1 5 ways to reduce healthcare costs in the Coastal Bend Understanding Your Health Coverage to Get the Most from It WRITTEN BY: William Heavin, LUTCF, ACBC, LRA Victor Lehman
2 The New Era of Healthcare This Guide will help you understand the basics of health insurance and what Obamacare covers. Then, you can meet with one of our Certified Counselors who ll help you pick the best plan that meets your budget, family s needs and will answer your questions. Best of all, it s free! You ll learn all about how important it is to have health insurance, how to save the most money when you buy it, and learn all about the benefits you can get. We re here to help you and your family. Even if your employer offers health insurance, there s a good chance you can get a cheaper price by using the Healthcare Exchange. Cost = $1,000 to cover her dependents through work. MEET A LOCAL TEACHER Obamacare gave her a plan with similar benefits for less than half the price! The Affordable Care Act became law on March 23, 2010 giving all Americans the chance to have health insurance at a reasonable price no matter how old they are. There s no reason you have to be sick, can t see a doctor or get the medicines you need because you don t have the money to pay for it. Obamacare can give you the coverage you need.
3 What You ll Find Inside: Q1. Q2. Q3. Q4. Q5. Q6. Q7. Q8. Q9. Q10. Q11. Q12. Q13. Q14. Q15. Q16. Q17. Why do we need health insurance? How to get the cheapest insurance Can we get help paying for it? Is there any other way to lower how much it costs? What happens if we don t earn much money? What do we get by having health insurance? Can we see any doctor or use any pharmacy? What happens if we don t get health insurance? Is there any way to avoid paying a penalty? What forms will we need to file with our income taxes? We want health insurance, so when can we get it? What happens if we miss the deadline? How to enroll and what you ll need Can we lower health costs after we sign up? Do we get anything for free? What happens next? Will our costs increase & how do we renew? Where do we go if we have questions or issues? It s the only treatment option he has under his current health plan!
4 Q1. Why Do We Need Health Insurance? It could be the difference between life and death! Get the medical care you need when you need it. Health insurance helps you stay healthy, extends your life and protects you from high medical costs. COVERAGE MATTERS 18,000 adults die each year because they don t have health insurance. Institute of Medicine What d happen if you or a family member became sick or suddenly injured? What would you do, and how would you pay for it? Most people don t have that much money. Or, wouldn t it be nice to see a doctor regularly when you re not sick to make sure you re doing okay? By having health insurance, you really save a lot of money that would need to be paid if something happens, you can see your doctors regularly and pay a reduced price for your medicine. If you don t have health insurance and something big happens, many people can t pay the bills and usually have to file for bankruptcy. Insurance prevents this from happening and limits how much you have to pay. DID YOU KNOW? Broken Leg = $7,500 3-Day Hospital Stay = $30,000 Cancer = $100,000+ *** Average cost
5 Q2. How to Get the Cheapest Insurance It s easy! How much you ll save depends on two things: 1. Number of people in your household this year based on your tax return. 2. Your income (single or joint, if married). This may allow you to receive discounts on how much you pay for your insurance and any health-care costs. If you qualify, you don t have to do anything. The Healthcare Exchange will send your part of the insurance payment directly to the health insurance company you choose. That ll be subtracted from what you owe each month for your coverage. Good news: you end up paying less! Take a look at this chart. See how much you ll earn in 2015 then we can help you find out how much you can get to lower the cost of your health insurance. The lower your income, the bigger your credit! Household Size Annual Income (for 2015) $11,670 $46,680 $15,730 $62,920 $19,790 $79,160 $23,850 $95,400 $27,910 $111,640 It s important to tell us or the Healthcare Exchange if your income changes during the year. You may get bigger discounts if your income drops or have to pay some of it back if it goes up.
6 Q3. Can We Get Help Paying for It? Yes, and it s easy too! To receive help paying for the cost of your insurance you must: Not have access to affordable coverage through your or your spouses employer. Not covered by Medicare, Medicaid, CHIP (Children s Health Insurance Program) or receive any other public assistance including Veteran s Administration benefits. Must be a U.S. citizen or have proof of legal residency (Resident Alien). If you re married, you must file a joint income tax return. It s a simple stress test - I do your blood work, send it to the lab, and never get back to you with the results!
7 Q4. Is There Any Other Way to Lower How Much It Costs? Some may qualify for what s called a cost sharing subsidy. It ll help lower what you have to pay when going to see your doctors, ending up in the hospital or buying prescription medicines. This extra discount is automatically applied to what your health insurance already covers. That means even though you chose and are paying for a Silver plan, you re actually getting all of the benefits of a Gold or Platinum plan! Just like with the savings mentioned in Q3, the federal government pays any amount you get to the health insurance company of your choice. Lower income residents save more $$$ with this extra discount. L k for your income level. Household Size Annual Income (for 2015) to qualify for a cost sharing subsidy $11,670 $29,175 $15,730 $39,325 $19,790 $49,475 $23,850 $59,625 $27,910 $79,925
8 Q5. What Happens If We Don t Earn Much Money? Don t worry about it! You ll be fine. Several health centers in our area will take care of you if you don t have health insurance. You only pay what you can afford. This is for those who don t earn enough to qualify for a subsidy to help pay for coverage. Here s a list of the services and where to apply: Check-ups when you re feeling well so you can stay well and not get sick; Treatment you need when you re sick; All of the proper care needed if you re pregnant; Immunizations and check-ups for your kids; Dental care and prescription medicines; and Mental health services and substance abuse care, if you need it. Corpus Christi Amistad Community Health Center 1533 S. Brownlee Blvd Sinton Community Action Health Center 621 E. Sinton St Kingsville Community Action Integration Center 201 Roots Ave Kleberg Community Action Health Center 415 S. 6th St. Kingsville Taft Community Action Integration Center 1621 E. Corral
9 Q6. What do We Get by Having Health Insurance? You can t be charged extra because you already have a disease, condition or illness like asthma, back pain, diabetes or cancer. Even if you were denied health insurance before, no insurance company can refuse you as long as you sign up when you re eligible. Also, women pay the same rate as men. All health insurance plans have these benefits: Laboratory services; Emergency services; Prescription medicines; Pediatric services for your kids; Hospitalization, including surgeries; Preventive & wellness services, chronic disease management; Ambulatory services (outpatient care without hospital admission); Pregnancy, maternity and newborn child care (before and after delivery); Mental health and substance abuse services, including counseling and psychotherapy; and Rehabilitation + any related services and devices (help you recover from injuries, disabilities, chronic conditions, or get back any physical or mental skills you lost); You ll pay a set monthly amount called a premium. There s also a small copay when you visit the doctor, buy medicines or get treatment until you ve met your deductible. After that, you pay a set amount or a percentage (10% or 30%) of the total cost (varies depending on the plan you choose). All insurance plans will pay the whole cost for some routine screenings, immunizations and other preventative services before meeting your deductible.
10 Q7. CAN WE SEE ANY DOCTOR OR USE ANY PHARMACY? Any plan has a group or network of doctors, pharmacies and hospitals they want you to use. It s your choice, but if you stay within their network, it ll help save you money because the costs are lower. Three types of plans are available for you to choose: HMO, EPO and PPO. HMO (HEALTH MAINTENANCE ORGANIZATION) You must choose a general family doctor from a list the insurance company will give you and see them first whenever you need treatment. If they can t treat you, they ll refer you to a specialist who can. PPO (PREFERRED PROVIDER ORGANIZATION) The most expensive option but allows you to see anyone without having to be referred or worrying whether they re in the network. If they re not, you ll just pay more for the visit than you normally would. EPO (Exclusive Provider Organization) Similar to an HMO but doesn t allow you to see any doctors who aren t in their network. Each plan recommends you use the providers in their networks because this is how you get the lowest prices and most benefits. The same applies to any optional dental or vision insurance you buy. Information about your network will be on the back of the ID card that your new insurance company gives you. We can also help you find any doctors, pharmacies or hospitals you d like to use.
11 Q8. WHAT HAPPENS IF WE DON T GET HEALTH INSURANCE? If you decide you don t want health insurance, it s going to cost you money because you ll have to pay a penalty on your income taxes. The penalty goes up every year. For 2015 you ll pay either of these (whichever is higher): 2% of your yearly household income based on your income; or $325 per adult and $ per child under 18 years old. Maximum penalty = $925. For 2016 the amounts go up: 2.5% of your income; and $695 per adult. We can help you understand all of this and how to avoid paying penalties when filing your income taxes. The real penalty is paying for healthcare without health insurance. 62% of bankruptcies result from unpaid medical bills. CNBC Business News
12 Q9. Is There Any Way to Avoid Paying a Penalty Yes, and there are several ways to qualify: If you re currently covered by you or your spouse s employer, Veterans Administration, Tri-Care, Medicare, Medicaid or CHIP that meets the government s minimum amount of coverage needed. You won t have to buy health insurance if the cheapest plan available through your employer or the Healthcare Exchange costs 8% or more than your income, or you don t have to file a tax return. If you belong to any of these groups: Native American Tribes or Alaskan Natives, are a member of any recognized health-care sharing ministry, or your religion objects to health insurance. U.S. Citizens who live in another country, certain types of non-u.s. Citizens or anyone who doesn t have proof of legal residency. Any hardships will be considered by filing a paper application. If you or a member of your household is in jail. Hardships requiring a paper application of you: Are homeless Are the victim of domestic violence Suffered from a disaster (natural or manmade) Were evicted in the last 6 months, going to be evicted or had your home foreclosed Filed for bankruptcy in last 6 months, have unpaid medical expenses from past 2 years Received notice your utilities would be shut off because you couldn t pay them Other types of hardships are available. Talk with your tax preparer to find out more.
13 Q10. What Forms Will We Need to File With our Income Taxes? By Jan. 31 of each year you purchased health insurance, you ll get Form 1095-A. Make sure you take a look at it carefully and correct anything that s wrong with it. We can help you take care of that. The information you received on form 1095A is used in your tax return. That information is added to form 8962 which is how you claim your tax credit. It s important to tell us or the Healthcare Exchange if your income changes during the year. You may get bigger discounts if your income drops or have to pay some of it back if it goes up. IMPORTANT INFORMATION If you took fewer (less) of the tax credit you could get, there ll be a credit on your tax return. If you took more tax credit than you were supposed to, you ll have to pay some of it back on your tax return. If you didn t take any of the tax credit offered to you, you may get a credit toward any income tax you paid.
14 Q11. We Want Health Insurance! When Can We Get It? For this year, the time to apply is already over. Open enrollment was Nov. 15, 2014-Feb. 15, You re able to apply for health insurance anytime if something big changes in your life. See the next page. Otherwise, you have to wait until the next open enrollment period: Nov. 1, 2015 Jan. 31, My doctor told me to avoid any unnecessary stress, so I didn t open his bill.
15 Q12. What Happens If We Miss the Deadline? You can only buy health insurance and receive discounts during open enrollment or when there s a special enrollment. But, don t worry because if something big happens in life, you have 60 days after that happens to buy your insurance. See the list below. LIKE WHAT? Becoming a U.S. Citizen or obtained proof of legal residency; Losing any coverage you had from another source; Get married or divorced; Released from jail; Child is born; Adopt a child; Moving to a different zip code Recognized as a member of a Native American Tribe or an Alaskan Native. Off hand, I d say you re suffering from an arrow through your head but just to play it safe, I m ordering a bunch of tests.
16 Q13. How to Enroll and What You ll Need The best and easiest way to get health insurance is to visit an Enrollment Center like ours where you can talk with someone in person, discuss your situation, ask questions and understand all of your choices. This is an important decision since you won t be able to change your mind after you ve enrolled, and you ll have to live with the plan you choose until next January. You can also do all of the work yourself by calling the Healthcare Exchange at or visiting them on-line at I sure hope we can sign up for health care before we die of natural causes. HERE S WHAT YOU LL NEED WHEN YOU RE READY TO SHOP FOR PLANS: Proof of residency, if not a U.S. Citizen; Social Security numbers for all family members being covered; Contact information for you and your household s employers, income amounts (have your W-2, pay stubs, wage or tax statements with you); and Best guesstimate of what you and your household s income will be for the year you apply for coverage.
17 Q14. Can We Lower Health Costs after We Sign Up? By having health insurance, you re already receiving a discount on the services, medicines and treatment you receive because the insurance companies have special prices for health-care providers you use. This isn t available to those who don t have it. People without health insurance can pay double for the same services that someone with insurance pays less for. Generally, the more it costs for a service or medicine, the more you ll save. When you see someone within your plan s group or network, you pay less. Sometimes the savings are just a little, sometimes a lot. For a flu shot, if someone paid cash and had no insurance, it ll cost them $40. But the person who has insurance may only pay $25. If you go to the doctor, it ll be $150 to see them if you re paying cash. With health insurance, it could cost $85 or less. You have to pay the discounted price for all services you get until you meet your deductible. When that happens, all of the other benefits of your plan really start to kick in! Stay inside your network as much as possible to save the most when you need a doctor, hospital, laboratory or any X-rays. There s an easy way to find out who s in your plan s network. Just call the insurance company or visit their website, listed on the back of your ID card, to review their list of providers.
18 Q15. Do We Get Anything for Free? There are some things, but you have to visit a provider in your plan s network to get them. PREVENTIVE SERVICES FOR WOMEN Anemia screening: done regularly during pregnancy Breast cancer genetic test counseling: at high risk Breast cancer mammography screenings: over 40 every 1-2 years Breast cancer chemoprevention counseling: at high risk Breastfeeding support & counseling with access to supplies Cervical cancer screening: sexually active Chlamydia infection screening: young & at high risk Contraception (FDA-approved methods, sterilization, education, counseling. Does not include abortion drugs) Tobacco use screening & intervention: for all, expanded services if pregnant Folic Acid supplements: who want to be pregnant PREVENTIVE SERVICES FOR ADULTS Screening for abdominal aortic aneurysm: men of certain ages never smoked Aspirin therapy to prevent heart attacks & stroke: of certain ages HIV screening: anyone ages 15-65, others at high risk Cholesterol screening: of certain ages or at high risk Immunizations Hepatitis A & B, Herpes Zoster, Human Papilloma Virus (HPV), flu shot, Measels, Mumps, Rubella, Meningococcal, Pneumonia, Tetanus, Diphtheria, Pertussis, Varicella Sexually transmitted infection prevention counseling: at high risk Gestational diabetes screening: weeks pregnant or at high risk Gonorrhea screening: at high risk Hepatitis B screening: pregnant HIV screening & counseling: sexually active Human Pappilloma Virus (HPV) DNA test: over 30 every 3 years with normal cytology Osteoporosis screening: over 60 Domestic violence screening and counseling RH incompatibility screening: pregnant or at high risk Sexually transmitted infections counseling: sexually active Syphilis screening: pregnant or at high risk Urinary tract or other infections screening: pregnant Well Woman visits: under 65 Alcohol abuse screening & counseling Diet counseling: at risk for chronic disease Obesity screening & counseling Syphilis screening: adults at high risk Tobacco use screening & cessation Depression screening Blood pressure screening Colorectal cancer screening: over 50 Type 2 diabetes screening: with high blood pressure
19 PREVENTIVE SERVICES FOR KIDS Alcohol & drug abuse assessments Autism screening: months Behavioral assessments Blood pressure screening Hearing screening: newborns Vision screening Lead screening Hemoglobinopathies or Sickle Cell screening: newborns Developmental screening: 3 years or under Dyslipidemia screening: at high risk Fluoride chemoprevention supplements Gonorrhea preventive medication: newborns Height, weight, Body Mass Index measurements Hematocrit or hemoglobin screening Will I be penalized for not having health insurance if I m young and actually invincible? Depression screening HIV screening: older at high risk Hypothyroidism screening: newborns Immunizations Hepatitis A & B, Haemophilus Influenza Type B, Human Papilloma Virus (HPV), Polio, flu shot, Measels, Rotavirus, Meningococcal, Pneumonia, Tetanus, Diphtheria, Pertussis, Varicella Iron supplements: age 6-12 months at high risk for anemia Cervical dysplasia screening: sexually active females Medical history Obesity screening & counseling Oral health risk assessment: newborns-10 years Phenylketonuria screening: at-risk newborns Sexually transmitted infection prevention counseling & screening: at high risk Tuberculosis testing & screening: at high risk
20 Q16. What Happens Next? Will Our Costs Increase & How Do We Renew? Your insurance plan automatically renews on Jan. 1 every year no matter when you bought it. Your plan might change the cost and benefits you ll get. Open Enrollment What s Changing? What Do You Need To Do? In November, you ll get a renewal notice by mail from the Healthcare Exchange. You can call or talk to someone for free at our Enrollment Center. If you received help paying your premium last year, you ll need to find out if you can still get help. They could go up or down, or may not be available any longer. It s based on you and your household s income. Then you ll know how much you ll have to pay each month for your insurance. Every year, new plans and health insurance companies are added with more options available than when you first signed up. The differences between each are: how much you ll pay each month (called a premium); benefits you ll get; amount of your deductible; what medicines are covered and how much they cost; and if your favorite doctors will still take your plan. Health-care providers and facilities also join and leave networks at this time. This is the only time you can change plans. Otherwise, what you bought the year before will be what you have again the next year. Just as when you originally chose your plan, we can help you figure out what plan is the best, and has the benefits you want at the price you want to pay.
21 Q17. Where do We Go if We Have Questions or Issues? YOU HAVE 3 OPTIONS: Speak with someone for free at our Enrollment Center. The insurance companies pay us to help you get what you want, make sure you understand all of your benefits and advocate for you if there are any billing issues or problems. Call the Healthcare Exchange. Call your health insurance company at the phone number on the back of your ID card. You see Ms. Garcia, by doubling up on patients in the MRI, we re able to cut costs in half passing the savings on to you! He was doing well at first, but then he started drifting in and out of health coverage.
22 Glossary, Explanation of Common Health Insurance Terms ADVANCED PREMIUM TAX CREDITS (APTC): A Also called a subsidy. A tax credit paid to the insurance company for you (see question 2). AFFORDABLE CARE ACT: the comprehensive health care reform law enacted in March ANNUAL LIMIT: a cap on the benefits your insurance company will pay in a year. COINSURANCE IN-NETWORK: the percent (for example 20%, based on the plan you chose), that you pay of the allowed amount for covered health care services. COPAYMENT IN-NETWORK: a fixed amount (for example $15, based on the plan that you chose, that you pay for covered health care services. COST SHARING REDUCTION: Also called cost sharing subsidy. A discount that lowers the amount you have to pay out-of-pocket for deductibles, co-insurance and co-payments. You must chose a Silver Plan and be in a certain income range (see question 4). DEDUCTIBLE: the amount you pay for covered services that don t have a co-pay. When you pay up to this amount from that point on the insurance pays (for example 80%) until you hit your maximum out-of-pocket. DEPENDENT: a child or other individual for whom someone may claim a personal exemption tax deduction. Children can be covered up to the age of 26 on a parent s plan. FORMULARY: a list of prescription drugs covered by your plan also called a drug list. HEALTH INSURANCE MARKETPLACE: a resource where individuals, families and small businesses can learn about, shop and purchase health insurance. HEALTH PLAN CATEGORIES: plans in the Marketplace are separated into 4 categories (Bronze, Silver, Gold, Platinum). The average percentages the plans will pay are 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum). This isn't the same as co-insurance, where you pay for a specific percentage of the cost of service. HEALTH SAVINGS ACCOUNT (HSA): a medical savings account available to taxpayers enrolled in a plan with a high deductible. Funds contributed to the account aren't subject to federal income tax at the time of deposit, must be used to pay for qualified medical expenses and roll over year-to-year if you don't spend them. High Deductible Health Plan (HDHP): high deductible health plans (HDHPs) can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.
23 NAVIGATOR: an individual or organization that's trained and able to help consumers, small businesses and their employees look for health coverage through the marketplace including completing eligibility and enrollment forms. These individuals and organizations must be unbiased, and their services are free. NETWORK PLAN: a health plan that contracts with doctors, hospitals, and pharmacies, etc. to provide members with services and supplies at a discounted price (see question 7). NON-PREFERRED PROVIDER: a provider who doesn t have a contract with your health insurer or plan to provide services to you. (see question 7). OPEN ENROLLMENT PERIOD: period of time during which individuals who are eligible to enroll in a qualified health plan can enroll in a plan in the marketplace (see questions 11 and 12). OUT-OF-POCKET COSTS: your expenses for medical care that aren't reimbursed by insurance. They include: deductibles, co-insurance and co-payments for covered services plus all costs for services that aren't covered. OUT-OF-POCKET MAXIMUM/LIMIT: the most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include: deductibles, co-insurance, co-payments or similar charges, and any other expenditures required of an individual that is a qualified medical expense for the essential health benefits. The maximum out-of-pocket cost limit for any individual marketplace plan for 2015 can be no more than $6,600 for an individual plan and $13,200 for a family plan. PREMIUM: the amount that must be paid for your health insurance or plan. PRIMARY CARE PHYSICIAN: a physician who directly provides or coordinates a range of health care services for you. QUALIFIED HEALTH PLAN: under the Affordable Care Act, an insurance plan certified by the health insurance marketplace providing essential health benefits (see question 6). QUALIFYING LIFE EVENT: a change in your life that can make you eligible for a special enrollment period to enroll in health coverage. For example getting married or divorced, having a baby, or losing coverage at work (see question 12). REFERRAL: a written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don t get a referral first, the plan may not pay for your services (see question 7). SPECIAL ENROLLMENT PERIOD: a time outside of open enrollment during which you and your family have a right to sign up for health coverage. In the marketplace, you qualify for a special enrollment period 60 days following certain life events that involve a change in family status like marriage or birth of a child, or loss of other health coverage.
24 LOCAL HEALTHCARE ENROLLMENT CENTER Service you expect, Attention you deserve 4717 GOLLIHAR RD. CORPUS CHRISTI, TX OR FAX: