presents The New Insurance Marketplace and MS Live Webinar November 19, pm Eastern

Transcription

1 presents The New Insurance Marketplace and MS Live Webinar November 19, pm Eastern

2 Guest Presenters Kent Rogers, MBA Principal Consultant Blue Fin Group and Margaret Weisser, LSW Manager of Client Services MSAA

3 Acknowledgements MSAA would like to take this opportunity to thank the supporters of this program. This webinar, as well as additional ACA program initiatives, are made possible through unrestricted educational grants from: Biogen Idec Genentech Genzyme, a Sanofi company Novartis Pharmaceuticals Corporation These supporters had no involvement in the development of this or other ACA program content.

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5 New ACA Publication Through the support of our funders, MSAA is pleased to offer a brand new, eight-panel brochure on this important topic. The Affordable Care Act and Multiple Sclerosis is available free of charge by: visiting our website, mymsaa.org, or calling (800)

6 Participating In The Webinar MSAA encourages you to actively participate in tonight s webinar by: Responding to the polling questions included in the program Submitting your questions throughout the webinar by typing in the Chat box on the lower left side. We will address as many questions as time allows at the end. Completing a follow up survey at the end of the program to help us improve future webinars and develop additional programs to meet your needs If you are experiencing any technical problems with tonight s webinar, you can also use the Chat box feature to type in your issue. The online moderator will respond to your chat and work to correct the problem.

7 The New Insurance Marketplace And MS Webinar Objectives The goal of this program is to provide you with an explanation of the new Marketplace under the ACA with specific emphasis on the needs of MS community. We will cover: Common insurance terms which are important for coverage selection Broad changes the Affordable Care Act enacted in insurance and the benefits for the MS Community How to enroll in the new Healthcare Marketplace/Exchanges Critical issues that affect the MS community (i.e., access to medication, step therapy pitfalls, MRI and durable medical equipment co insurance costs)

8 What Should I Know To Start? As a consumer of healthcare, you ll need to understand the terminology

9 What Does That Mean? Co Pay It is typically a flat dollar of $10 15 for generics and $25 35 for preferred brand drugs. So called non preferred drugs will cost more than $45 per month. Co Insurance This is a relatively new initiative by insurance plans in response to specialty medications that can cost thousands of dollars per month. Instead of a flat dollar amount, it s a percentage of the cost of the medication (e.g. $150 $400 per prescription).

10 What Does That Mean? Premium Just as with auto insurance, you pay a monthly fee to have the benefit of insurance coverage. Consider this your monthly fee just to have the benefit of healthcare insurance. The insurance companies use this fee to manage medical/pharmacy costs for all patients. Deductible This is the amount of money you will pay as a beneficiary for your medical and pharmacy care within a calendar year period before the health plan begins to help with a percentage of the cost. In other words, if your deductible is $3000 and you have an accident which causes you to be hospitalized, have rehabilitation services, etc. etc., you will pay out of your pocket until you ve spent $3000, then the plan will assist. Maximum Out of Pocket This is the most you will pay out of your pocket including your deductible (check your health plan) and any covered costs you have incurred above that amount. Consider this to be the most you ll pay if the worst happens. Premiums are not included in this amount.

11 Here s The Math If you have a $500/month premium and a $3000 deductible, the most you will pay in a given year outside your co pays for drugs, office visits and other services is the following: 12 Months of Premiums $6, Deductible $3, Maximum Out of Pocket $5, Total max out of pocket $11, (co pays not included)

12 One More Thing If your employer pays a part of your premium, your total yearly cost for healthcare may be very low. That s because your employer pays toward your monthly premium and may pay for your deductible. Your portion typically comes out of your paycheck so you don t feel the monthly cost of healthcare. Individuals may see a cost savings or have better access to healthcare that they did before, but others may notice they have to pay more than they previously did.

13 The Affordable Care Act a.k.a. The ACA or Healthcare Reform

14 Why Is Healthcare Reform Needed? Aging Population Rising healthcare costs Rising percentage of our economy Costs Exceed Nation s Income

15 What s In It For The Patient? A few aspects of the new law Pre Existing Condition Exclusions are eliminated Coverage is now available to dependent children up to age 26 No yearly/lifetime benefit caps Insurers must justify any premium increase of 10% or more before it can take effect Female customers are no longer charged more then men for accessing the same plan Many patients who could not qualify for Medicaid or a subsidized insurance plan now can

16 Before We Continue Let s learn more about the status of your healthcare insurance coverage

17 Mark Your Calendars Enrollment Began Deadline for January HIX Coverage Begins Deadline for April HIX Coverage Begins October December January March April OUR NEW HEALTHCARE SYSTEM

18 Step 1: Determine Your Current Expenses What is your monthly income? Can you afford a plan that will not cut into your monthly budget? Where is your spending more flexible? Four levels of coverage to consider: Bronze, Silver, Gold and Platinum Each pays up a certain percentage of your healthcare costs Please note: Only Silver plans qualify for out of pocket assistance (copay/co insurance help for those that qualify) which differs from premium assistance. Bronze level plans do not offer this. Remember that the lowest cost premium will not always save you the most money if you are using health services frequently. So, it s important to carefully consider all of your options.

19 Step 2: Determine Your eligibility Are you eligible for public assistance? Utilizing the Marketplace Eligibility Tool, you can determine if you are eligible for either: Medicaid Tax Credits (assistance with monthly premiums)

20 The ACA Website

21 Utilize The Website To Navigate Your Choices Based On Your Particular Situation

22 You Will End Up With One Of Two Options 1) A Healthcare Insurance Exchange plan 2) A Medicaid Plan

23 There Are Three Types of Healthcare Exchanges State-Based Exchange State Partnership Exchange Federally Facilitated Exchange

24 Who Is Likely To Enroll In The Marketplace People who cannot afford insurance Those who make too much money for Medicaid, but have not had employer sponsored insurance People previously denied coverage Those not able to find insurance because of medical conditions; may or may not have been in high risk pools People who feel they don t need coverage Those in their 20s and 30s who have chosen not to pay for insurance in the individual market

25 Who Is Not Qualified For The Marketplace? American Indians, prisoners, undocumented immigrants, various religious groups Income so low that a tax return is not filed Enrolled in Medicaid, Medicare, or a veteran s program

26 Am I Eligible For Medicaid Medicaid eligibility has expanded under the ACA Many states have either enacted this expansion or are leaning toward doing so If you are eligible, the website will direct you to the appropriate enrollment body within your state

27 Income Will Determine Whether You Qualify For Medicaid Or A Healthcare Exchange Income (% of FPL) Coverage Premiums and cost sharing <133% of FPL Medicaid No premiums and cost sharing is minimal 134%-250% of FPL Exchange Subsidized 3 to 8 % of income 251%-400% of FPL Exchange Subsidized 8 to 9.5% of income Source: Federal Register published on January 26, 2012

28 Next Steps... So If I do not qualify for Medicaid but I do for private insurance now what?

29 Consider What You re Going To Spend & What You ll Get For Your Money The Deductible Monthly Premium Covered Medications My Primary Care Doc My MS Specialist

30 You Should Know As Part Of The New Law, Essential Health Benefits Must Be Covered

31 The Premium The more you spend per month (your premium) to have insurance, the more choices you have for your medications and treating physician. In turn, the more likely the lower your yearly maximum out of pocket and your yearly deductible will be. The trade off is that if you do not use the healthcare system, you re still spending money. Deductible Premium

32 Factors To Consider Your benefits with: 1) Choice of Dr. 2) Choice of Meds 3) Covered Costs Your expenses on: 1) Monthly Premiums 2) Co-Pays 3) Yearly Deductible $$$

33 The Individual Mandate What Happens If Individuals Choose Not To Be Insured? A penalty of $95 for adults, up to $285 per family, or 1% of taxable income, whichever is greater will be assessed A penalty of $695 for adults, up to $2,085 for a family or 2.5% of taxable income, whichever is greater will be assessed Source: PPACA Legislation

34 What to Look For... Now If You ve Determined You Have To Purchase Healthcare, What Should You Look Out For?

35 Are My Medications Covered? A key focal point for the MS community is determining which medications are available to you Not all plans will cover all drugs If you have been prescribed a specific disease modifying therapy (DMT), you must confirm if it is a part of the drug formulary for your targeted plans

36 Are My Medications Covered?(cont.) This same rule applies for any symptom management therapies you may be prescribed as well Special attention must be paid to the possibility of your needed medications being placed in Specialty Tiers (ex: Tier 1, Tier 2, etc..) Instead of a flat co pay, certain higher cost medications are placed in a Tier that charges a percentage of cost. Be aware of percentage costs vs. dollar amounts. (ex: 25% of monthly DMT costs can be hundreds of dollars)

37 Can I Still See My MS Doctor? Many people with MS may have developed a specific healthcare team. This team may include your Neurologist/MS Specialist, possibly a PT, OT, Urologist, Neuropsychologist, etc Keep track of who your medical team is in full detail, and determine if the plans you have targeted include these physicians/allied healthcare providers of choice.

38 Remember! If you have to go out of network to see your physician, your co payment costs per office visit will be much higher if they are allowed at all under your plan! If a plan doesn t cover all of your specialists, you may need to prioritize which are most important for you to keep in network.

39 Are There Co insurance Costs For DME & MRIs? MRIs are an essential part of staying one step ahead of your MS disease course Looking at each plan that you have targeted, you can extrapolate what the cost of MRIs may be to you, particularly via co insurance The unpredictability of MS may enhance your need for durable medical equipment (DME) Look carefully into the co insurance or co pay costs for DME items

40 How Do I Appeal? By this point, you may have shortened your list down to a few insurance options Take note of specific plan language at this point (Evidence of Coverage), and understand that each plan will have an appeals process While procedural denials are less likely in the new Marketplace, it is wise to know how to approach any issues you may run into with your healthcare provider

41 If Your Circumstances Change Let Your Insurance Plan Know If your employment or income status changes at any time during the year, it is imperative that you report this information to your insurance provider or your State Exchange This information is utilized to determine your eligibility for premium assistance, as well as Medicaid Failing to do so could leave you subject to penalties

42 Now You re Ready To Select A Plan! With this information, you should be ready to enroll in one of the plans within the Marketplace Please note that MSAA is here to help: MSAA Client Services (800) , ext. 154 The Marketplace also provides Navigators that can help walk you through the application process and answer specific questions about plan choices!

43 Mark Your Calendars Enrollment Began Deadline for January HIX Coverage Begins Deadline for April HIX Coverage Begins October December January March April OUR NEW HEALTHCARE SYSTEM

44 Questions?

45 Thank You This concludes tonight s webinar: The New Insurance Marketplace and MS This webinar will soon be available on MSAA s website, mymsaa.org. As a reminder, additional ACA information is available now on our website under About MS. Once again, I would like to thank Kent Rogers and Margaret Weisser for their excellent presentation tonight as well as program sponsors Biogen Idec, Genentech, Genzyme, a Sanofi company; and Novartis Pharmaceuticals Corporation. Please be sure to complete the very brief survey that immediately follows the conclusion of this program. On behalf of MSAA, thank you for joining us.