That’s why he was surprised a few months later when his health insurer, Molina Healthcare of Florida, charged him $536 — the full cost of one month of insurance without the tax credits that made his plan affordable.

The reason? A problem processing paperwork that sometimes results in the government cutting off tax credits when there are inconsistencies in documentation, especially when it comes to income estimates. The problems are affecting thousands of consumers around the country, say enrollment agents and healthcare counselors, including some in South Florida — where more people signed up for insurance plans under the Affordable Care Act than in 47 entire states.

The issue isn’t new. A U.S. Department of Health and Human Services from the Office of the Inspector General said that between October and December of 2013, the federal marketplaces were unable to resolve 2.6 million data inconsistencies, which occur when the marketplace can’t cross-check applicant information with other data.

The report found that the federal marketplace “was unable to resolve inconsistencies even if applicants submitted appropriate documentation” and noted that “an inconsistency does not necessarily indicate that an applicant provided inaccurate information.” When the report was published last summer, the Centers for Medicare and Medicaid Services said it was working toward swifter resolutions.

Eventually, 97,000 of the households with income inconsistencies either lost their tax credits or had them adjusted for 2014 coverage.

The paperwork processing problem, however, persists.

In 2015, the number of consumers who had their tax credits adjusted or lost due to an income inconsistency rose as enrollment went up. According to a recent , 223,000 households had their tax credit or cost-sharing reductions adjusted for their 2015 coverage.

HHS could not say how many consumers overall saw their tax credits revoked because of an inconsistency in their documents, nor could it say what percentage of those people turned out to have been wrongly denied subsidies.

The Issue With Income Projections

The problems frequently seem to start with the income projection portion of the Obamacare application.

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A 2013 law barred the Florida Office of Insurance Regulation from regulating proposed rates in Affordable Care Act plans, stating that the state office could not have a final say over federal laws and regulations such as the ACA. That meant the office spent the first two years of the ACA’s enforcement in , determining if rates were in compliance with state and federal rules but unable to act if they weren’t.

That law expired this year.

Insurance office staff actuaries will now be able to review the insurers’ proposed changes and have the final say in whether the proposals are justified, said Harvey Bennett, spokesman for the office. If not, insurers will have to file new rates or, in certain cases, may appeal the decision.

Cigna, with an increase of 12.82 percent, said part of its justification for the jump comes from the data insurers now have on the newly insured ACA population.

“As our understanding of the specific clinical experience, needs, claims and medical trends of our individual customers becomes more extensive, Cigna continues to refine its offerings so that our health plans are more closely aligned with the needs and preferences of the communities we serve,” said Cigna spokesman Joe Mondy in a statement.

Other plans with increases greater than 10 percent included United Healthcare (18.19 percent) and Preferred Medical Plan (14.5 percent.) Missing from the mix was the state’s largest insurer: Florida Blue.

For 2015, Florida Blue averaging 17.6 percent on its exchange plans. The proposed 2016 rate will increase by less than 10 percent but the company chose to keep the actual rate under trade secret protection citing competitive reasons.

Still, the proposed rates for many of the companies will likely change before they are finalized at the end of the summer.

Miami Herald reporter Daniel Chang contributed to this report.

This story was produced in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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Sen. Rene Garcia, a Miami Republican who chairs the Senate healthcare budget committee, in a panel discussion with Sen. Anitere Flores, R-Miami, and Rep. David Richardson, D-Miami Beach, said a health care crisis still exists in Florida after the Legislature adjourned without passing a budget. About 850,000 Floridians fall into the healthcare “gap” created when Florida chose not to expand Medicaid.

Garcia said he is frustrated with the House’s refusal to explore options for Medicaid expansion: “It just makes no sense to me that you cannot sit in a room and have a conversation as to how we are going to fix the problem.”

The panel offered some hope of a solution to the impasse, noting that House appropriations chair Rep. Richard Corcoran, R-Land O’ Lakes, called the Senate’s proposed Medicaid expansion plan  earlier this week, with the caveat that the Senate guarantees it will take up several other House proposals.

“Maybe … things have to get worse before they have to get better,” Flores said. “The sad thing about that is that in the issue of healthcare, when things get worse before they get better, it means that people die.”

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A few months later, a health scare would put the South Florida woman’s high-stakes gamble to the test. But at the time, she said, the calculation was clear. Paying a “several hundred dollar” penalty for remaining uninsured was much cheaper than forking over a monthly insurance premium of at least $200 under the Affordable Care Act — the only insurance she qualifies for.

For Denig, buying insurance for herself is way down on a list of expenses that starts with taking care of her two teenage sons. And the penalty, which is designed to exert increasing pressure on the uninsured to sign up for a plan, wasn’t high enough this year to change her priorities.

The Obamacare fee is still small enough this year — $95 or 1 percent of household income in 2014, whichever is greater — to make it worthwhile for people like Denig to opt out of health coverage. The U.S. Department of Health and Human Services estimated earlier this year that 2 to 4 percent of consumers would pay the penalty, but final numbers have not yet been released by the Internal Revenue Service.

That’s likely to change, though, when the penalty nearly quadruples next year and then spikes to $695 or 2.5 percent of household income, whichever is greater, in 2016.

For Denig and others, the affordability of insurance is still the key question — and the main frustration.

“I feel let down and defeated,” Denig, 41, said of the high premiums she was offered and rejected. “Then they’re gonna punish me by making me pay for it?”

The Margate office manager said that when she checked her Obamacare eligibility online, she was floored to see her premiums ranged from $200 to $500 per month. Financial assistance to reduce premiums is available to those whose incomes are below 400 percent of the federal poverty level, which for an individual is $46,680 a year.

Herrera said an increase from a $50 premium to a $100 premium has pushed some families to forgo coverage, while others have chosen penalties when their premiums were as high as $600 and $700.

“They tell me, ‘I’m not going to stop eating so I can have health insurance,’” Herrera said.

Miami Beach real estate agent Robert Young goes to a health center to stitch together his healthcare while he waits for an option that doesn’t force him to pay the penalty. He paid the minimum penalty for 2014 and will pay again when tax time rolls around next April.

“I had to give up surfing because I can’t afford to break anything else,” said Young who goes to the Miami Beach Community Health Center. There, he pays $35 for a doctor visit and $50 for a dental cleaning. His premiums under Obamacare were priced at about $500 a month. He has been uninsured for a decade.

Young knows the 2016 penalty — $695 or 2.5 percent of household income — will make him reconsider. At one point, he said, the penalty will surpass the premiums and then he will be left with no options — unless something changes on either end.

“Am I going to keep paying penalties? Probably,” said Young, who is in his 50s. “I can’t afford it otherwise.”

A Flaw in the Application

The law offers some ways to reduce the number of consumers paying a penalty, said Justin Giovannelli, a research fellow at Georgetown University’s Health Policy Institute. But the application form still leaves out household expenses when calculating need, an omission that health counselors have said might hurt those who sign up.

The ACA caps the amount a person’s premium can take from their income. The cap is no more than 2 percent of income at 100 to 133 percent of the federal poverty level and can go as high as 9.5 percent of income for those between 300 and 400 percent of the federal poverty level.

“That doesn’t mean that the legal definition of what’s affordable and not doesn’t leave some people paying a lot money,” Giovannelli added.

Those above 400 percent of the federal poverty level don’t get a cap or financial assistance on their premiums.

Still, exemptions for those who suffer hardships or have trouble paying bills have bailed some consumers out of the penalty.

Herrera, of CHI, said he’s been able to file various exemptions for consumers who felt their premiums were too high, stating that other expenses make purchasing healthcare difficult on their budget. Most have been approved, and the penalty waived.

But a health counselor for the Epilepsy Foundation, Juanita Mainster, said the flaw in the law has been a barrier for enrollees: When consumers sign up for health insurance all they are asked to report is their gross income — not expenses.

“I had people that came in and said, ‘Well, I have to pay my car payment and I have to pay whatever other expenses, and why can’t they take that into consideration?’” Mainster said.

That was the concern for Giancarlo Alfano, 26, who had to give up his $70 a month Obamacare plan when he landed a full-time job. The job caused his income to rise and his premium to skyrocket to nearly $400.

For the administrative assistant, who moved to Miami from Venezuela last January, the job was the break he was hoping for — but it came at a price.

“Now that I’m making more money than I was before, I don’t have any benefits, and I don’t think that’s very fair,” Alfano said.

He got married in August, and he and his wife, Paola, decided they could forgo coverage if it meant beginning to make a life together.

“We want to start building up our finances, buying a house, building a family,” Giancarlo Alfano said. “We decided let’s just take the penalty because it’s going to be less expensive than having to pay for insurance.”

A Rainy Day

For the penalty payers, a health scare can change everything.

In the case of Denig, the single mother from Margate, that fear became a reality only months after she decided to risk a year without insurance.

A tumor in her breast led to mammograms, MRIs and, eventually, surgery. Luckily, the growth was benign.

But her rainy day funds — only for emergencies — evaporated.

“The rain came,” Denig said. “And in Florida, it rains a lot.”

She is out of money if another health problem comes her way. Her eldest son, who graduated from high school last year, went to work at a part-time job the next day. The family is unable to pay for college, even though — according to the ACA — Denig can afford hundreds of dollars a month in insurance.

And the ever-growing penalty looms in the horizon.

“Next year, the penalty will be so high it will completely swallow my income tax refund, and what will I do then?” Denig said.

Next year, there won’t be a rainy day fund.

“As the months roll by, I feel the noose tightening around my neck,” she said.

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In September, the insurer will debut three “integrated care” facilities designed to cater to South and Central American populations by offering primary care, specialty services, labs and diagnostics under one roof — a model that is common in Latin America.

The move reflects a consumer-focused style of administering care that has grown in popularity since the implementation of the Affordable Care Act. Now, more consumers are insured than ever before — 1.6 million Floridians enrolled in the marketplace in 2015 alone — many also leaving their employer’s coverage to shop for individual plans on the exchange.

The result: Consumers want more transparency and affordability, with the option to price compare and get speedy service.

Enter retail health care — the Expedia model for medical services — in which clinics post their prices and allow consumers to choose which services they want, where and when. No making appointments. No waiting for doctors. No ambiguous price schemes.

Krista Bowers, managing director for Miami-based health care consulting firm BDC Advisors, said that out-of-pocket costs and high deductibles, which are common in the most popular marketplace plans, have made consumers more price conscious. And that has fueled the growth of a retail-centric clinic model.

“They have more skin in the game,” Bowers said. “The more money you have at stake, the more you’re willing to shop.”

People don’t want to wait months to get an appointment with a primary care provider, Bowers said, nor do they want to guess how much a service will cost.

“The traditional kind of physician office, because of its inability to be super effective and because of its inability to offer convenient costs, is being attacked,” Bowers said.

In the last decade, more retailers have joined the charge, led by CVS, which opened its MinuteClinics in 2006 offering anything from flu shots to physicals. Now there are more than 960 MinuteClinics nationwide. About 300 have opened since 2012 alone, including 33 in Florida.

Andrew Sussman, president of the MinuteClinics, said that a primary care doctor shortage, an aging population and an epidemic of chronic disease has powered the retail health care option.

According to a report released this month by the Association of American Medical Colleges, there will be a predicted shortage of 46,100 to 90,400 physicians by 2025.

This is where the retail clinics will fill the void, experts said, by not replacing the primary care physician, but rather adding another avenue for care.

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The numbers were released from the U.S. Department of Health and Human Services just as the legality of the financial help, which comes in the form of tax credits, is being tested in the courts. The U.S. Supreme Court heard arguments March 4 in a case challenging tax credits under the provisions of the ACA.

About 93 percent of the nearly 1.6 million Floridians who signed up for health insurance on the federally-facilitated marketplace during the enrollment period that ran from Nov. 15 to Feb. 15 received a tax credit to lower the cost of their monthly premium. In 2014, 91 percent of Florida consumers had financial help.

Only Mississippi ranked higher, with 94 percent of enrollees receiving a tax credit.

“The figures released today tell a story of health coverage consumers rely on for financial and health security — and of coverage they don’t want to lose,” said HHS Secretary Sylvia M. Burwell, in a press release.

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“Most people hand you that card like they are giving you an American Express Platinum without a limit,” said Martinez, vice president of the Dade County Medical Association, the largest physician group in the South Florida county.

But for many physicians, the so-called Obamacare cards also mean new challenges — consumer misinformation, increased paperwork, heavier patients loads and the worry of unreliable reimbursements and payments.

“We have turned people away,” Martinez said. “ I know some colleagues who said, ‘At this time we are not taking any Obamacare patients.’ It’s a preventative action to avoid having these problems.”

The ACA does not penalize doctors for refusing to take Obamacare patients, but those who do may be in violation of their their contractual agreements with insurance companies.

The stresses for providers then become evident from the moment new patients come in.

Some don’t know the name of their insurance companies. Many are surprised by high deductibles. Doctors are placed in the sometimes-difficult position of teaching patients that insurance doesn’t mean everything is covered.

Until the deductible is paid, services doctors provide outside the ACA’s free preventative care screenings go unpaid, a situation that can become volatile when a screening reveals a chronic condition that requires deductible payments before treatment begins.

“They look at you like if you’re crazy and say, ‘No, but I have insurance,’” Martinez said. “We become the target of their frustrations. We are the doctors. We are the bad people. They have the card and [they think] we don’t want to see them.”

Wollschlaeger said explaining deductible costs has led to “bad blood” between him and several of his patients, with some even leaving his practice.

“I have to explain that it’s not me, it’s the insurance plan they chose,” he said.

Communicating with insurance companies and ensuring payment for services is often difficult, too.

Under the ACA, patients who stop paying their monthly premiums have a 90-day “grace period” to start paying their bills. After the first 30 days, these patients go into a “pending” status with their insurance company. Once pending, the patients can continue to receive care, but physicians will not be reimbursed by the insurance company, and if the patients can’t cover the costs either, the doctors are left unpaid.

Martinez said his office staff spends up to 30 minutes on the phone with insurance companies to establish if ACA patients are still paying their monthly premiums. Even after insurance companies say the person is on the plan, they often add the caveat of “no guarantee for payment,” Martinez said.

Money isn’t the reason most doctors go into the profession, he said, but it is necessary to keep his practice afloat and pay his staff.

“People don’t understand that running a medical office is like running a small business,” Martinez said.

And then there’s the extra paperwork that must be completed, from charts for new ACA patients to quality of care self assessments.

Wollschlaeger said administrative tasks have become about 40 percent of his workload, up from 20 percent before the ACA. On Monday, he finished seeing patients and started paperwork at 6 p.m., a time he would have used for that modern-day rarity, house calls.

“Something has to give,” Wollschlaeger said. “More paperwork means less patient care.”

Steven Ullmann, director of the Center for Health Sector Management and Policy at the University of Miami, said the average load for a primary care doctor is about 3,000 patients a year. This year, Florida enrolled 1.6 million consumers in the federal marketplace, adding to the primary care burden.

According to a 2014 survey by the Physicians Foundation, 81 percent of doctors describe themselves as over-extended or at full capacity, up from 75 percent in 2012 before enrollment began. About 44 percent said they planned to cut back on the number of patients they see, stop taking new patients altogether, work part-time or retire.

Wollschlaeger has come up with his own solution to juggle the growing patient load: work more hours.

As the program continues to develop in the next few years, doctors say consumer education and streamlining of paperwork and payments will help.

“The success stories of the system are when a patient tells me that it’s the first time that they can get regular care,” Wollschlaeger said. “I want the system to work.”

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The other alternative was Florida Health Choices, a voluntary marketplace created in 2008 for Floridians to purchase coverage. It operates independently of the federal exchange at healthcare.gov — which enrolled 1.6 million Floridians — and unlike the federal exchange, does not offer subsidies.

With the open enrollment period over on Feb. 15, the numbers are in. A total of 42 consumers enrolled for health care plans this year and another nine people obtained other insurance coverage on the state marketplace. Their total premiums: $253,170.

The state has spent $2.4 million to run the program, despite signing up fewer than 50 Floridians, said Rose Naff, CEO of the state exchange.

The average monthly premium for a plan at Florida Health Choices was $427, Naff said.said Rose Naff, CEO of the state exchange.

Still, Naff insisted it is not a healthcare.gov vs. Florida Health Choices issue.

“We are not in competition with healthcare.gov,” Naff said. “Our target audiences are miles apart from each other. We don’t offer any subsidies and we are not giving it away for free.”

She said about 25 percent of consumers who contacted the Florida exchange left to pick a plan on the federal exchange instead.

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