Health Insurance Basics. Ashley Frevert, Field Navigator Northeast Nebraska Community Action Partnership, Inc. Pender, Nebraska

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1 Health Insurance Basics Ashley Frevert, Field Navigator Northeast Nebraska Community Action Partnership, Inc. Pender, Nebraska

2 What Is Health Insurance? Health Coverage your legal entitlement to payment or reimbursement for health care costs Health Insurance a contract between you and your health insurance company that requires your company to pay some or all of your costs of health care services Creditable Coverage Group health plans Individual health insurance Student health insurance Medicare/Medicaid CHAMPUS/TRICARE Federal Employee Health Benefits Program Indian Health Service Peace Corps Public Health Plan CHIP State health insurance high risk pool

3 Health Insurance Terms Premium The amount of money that must be paid to have insurance; paid by you and/or your employer either monthly, quarterly or yearly Deductible The amount of money you pay for health care services, generally before your health insurance plan begins to pay May not apply to all services Coinsurance The amount of money you pay as your share of coverage services, calculated as a percentage (ex. 20%) Copayment The fixed amount of money you pay for covered services at the time of service Varies by type of health care service (ex. $30) Out-of-pocket Maximum/Limit The amount of money you pay during your policy year before your health insurance plan begins to pay 100% of total costs Includes deductibles, coinsurance, copayments or similar charges that are a qualified medical expense

4 More Terms In-network vs. Out-of-network When receiving a health care service, in-network services are usually cheaper than out-of-network services Coinsurance and copayments may differ (check with providers before receiving the services) Claim A request for payment that your health care provider submits to your health insurance company when you receive items or services that are covered Formulary Also called a drug list A list of drugs covered by a prescription drug plan or health insurance plan offering prescription drug coverage Cost-sharing The costs covered by your insurance that you pay out-of-pocket (ex. deductibles, copayments, coinsurance) Summary of Benefits and Coverage (SBC) Simple and easy-to-read document detailing information about health plan benefits and coverage Summarizes key features of the plan including covered benefits, cost-sharing provisions and limitations/exceptions

5 The Affordable Care Act How does the Affordable Care Act affect health insurance? Insurance companies can no longer charge higher monthly payments based on health status or gender Children can stay on a parent s plan until age 26 if the plan covers dependents Insurance companies can t refuse health coverage to a person who has a preexisting condition Annual and lifetime coverage limits are now unlawful New health coverage options are made available Strong protections have been created for people who need health coverage People can now browse and compare health insurance plans in one place The Health Insurance Marketplace

6 Essential Health Benefits In the Health Insurance Marketplace, a comprehensive package of items and services for an insurance plan is required to be considered a qualified health plan. Doctor visits Emergency services Hospitalization Maternity and newborn care Mental health and substance abuse disorder services Prescription drugs Rehabilitative services Laboratory services Preventive and wellness services Pediatric services (dental and vision)

7 Your First Doctor Visit What do you bring to your visit? Insurance card Photo I.D. Forms you might have needed to fill out ahead of time Medical records List of current medications/vitamins (how much and how often) List of allergies (seasonal, toward any medications, etc.) Be prepared to pay your copayment. Be prepared with a list of questions you want to ask. Nervous? Bring someone with you!

8 Your First Doctor Visit Ask lots of questions! If you aren t 100% sure of your next steps after your appointment, ask your doctor to repeat your instructions or write them down If you want more information about a certain medication, ask your doctor at the time of visit or your pharmacist when you pick up the prescription If you get home and you have more questions, don t hesitate to call the doctor s office and speak with the doctor or the doctor s nurse

9 Doctor s Office vs. Emergency Room If you have an emergency or life-threatening situation, call 9-1-1! Doctor s Office Go when you feel sick and when you feel well You usually see the same doctor each time you go Doctor will check all areas of your health May have shorter wait time; longer visit Doctor can access your entire health record Emergency Room Go only when you feel very sick or have life-threatening situation You will see the doctor that is working that day Doctor will check only the problem that you brought up to them May have longer wait time; shorter visit Doctor may not be able to access your entire health record YOU MAY HAVE A HIGHER COPAY/COINSURANCE FOR EMERGENCY ROOM VISITS

10 Scenarios Doctor s Visit or Emergency Room? What s the term? Is it covered? Is it considered creditable coverage? Does it meet qualified health plan requirements?

11 Scenario #1 You ve noticed over the past week that you ve been sneezing more and more often. It s Wednesday evening and you have a slight fever. Doctor s Visit or Emergency Room?

12 Scenario #1 Discussion Ask yourself Are my symptoms severe enough to go to the hospital? Are my symptoms life-threatening? Do I need immediate medical attention, or can I make an appointment to see the doctor tomorrow? If you decide it is not an emergency Make an appointment with your doctor as soon as possible If necessary, visit your nearest convenient clinic Payment may be required at time of service

13 Scenario #2 You arrive at your doctor s appointment for your fever the next day. The receptionist views your insurance card and requests a fixed fee at the time of service. What s the term for your payment at the time of service?

14 Scenario #2 Answer Copayment The fixed amount of money you pay for covered services at the time of service Varies by type of health care service (ex. $30) Remember Your copayment for a doctor s visit will be different than if you went to the emergency room Usually, a doctor s visit is cheaper

15 Scenario #3 After going to your doctor s appointment, you were diagnosed with Influenza. You decide that this coming Fall, you will be getting a flu shot from your doctor to prevent being sick again. Is your flu shot covered by your insurance company?

16 Scenario #3 Answer Preventive Services If you receive a preventive service (such as a flu shot), all Marketplace plans and most other health insurance plans must cover the following list of preventive services without charging you a copayment or coinsurance Abdominal Aortic Aneurysm one-time screening (men of specific ages who have ever smoked) Alcohol Misuse screening and counseling Aspirin use (to prevent cardiovascular disease for men and women of certain ages) Blood Pressure screening Cholesterol screening (for adults of certain ages or at higher risk) Colorectal Cancer screening (for adults over 50) Depression screening Diabetes (Type 2) screening (for adults with high blood pressure) Diet counseling (for adults at higher risk for chronic disease) HIV screening (everyone age 15 to 65 and for other ages at increased risk) Immunization vaccines Obesity screening and counseling STI prevention counseling Syphilis screening (for adults at higher risk) Tobacco Use screening (for all adults and cessation interventions for tobacco users)

17 Scenario #4 While talking to your best friend over the phone about your recent illness, she states that she has a prescription drug plan that covers her yearly allergy injections. She claims to not get sick often, but the plan she has covers what she needs. Does she have creditable coverage under the Affordable Care Act?

18 Scenario #4 Discussion Creditable coverage Group health plans Individual health insurance Student health insurance Medicare/Medicaid CHAMPUS/TRICARE Federal Employee Health Benefits Program Indian Health Service Peace Corps Public Health Plan CHIP State health insurance high risk pool A prescription drug plan or membership in an organization that provides prescription drug benefits is NOT considered creditable coverage

19 Scenario #5 After speaking with your friend, you decide to help her with enrolling in a health insurance plan. However, your friend has already went to the local insurance agent, who has given her different options. She tells you that one of the plans does not cover prescription drugs and wants to keep her prescription drug plan. Does this health insurance plan meet qualified health plan requirements?

20 Scenario #5 Answer To be a qualified health plan in the Health Insurance Marketplace, the health insurance plan must meet the following requirements Provide essential health benefits Establishes limits on cost-sharing (like deductibles, copayments and out-of-pocket maximum amounts) Must be certified by each Marketplace in which it is sold Prescription drug coverage is an essential health benefit Without this coverage, it is NOT a qualified health plan

21 Your Insurance Card

22 Websites

23 Contact Information Ashley Frevert, Field Navigator Northeast Nebraska Community Action Partnership, Inc. 603 Earl Street PO Box 667 Pender, NE (402) ext

24 Questions? Thank you!

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