly through an insurance company or with the assistance of a broker, provides you with additional coverage choices and provider networks. Generally speaking, if you qualify for premium tax credits, private insurance is likely to be more than marketplace plans when compared relative to the same coverage. As you evaluate the differences in the Florida health insurance marketplace, take time to evaluate your coverage needs, your out-of-pocket costs, and whether you prefer a larger number of providers to choose from or are willing to pay a lower premium for fewer provider options. Comparing health insurance plans will help you select one that best suits your needs and those of your family. How Private Plans Differ From ACA Marketplace Plans Recognizing the distinction between private and ACA Marketplace insurance plans helps us set realistic expectations from the start. Many regulations govern the ACA and private insurance plans, affecting coverage and eligibility under different circumstances. 1. Enrollment Periods ACA Plans: Enrollment Periods only for Open Enrollment and qualifying life events. Private Individual Health Insurance Options: Private plans are usually available year-round. People who do not complete ACA enrollment by the expiration date or experience a qualifying life event at another time can obtain coverage through private plans available year-round. 2. Subsidies ACA plans: May include premium tax credits based on income. Private plans: No subsidies available. For individuals who don’t qualify for ACA subsidies, private plans are sometimes considered for cost comparison. 3. Provider Networks Private plans often: Offer PPO-style access Provide broader provider networks, including a wider range of specialists. Allow out-of-network coverage (varies by plan) ACA plans are more commonly: Use HMO or EPO structures. Have narrower networks to control costs. 4. Benefit Structure ACA plans must include essential health benefits, such as maternity and mental health coverage. Private plans: May offer customizable benefit structures. Can focus on major medical coverage. Vary widely in covered services. Private plans may also include exclusions that differ from those in ACA plans, so it is important to review them carefully. A licensed agent can explain what is and isn’t included in a specific plan. Who Typically Explores Private Health Insurance in Florida? Private plans are not for everyone, but certain groups often compare them: Private health insurance may have specific eligibility criteria or coverage options for individuals with a disability, and may require proof of disability. 1. People Who Don’t Qualify for ACA Subsidies If you make too much money to qualify for meaningful ACA assistance, marketplace premiums can become costly. Many people in this situation want to look at private plans to shop for lower monthly premiums and find out which networks are offered. 2. Self-Employed Individuals Self-employed Floridians often have: Variable income Difficulty estimating ACA subsidy eligibility Changing coverage needs For some, private plans may offer a more reliable price structure. 3. Early retirees who are not yet eligible for Medicare (age 65 or younger) Those who retire earlier than their 65th birthday may look for the following from a private plan. Broader provider access Stable monthly premiums Year-round enrollment flexibility 4. Healthier Individuals Seeking Major Medical Coverage Some private plans are designed to protect against larger medical events rather than routine care, which can affect pricing and benefit design. Potential Advantages of Private Health Insurance Depending on the plan and individual profile, private health insurance may offer: More flexible enrollment timing PPO-style networks Access to providers outside ACA networks Different deductible and premium combinations Potential cost savings for unsubsidized individuals Private health insurance may also provide access to quality care by connecting members with high-quality doctors and hospitals. These features vary by carrier and plan type and should always be reviewed carefully. Important Limitations to Understand The following are important considerations with regard to Private Health Insurance: Most plans do not cover any