Benefits Plus: An Overview of Private Insurance. Presented by Jacques Chambers November 21, 2013

Transcription

1 Benefits Plus: An Overview of Private Insurance Presented by Jacques Chambers November 21, 2013

2 Housekeeping Please log in using your own individual link. Audio Options: Using your phone, dial: Access Code: and Security Code: Using VoIP, Select the Audio button at the top of your participant window. Select Use your Computer Mic and Speaker. If your computer has this feature available, it will allow you to select your available microphone. Once you make your selection, it will automatically connect you to the audio meeting. All lines will be muted until Q&A. This training will be recorded. Presentation slides and the recording will be posted to Please answer the post-survey to improve future training. 2

3 A&PI Wellness Center s Mission Asian & Pacific Islander Wellness Center transforms lives by advancing health, wellness, and equality for people of all races, ethnicities, sexual orientations, gender identities, and immigration statuses. We believe everyone deserves to be healthy and needs access to the highest quality health care. To us, health care is grounded in social justice. Visit us at 3

4 About A&PI Wellness Center We are a health services, education, research, training, and policy organization with over 25 years of experience providing culturally and linguistically competent services to communities of color and LGBT Americans. We are an anchor institution in San Francisco s Tenderloin neighborhood, providing primary care for residents of all races and ethnicities living with HIV. We run the largest drop-in center serving San Francisco s diverse transgender community, with programming for trans women of color, trans men, and trans youth. 4

5 California Statewide Training & Education Program (CSTEP) CSTEP sets the standard in HIV treatment and public benefits education and training for HIV, health and other providers in California. FREE, Multi-level, Technically and culturally competent CSTEP Treatment offers up-to-date information about HIV and HIV treatment options. CSTEP Benefits provides information related to accessing federal, state and local HIV-focused disability and health care benefits Visit us at 5

6 About the Presenter Jacques Chambers Disability Benefits Counselor Chambers Benefits Consulting Phone: (323) or (888) Web: 6

7 CEU DISCLOSURE Definition: Conflict of Interest (or lack thereof): A conflict of interest exists if any individual entity that is in a position to influence the content, design, or implementation of the educational activity is ALSO in a position to benefit financially from the success of the activity. Commercial Company Support: This session has no commercial support. Training Coordinator: Myrnelle Dizon Speakers: Jacques Chambers and Myrnelle Dizon All the speaker(s)/trainer(s) and planners disclosed that they have no conflict of interest or relevant financial relationships with any commercial interests. Product Endorsement: Speakers will not endorse any specific commercial products. CSTEP does not endorse any product, service, or company referred to in this activity nor any company providing support for this activity. Off-Label Product use: Speakers will inform the attendees if they recommend any off-label product use (use of a product for a purpose other than that for which it was approved by the Food and Drug Administration). 7

8 To Request for CEUs Total Approved CEUs for this Course: 2.0 Hours Qualified Positions for CEUs: MFTs, Nurses, and Social Workers* If qualified and/or interested, please your position, license# and contact information to Myrnelle Dizon at 8

9 PRIVATE INSURANCE 9

10 Overview and Objectives Overview: Employer Provided or Individually Purchased Coverage Life Insurance Disability Insurance Health Insurance Overview of Affordable Care Act (ACA) Objectives: To provide an overview of the private insurance benefits most useful to people living with HIV/AIDS (PLWHA). To demonstrate the differences between employer-provided and privately purchased benefits. To generally show how ACA will work and provide needed assistance to PLWHA. 10

11 Employer Provided v. Personal Employer Provided Benefits are subject to federal law, ERISA. Must meet minimum requirements on information and rights. Limited Damages available. Summary Plan Descriptions Personal Insurance Subject to state insurance laws which may provide substantial damages for bad faith. 11

12 Life Insurance Whole Life Term Life Medically Underwritten Guarantee Issue (group, graded benefit) Summary Plan Description for Group Policy/Contract for Personal Disability Waiver of Premium Other riders Viatical or Life Settlements 12

13 Disability Insurance (Income Replacement) Elimination/Waiting Period Maximum Benefit Period Definition of Disability Own (Regular) Occupation Any Suitable Occupation Income Taxability of Benefits Partial/Residual Disability No Permanent Disability 13

14 Individual Disability (Disability Income) Medically Underwritten Benefit is a flat dollar amount based on earnings at time of application. Benefit paid in addition to any other disability benefit. All provisions are in the Contract. 14

15 Employer Provided Disability (Long Term Disability) Benefit is a percentage of income at time of disability. Basic Monthly Earnings defined in the Summary Plan Description Other disability benefits are subtracted from normal benefit amount (SDI, SSDI). Minimum Benefit Definition of Disability All Provisions in Summary Plan Description. 15

16 Filing a Disability Claim Three parts of claim form Employee/insured Employer (not always with DI) Physician Carrier will request medical records Review medical records every 6 to 12 months. Tendency to terminate benefits at definition change. Always appeal 16

17 Health Insurance Types of Benefit Plans Health Maintenance Organizations (HMO) Exclusive Provider Organizations (EPO) Preferred Provider Organizations (PPO) 17

18 Health Maintenance Organization Must use contracted facilities; otherwise no coverage. Staff Model v. Group Practice v. Independent Practice Association (IPA) Emergency Exception Primary Care Physician (Gatekeeper) Outside service area generally urgent care only. 18

19 Exclusive Provider Organization Must use contracted providers; otherwise no coverage. Must stay in group practice or IPA. Emergency Exception Unlike HMO, there is no gatekeeper, insured may self-refer to specialists. 19

20 Preferred Provider Organization Some coverage for non-contracting providers but less than for contracting providers No gatekeeper physician Typically more expensive 20

21 What the Insured Pays Co-Pays: Small payment collected at point of service. Deductibles: Amount paid before insurance pays anything. Typically calendar year May apply to just certain charges or to all Co-insurance: Percentage paid by carrier. Out-of-Pocket Limit: Calendar Year 21

22 What is not Covered? (Exclusions) Voluntary procedures such as cosmetic surgery Routine dental work and corrective lenses Participating in the commission of a felony Acts of war At present, most do not cover gender reassignment. Alternative health treatments Limitations on Chiropractic and Acupuncture Limits on mental treatment being eliminated. 22

23 Employer Provided Coverage Advantages Employer pays a portion of the premiums. Employer s payment not considered taxable income to employee. Disadvantages Little or no choice of coverage. Employers reducing portion of premiums and increasing deductibles to reduce their costs. 23

24 Affordable Care Act (ACA) Impact on Employer Provided Plans Employers with 50 or more employees will be required to offer health insurance to their employees effective January 1, 2015 (Note: This has been postponed for one year). Employers with less than 50 employees will not be required to provide health insurance, but there are tax credits for those who do. 24

25 ACA Individual/Family Health Insurance Effective April 4, 2014 all legal residents must have some form of health insurance: Individual health coverage Be eligible for employer provided health coverage Medicare Medi-Cal/Medicaid Military, veteran, tribal coverage Income tax penalty for not having insurance: 1% of 2014 household income, increasing future years 25

26 Who is NOT required to have insurance? Undocumented residents Unaffordable (their portion of premium exceeds 8% of household income) Persons below the tax filing threshold Native American tribal members People living outside the United States Persons opposed to health insurance for religious reasons 26

27 ACA Requirements Insurance companies must accept all applicants regardless of their medical history or pre-existing conditions. Rates may vary only due to: Geographic area Plan Age of insured (oldest rate cannot exceed three times that of youngest rate. Cigarette smoker (not used in California) 27

28 ACA Requirements Essential Health Benefits Ambulatory patient services Emergency Services Hospitalization Maternity and Newborn Care Mental health and substance use disorder services, including behavioral health treatment Prescription Drugs Rehabilitative and habilitative services and devices Laboratory Services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care 28

29 ACA Requirements Preventive care must be covered 100% with no deductible Unlimited Maximum Benefit Amount All plans must have an annual out-of-pocket limit that does not exceed $6,350 individual and $12,700 family Open Enrollment: October 1 through December 15 for January 1 effective date Enrollment permitted without penalty from January 1 through March 31, 2014 (Only in 2014). 29

30 Medi-Cal under ACA Coverage is Medi-Cal if income below 138% Federal Poverty Level (FPL) - $15,856 Single No asset/resources limit No disability requirement May enroll anytime during the year, but penalty may apply depending on time without coverage will refer persons to Medi- Cal link 30

31 Federal Poverty Level (FPL) Runs from April 1st to March 31st Current year One person - $11,490 Add $4,020 for each additional member of household Percentages used in Obamacare 138% - $15, % - $17, % - $22, % - $28, % - $45,960 Complete List at: 31

32 Purchasing Coverage Health Insurance Exchanges for California residents Private Health Exchanges Health Insurance Companies All plans from all sources must provide the 10 Essential Benefits Subsidies only available at Health Insurance Exchanges 32

33 Covered California Plans Offered Platinum: Covers 90% of average annual cost Gold: Covers 80% of average annual cost Silver: Covers 70% of average annual cost Bronze: Covers 60% of average annual cost HMOs and EPOs use copays PPOs use deductibles and coinsurance 33

34 Enrolling in a Plan Go to and find costs and plans at Shop and Compare tool Disregard personal premium costs only if on ADAP. Consider: <200% FPL Silver Plan will have lowest out-ofpocket due to plan subsidies >200% FPL Platinum plan will have lowest out-ofpocket 34

35 Enrolling in a Plan Search for: Physicians in Network Prescriptions on Formulary (all or non-adap only) Enrollment can be: On-line (eligibility for Ryan White programs not considered by website) Telephone assistance (lack of Ryan White knowledge) Certified Enroller Use one familiar with Ryan White programs (ADAP, OA-HIPP, Ryan White Clinics) 35

36 Questions Use the Chat feature to type your question, or Use the Raise Hand feature If using a phone, When it is your turn to ask your question, press *7 to unmute your phone. After you have asked your question, press *6 to mute your phone. 36

37 Upcoming CSTEP Trainings Benefits Plus: Webinar Medicare December 4, :00A 12:00P Treatment II Extended: In-Person Trainings December 9 10, :00A 5:30P o Asian and Pacific Islander Wellness Center, San Francisco February 6 7, :00A 5:30P o Desert AIDS Project, Palm Springs Please visit for more information. 37

38 Contact Us: Jacques Chambers, Presenter Myrnelle Dizon, Training Coordinator For more information on upcoming trainings and additional resources, please visit: 38

39 THANK YOU! Please remember to complete the post-training survey which will pop up in your window after we end the training. 39