CORAL GABLES -- The venomous caterpillar that stung Marci Montgomery in her Coral Gables garden in July has a nickname -- "The $2,600 Worm" -- because that's the amount of the bill she received for about four hours of treatment in the emergency room.
Montgomery, 62, went to Coral Gables Hospital after a Florida puss caterpillar delivered a sting so painful that it felt as though she'd broken her hand.
She has health insurance through Aetna -- a plan Montgomery bought on the Affordable Care Act exchange at healthcare.gov -- but she's on the hook for the $6,000 deductible.
"I could have bought a new refrigerator for that," Montgomery said of the bill. "Now I have to scrape up $2,600 because a caterpillar stung me."
Open enrollment, the three-month period when people can sign up for health coverage, begins Sunday, and Montgomery plans once again to choose from the 57 plans for sale in 2016.
Like many consumers who must buy their own health insurance or pay a fine under the law, Montgomery is thinking first about what she can afford for next year. Though well aware of her deductible and the financial risk she was taking, many others do not fully factor that cost into their choice of an insurance plan.
A self-employed marketing consultant, Montgomery earns too much to qualify for financial aid under the law. Still, it's a challenge to meet her current plan's premium of $733 a month.
"I have college loans for my kids. I have a lot of obligations. So money is tight for me in terms of a monthly budget," she said. "(Paying) $733 a month is something I really have to work on. I put it on a credit card, and that's driven up my balance, and I have to look at these 21-month, zero-interest cards to try and manage that debt."
The cost of coverage remains a top concern among most Americans shopping for coverage on the exchange -- and, perhaps as importantly, for those who are eligible for financial aid but remain uninsured.
According to the nonprofit Kaiser Family Foundation, about 825,000 Floridians had no health insurance in early 2015 even though they were eligible for financial assistance to make their coverage more affordable under the health law commonly known as Obamacare.
Nationally, about 10.5 million uninsured Americans are eligible for financial aid to buy a plan on the exchange, according to the U.S. Department of Health and Human Services. Nearly eight in 10 people without insurance have less than $1,000 in savings, HHS has reported, and about half have less than $100 in savings.
Many of the eligible-though-uninsured are younger than 34, more likely to be male, and tend not to know enough about the exchanges and the financial aid available to them.
In the weeks leading up to open enrollment, HHS has promoted coverage for $100 or less a month for those who qualify for financial aid. And affordability has been a frequent talking point for HHS Secretary Sylvia Mathews Burwell, who spoke with reporters in October about enrollment efforts for 2016.
"We're going to be talking a lot about financial assistance since we know costs are on our customers' minds," Burwell said.
Cost isn't the only reason people are dropping or losing coverage, or choosing to remain uninsured.
Last February, 11.7 million people had signed up for a plan through the ACA state and federal exchanges. But by June, only 9.9 million were still covered through an exchange. In some cases, HHS ended coverage for consumers who failed to prove citizenship or immigration status (about 423,000 people in 2015.) And about 967,000 households had their financial aid adjusted after verifying their income.
Others gained coverage through an employer, or their income dropped after enrolling and they no longer qualified for financial aid.
Enrollment counselors and consumer advocates believe many of the eligible uninsured -- as well as the newly insured under the health law -- still don't understand what insurance is for or how to use it.
They're confused about provider networks, frustrated over unexpected bills or unaware they must pay deductibles and other out-of-pocket costs in addition to the monthly premium, said Karen Egozi, president of the Epilepsy Foundation of Florida, which received a three-year $1.8 million "navigator" grant from HHS this fall to help consumers enroll for coverage on the exchange.
"A lot of people get the insurance, and they don't use it all year. They think there isn't anything they need to do," Egozi said. "A lot of people signed up for insurance -- not necessarily through a navigator but maybe through an insurance company or an insurance agent or one of these Mall of the Americas places where they stand in line and they made bad choices.
"We get a lot of those," she said. "They don't even remember their email accounts, so they can't check to see if there's been correspondence from the marketplace. There's been a lot of problems."
Entering the third year of the ACA exchanges, Florida navigator groups plan to make an extra effort to educate consumers about coverage, said Jodi Ray, director of Florida Covering Kids & Families at the University of South Florida, which received a three-year, $5.9 million grant to counsel consumers.
"I know we were trying to work very hard to get a lot of people into coverage the first two years," she said. "But one of the things that we're really focusing on this year is the education, the coverage-to-care component -- what exactly does health insurance mean and how to value it."
The Epilepsy Foundation, one of four navigator groups serving Miami-Dade, plans to send 25 to 30 counselors to hospitals, health fairs, community centers, college campuses and other areas to help locate the eligible uninsured.
Egozi said a social-media campaign and a diverse group of counselors will also play a key role in outreach.
In addition to navigators focusing on education, the federal Centers for Medicare and Medicaid Services, which administers the insurance exchange at healthcare.gov, has redesigned the website, adding new features to help consumers estimate costs and determine whether a plan includes their preferred doctor or hospital.
Consumers also are urged to shop around instead of sticking with the same plan because the lowest-priced plan in 2015 will not necessarily be the lowest-priced plan in 2016.
Those who are eligible for coverage but don't sign up will pay a larger penalty in 2016: $695 per adult or 2.5 percent of an individual's annual income, whichever is higher.
"More and more and people are going to stop and look and ask, 'Do I want to pay this penalty?' " said Egozi of the Epilepsy Foundation. "I think it's becoming more real."
For consumers such as Montgomery, the Coral Gables woman stung by a venomous caterpillar, the emergency room bill was a stark reminder of why she needs health insurance.
"There's a lot to lose if you don't have some kind of coverage," she said, "and I just continue to think: If I can run up a $2,600 bill in a few hours from a caterpillar sting, what can you run up if some uninsured driver hits you in the middle of an intersection and you break bones?"