Florida homeless people duped into Affordable Care Act plans they can’t afford

MIAMI — Mary Zhelyazkova was surprised when a pharmacist at Florida’s largest safety net hospital told her she couldn’t fill her prescriptions.

Zhelyazkova, 40, lives in a homeless shelter and needed Saboxson, a drug to manage opioid withdrawal symptoms.

She said she gets Saboxson for free at the Jackson Memorial Hospital pharmacy through the Ryan White HIV/AIDS Program, which provides little or no medical care to people living with HIV.

But in late 2021, she said, a strange man approached her on the street and offered her $5 to sign up for Florida Blue’s “free” health insurance plan. The person instructed her to use her false address and misrepresent her income so that she would be considered covered by her insurance, she said.

When the plan went into effect the following year, Zhelyaskova learned of the downside.

Taking out private insurance disqualified her from Ryan White’s insurance. And Florida Blue’s provider didn’t include hospital pharmacies in her network. She needs to go to Walgreens and to do that she needs transportation. She also had to provide a $20 co-payment, which she couldn’t afford.

“I had to withdraw. It was terrible,” said Zhelyazkova, adding that she went without medicine for several days until a nonprofit needle exchange program paid for it.

Zhelyazkova, one of potentially hundreds of homeless people in Florida who were approached by agents and brokers asking for commissions, said state insurance regulators, doctors and policyholders said they were justified in paying their medical bills. He says he is enrolled in a zero-cost medical plan at Kaho Market. counselor.

It is speculated that rogue agents and brokers register homeless people in order to earn a commission on the sale, and are fraudulent by lying about their income and home address.

The federal government also pays monthly premiums for the Affordable Care Act Plan for eligible low-income consumers, but the insurance comes with copays, deductibles, and other copayments. , often unable to pay for those with little or no income.

In a growing number of reports, state and federal regulators are investigating cases of agents and brokers providing fraudulent information regarding Affordable Care Act applications.

In the fiscal year ending September 30, 2022, the federal agency that oversees the market for the Affordable Care Act announced that in the fiscal year ending September 30, 2022, more than 20,000 people will report that they took out insurance without their consent or that false information was submitted. It said it had received more than 5,000 complaints. For applications by agents or brokers. The Centers for Medicare and Medicaid Services also said it conducted more than 700 license authorizations during the same period to identify potentially problematic brokers.

The 10 states most likely to opportunistically recruit homeless people into Affordable Care Act plans have refused to extend Medicaid eligibility to nearly all low-income adults States like Florida, which is one of the In a 2015 case, agents in North Carolina registered hundreds of homeless people for the Affordable Care Act. The state introduced expanded Medicaid in March, but it has yet to go into effect.

In the expanded nation, most single adults in poverty would be eligible for Medicaid. In non-expansion states, including Florida, consumers typically earn at least 100% of the federal poverty level to qualify for the Health Act tax credit that reduces their monthly premiums and out-of-pocket costs. There must be. In 2023, $14,580 per person, with a family of three he would equate to $24,860. However, just because consumers have no income this year does not prevent them from predicting that they will have enough income next year to qualify for tax credits. Consumers are not required to document their income in Marketplace applications if government data indicates that they have been inadequate in the last few years. On the surface, it may appear that the uninsured homeless are covered, said Sabrina Corlett, a health insurance policy expert at Georgetown University. “It’s not that bad,” she said.

But that doesn’t make it a victimless crime. The federal government will eventually subsidize health insurance companies to cover people not covered by the plan. Homeless people, on the other hand, are disqualified from more appropriate programs such as hospital charity care and Ryan White. “It’s a serious problem,” Corlett said.

Physicians caring for homeless people also say the interruption in care has forced homeless patients to relapse into drug use, suffer mental health crises, and stop treating chronic conditions such as cancer and diabetes. He said there is a risk of

“Patients are stuck in a situation where they can’t pay out-of-pocket costs under their insurance plans,” said David Serota, an infectious disease expert at the University of Miami’s Miller School of Medicine. “But they also cannot access those services through programs for the uninsured poor.”

Serota sees patients at the Jackson Memorial, a Miami-Dade County hospital that provides charity care. At least 20 patients have been affected in the past three years, and “many more” his colleagues have seen, he said.

It may take weeks or months to cancel your new health insurance policy and reapply for public benefits. And Erin Richards, a certified application counselor and Affordable Care Act program coordinator in Pinellas County, near Tampa, said the disruption could heighten the skepticism that marginalized communities have about the system. Stated. She has helped many reapply for local Homeless Resident Programs after homeless residents were tricked into enrolling in the Affordable Care Act Plan.

“We are working to get them to trust the system again and get the care they need and have long neglected,” Richards said. Since marketplace registration began in the fall of 2013, agents and brokers have registered unqualified consumers for the Affordable Care Act. “It’s not at the level that we’ve seen recently,” said registration navigator and executive director Katie Lauders-Turner. The Family Healthcare Foundation is a non-profit organization in Tampa that helps low-income residents get free or low-cost care.

Richards and Turner said the health insurance company most commonly found among homeless people is Florida Blue, the state’s largest health insurer. In Florida, he has 15 companies offering plans on the Affordable Care Act marketplace. Only Florida Blue covers all 67 of his counties in the state.

Florida Blue executives said the company’s compliance team is investigating “individuals who fraudulently enroll consumers in health insurance,” but when asked how often such scams occur did not respond.

The most common way agents receive commissions is by member, by month. In other words, the agent or broker will receive a monthly commission for each registered consumer for as long as the consumer remains registered. Dave Sherrill, an insurance broker and executive director of the Florida Association of Insurers, estimates that most plans pay $20 to $30 a month per member. Devin Garetta, director of public affairs and chief financial officer for the Florida Department of Financial Services, said the Florida insurance regulator is investigating the incident with police and CMS.

Since 2020, the state has received three consumer complaints about the issue in the South Florida, Tampa, and Gainesville areas, Garetta said. No “arrests or administrative actions” have been taken, he said.

But Turner is concerned that the incident has gone unreported. This type of fraud can be difficult to investigate because homeless victims may fear law enforcement or be unwilling or unable to make the necessary reports to document such crimes. There is, she said.

“It was a big challenge,” Turner said.

This article was produced in partnership with KFF Health News (formerly known as Kaiser Health News). KFF Health News produces in-depth journalism on health issues and is the National News Editorial Office, one of KFF’s core operating programs, and an independent source of health policy research and opinion polls. and journalism. The St. Petersburg Health Foundation also funded this article.