Open Enrollment Period 2016 and the Cancer Insurance Checklist

Transcription

1 Open Enrollment Period 2016 and the Cancer Insurance Checklist An educational webinar hosted by: On behalf of the Cancer Insurance Checklist Partners: The Assistance Fund, Association of Community Cancer Centers, Avalere Health, Chronic Disease Fund, Cutaneous Lymphoma Foundation, International Myeloma Foundation, The Leukemia & Lymphoma Society, Living Beyond Breast Cancer, Lung Cancer Alliance, Melanoma Research Foundation, Men s Health Network, National Coalition for Cancer Survivorship, Oncology Nursing Society, Ovarian Cancer National Alliance, Patient Services, Inc., Prevent Cancer Foundation

2 Linda House Cancer Support Community (CSC) Linda House, President, CSC Linda House serves as the President of the Cancer Support Community. In this position Linda oversees several areas of CSC including affiliate relations, strategic growth and business development, marketing and communications and the Cancer Policy Institute. Linda joined CSC after many years working in the cancer care environment, several of them being direct patient care in the acute oncology and hospice care setting. Linda serves in a variety of advisory roles in the national cancer community including the National Cancer Institute s National Council of Research Advocates, the Leadership Council for the Academy of Oncology Nurse Navigators, C-Change Together Value of Cancer Care and Workforce panels, the Patient Quality of Life Coalition Steering Committee and the patient advisory board for the Patent Resource Cancer Guide to name a few. Linda is also an active volunteer with a number of organizations in her local community where she sits on the Board of Directors for the Indianapolis Children s Choir among others.

3 Presentation Overview Overview of the ACA Open Enrollment Period 2016 The Health Insurance Marketplace Enrollment Basics Choosing a Plan Financial Assistance What s New for 2016? Open Enrollment Information & Resources The Cancer Insurance Checklist Testimony: Patient s Experience Q&A

4 Questions & Answers Please type your questions in the Q&A field on the bottom right We will answer as many of your questions as possible

5 Fran Castellow, MSEd. Patient Advocate Foundation Fran Castellow, MSEd., President of Operations, PAF Ms. Castellow serves as President of Operations at Patient Advocate Foundation. In this position, Ms. Castellow has top executive management responsibility and authority for the Mission Delivery, Finance, Information Technology, and Facilities functions of the organization. In her role, she provides strategic planning and operational leadership, shaping the patient programming priorities and delivery model for the foundation. For over a fifteen years, Ms. Castellow has worked to build strong strategic alliances with stakeholders in the healthcare and non-profit sectors, leveraging these relationships to successfully secure millions in grant support for the patient programming provided by the foundation through its case management and financial aid services. This support has enabled the foundation to serve over 800,000 patients and their families since 1996.

6 Our Mission Patient Advocate Foundation seeks to safeguard patients through effective mediation assuring access to care, maintenance of employment and preservation of their financial stability relative to their diagnosis of chronic, life threatening or debilitating diseases by providing in-depth case management and direct financial assistance Our Impact Since our inception in 1996, PAF has provided direct, sustained patient assistance to more than 800,000 patients and touched millions more American lives through the PAF website, online chats and outreach events

7 Patient Impact in ,962 1,024, % $50M Patients who have received direct, sustained assistance with financial, insurance navigation and practical issues including cost of living expenses Contacts made on behalf of patients to relevant stakeholders to resolve healthcare access issues Diagnoses of patients who received case management services Case management patients who contact PAF do so related to a Medical Debt Crisis Total amount of Financial Assistance Allocated to qualified patients through the PAF Co-Pay Relief Program and Financial Aid Funds

8 Agenda Open enrollments are special periods of time throughout the year where you impact your health insurance throughout the year o What is the Affordable Care Act (ACA)? o What and When is the open enrollment period? o What is the Health Insurance Marketplace? o Requirements for Health Insurance o Enrollment Basics o Choosing a Plan o Financial Assistance o What s New for 2016? o Tips from the Pros o Open Enrollment Information & Resources

9 What is the Affordable Care Act (ACA)? The Patient Protection and Affordable Care Act (PPACA) was historic health care legislation signed into law on March 23, 2010 The law established the health insurance marketplace and added new rights and protections including: Consumers cannot be denied coverage due to pre-existing conditions Consumers cannot be charged higher premiums due to health status or gender Coverage of routine care costs for approved clinical trials Coverage of preventive services at no out of pocket cost No more lifetime or annual limits on coverage for essential services Right to appeal health plan decisions - internal and external review processes

10 When is Open Enrollment for 2016? November 1, 2015: Open Enrollment starts first day you can enroll in a 2016 Marketplace plan January 1, 2016: First date 2016 coverage can start January 31, 2016: 2016 Open Enrollment ends If you don t enroll in a 2016 plan by January 31, 2016, you can t enroll in a health insurance plan for 2016 unless you qualify for a Special Enrollment Period

11 What is Open Enrollment? Decisions made during open enrollment impact the next 12 months of coverage Avoiding a decision during open enrollment can have lasting impact Decisions directly impact cost of healthcare Be thoughtful and intentional in decisions made during open enrollment Take time to Research plans Compare coverage Project and anticipate care for next year Budget, Analyze costs Gather paperwork Submit paperwork before deadlines DEFINITION: OPEN ENROLLMENT The defined period of time that occurs each year, when new enrollment and changes to current plan selection is processed, cementing the health plan that will remain in effect for next full year Period can range from 2 weeks to a few months Changes go into effect at the beginning of the next plan year

12 What is the Health Insurance Marketplace? Online hub available in every state that allows only Qualified health plans Allows consumers to research and compare plans directly One-stop shopping for those looking to enroll in plans or those that may be eligible for Medicaid or CHIPs Plans are grouped by category to help sort options, called Bronze, Silver, Gold, Platinum/ The category of plan you choose affects your out- of-pocket costs: Bronze 60% Silver 70% Gold 80% Platinum 90%

13 Who is Eligible for Marketplace Enrollment? Individuals (and families) who are currently uninsured Those that currently have non-comprehensive or limited coverage Those looking to switch from their current coverage to a Marketplace product, whose current plan was not renewed, or simply to compare and research coverage options If you have job-based insurance and switch plans Won t qualify for lower costs based on income unless job based insurance is unaffordable May lose employer contribution to your premiums Special Enrollment period with qualifying life event Medicare enrollees are NOT eligible

14 Enrollment Process: How Does it Work? Create an account First provide some basic information. Then choose a user name, password and security questions for added protection. Apply Starting November 1, 2015 you ll enter information about you and your family, including your income household size, and more. Visit HealthCare.gov* to get a checklist to help you gather the information you ll need. Pick a plan Next you ll see all the plans and programs you re eligible for and compare them side-by-side. You ll also find out if you can get lower costs on monthly premiums and outof-pocket costs. Enroll Choose a plan that meets your needs and enroll! Coverage starts as soon as January 1,

15 Enrollment Process: How Does it Work?

16 Enrollment Basics Enrollment time periods vary but should be defined and publically available Marketplace Late Fall each year Employer Based ex) July of each year Medicare October Dec of each year Know the Enrollment Date compared to the Effective Date of plan policy You commit to monthly premiums for the entire plan year You may have multiple eligibility options and arrangements to enroll under. Consider and compare costs for different options Open enrollment allows the opportunity to look inside the plan details before committing Special Enrollment The window of time following a life event that allows you the opportunity to enroll or switch plans Examples: Getting married or divorced Having or adopting a baby Loss of employer based coverage Turning 26 and loosing coverage under parent's plan Loosing eligibility for Medicaid or CHIPS Changes in citizenship Leaving incarceration New employee at workplace Voluntarily dropping coverage before the plan year ends, and/or nonpayment does not qualify If you enroll during special enrollment, you may end up with a partial plan year, until the following open enrollment

17 Exceptional Circumstances For Special Enrollment Faced a serious medical condition that kept patient from enrolling An unexpected hospitalization or temporary cognitive disability Misinformation or misrepresentation Misconduct by a non-marketplace enrollment assister resulted in Not getting enrolled in a plan Being enrolled in the wrong plan Not getting the premium tax credit or cost-sharing reduction Enrollment error / technical error between the Marketplace and the insurance company Other exceptions

18 What will I need to Enroll? During enrollment you should have the following paperwork available: Information about your household members, both those who will be covered and those who will not be covered under new plan Age, date of birth, mailing addresses & contact info for everyone Social security numbers and individual identification materials Household income information and/or W-2 forms Best estimate of income for 2016 Policy numbers for current health insurance plans Employer coverage tool form for every job-based plan you or someone in the household is eligible for, even if not enrolled

19 Questions & Answers Please type your questions in the Q&A field on the bottom right We will answer as many of your questions as possible

20 Choosing a Plan: Common Elements to all Qualified Plans Cannot be denied coverage due to pre-existing conditions Cannot be charged higher premiums due to health status or gender (but can for smoking-use and age) Includes coverage of routine care costs for approved clinical trials No more lifetime or annual limits on coverage for essential services Coverage of preventive services at no out-of-pocket cost** 10 categories of Essential Health Benefits coverage Defined list of services that are not-covered or excluded within plan language Your insurance plan contains the provisions of your contract with the insurance company to provide medical services **Grandfathered plans still in existence may not have to follow all ACA rules and provisions Be cautious and know the specifics if you are a new enrollee into a grandfathered plan. Ask if your plan is grandfathered

21 Essential Health Benefits **Grandfathered plans still in existence may not have to follow all ACA rules and provisions, including offering the Essential Health Benefits. Be cautious and know the specifics if you are a new enrollee into a grandfathered plan.

22 Choosing a Plan Read the Plan Summary: Compare cost-sharing elements (co-pays, co-insurance, deductibles, out-of-pocket max) Review Non-Covered Benefits or Exclusions Perform sample calculations for various scenarios Know the difference in plan types (HMO, PPO, etc.) Understand your typical medical needs Prescription coverage: May need you to research on Insurer s website List of covered drugs ( formulary ) Prescription tiers medications are assigned to a category based on drug usage, cost and clinical effectiveness Specialty drug tiers the highest drug category, typically with the highest copayment or coinsurance amount Review network pharmacy and/or mail pharmacy options Cost Comparison: **Keep in mind that your annual total cost of care goes beyond the monthly premium

23 Example Comparison AcmeStar Classic 100 Bronze AcmeStar Direct 400 Silver Monthly Premium $274 / month $ / month Deductible $1,000 $1,000 Out of Pocket Maximum $2,250 $1,250 Primary Care Doctor Visit Specialist Visit ER / Emergency Room $25 $25 $30 In-Network, Not covered Out-of- Network $500 In-Network, 50% Out-of-Network $35 In-Network, 50% Out-of- Network $500 In-Network, 25% Out-of- Network **These plans specifics and figures are fictional and only for example purposes

24 Example Comparison Drug Plans AcmeStar Classic 100 Bronze AcmeStar Direct 400 Silver Prescription Drugs - Generic $5 $5 Prescription Drugs - Preferred Brand Names $15 In-Network, 50% Out-of- Network $15 In-Network, 50% Out-of-Network Prescription Drugs - Specialty Drugs 15% In-Network, No Out-of- Network Coverage 15% Prescription Drugs Outof-Pocket Maximum None $5,000

25 Is there Financial Assistance Available for me? Yes! The Marketplace is the only place to apply for financial assistance to help pay for insurance Financial Assistance programs include: Premium subsidies (Tax credits) Cost-Sharing Assistance May have to repay if financial situation improves without adjustment to credit amount If your family is enrolling in a marketplace plan- everyone does not have to enroll into the same plan. Can be individually based

26 Monthly Premium Insurance Tax Credits Tax credit that lowers the monthly cost of the insurance premium Eligibility is based on: Household income, between 100% to 400% of the Federal Poverty Level (FPL) for the 2015 benefit year Obtaining qualified health insurance through the Marketplace from SILVER plan or higher Ineligible for government sponsored coverage, affordable employersponsored insurance Can choose benefit given immediately rather than waiting until tax time Credit sent directly to insurer each month on your behalf

27 Who Is Eligible For Cost Sharing? Cost sharing reduces the deductible and Out of Pocket Maximums (OOP) for qualified enrollees Eligibility for reduced cost sharing is based on Household income, between 100% to 250% of the Federal Poverty Level (FPL) for the 2015 benefit year Receiving the Premium Insurance Tax Credit Obtaining qualified health insurance through the Marketplace from SILVER plan or higher

28 Employer-based Plans Some employers offer numerous choices, others do not. All pay for a portion of the monthly premiums on behalf of employee (not always for family or dependents) May have workplace requirements for eligibility (ex: hours worked each week) Other benefits may go along with health plan options including Health Savings Accounts along with High Deductible Plans Flexible Spending Accounts / Cafeteria Plans Supplemental Plans ex) Accident or Cancer Plans Vision Plans & Dental Plans *additional premiums for supplemental plans Some small businesses may utilize the SHOP Marketplace for their plan selection Link in Resource List If you decline employers insurance, you may not be eligible for financial assistance through the Marketplace

29 Direct Enrollment with Insurance Company Many insurance companies are also matching Marketplace open enrollment period in the fall with limited enrollment at other times You can compare and research among that Insurer s products only May be able to offer you Marketplace plans and other non-marketplace plans in their portfolio Web brokers: getinsured.com, healthsherpa.com, ehealth.com, gohealth.com

30 After Enrollment You should receive a confirmation of effective plan dates following enrollment Ability to gain electronic access to insurer s website, with more details of plan and provider network, formulary, copy of policy numbers You should receive a welcome packet and plan summary in the mail You will get printed insurance cards in the mail You will begin to see premium invoices connected to payment details If receiving financial assistance, you will get a statement for tax purposes If you do not receive these things, follow up immediately to ensure enrollment was completed and processed accurately!

31 What Happens if I Miss Enrollment? You may be uninsured for the year! And you will be responsible for the penalty *unless you qualify for Special Enrollment period or begin a new job offering employer-based benefits

32 What is New for 2016? Open Enrollment dates keep shifting and shrinking each year Tax penalty has increased again in 2016 to 2.5% of HH income or up to $2,085 per household, depending upon size Better defined tax processes Penalty payments Proof of insurance Premium subsidy and cost share amounts Improved customer service and technology experiences during enrollment New out-of-pocket cost feature based on user s personal situation Simplified re-enrollment & ability to compare with available plans If you don t update your application or change plans by 12/15/15 you ll be auto re-enrolledhowever your premium tax credit may not be accurate States continue to tweak Medicaid expansion plans In some situations, marketplace plans will auto-renew. Make sure you proactively review and renew your insurance selection! Improvements to SHOP marketplace for small businesses

33 The Patient Experience: PAF s Front Line View We have found the premiums to still be unaffordable for many Many individuals are not eligible for premium subsidy. When combining the premiums with the yearly deductibles, this puts the coverage out of reach for a high percentage of our patients We have noted some employer group plans increasing their deductibles and/or shifting to only offering a High deductible health plan, coupled with more restrictive networks The cost shifting in employer sponsored plans have prompted some patients we serve to reduce their hours (going PT, in order to lose group benefits) to become eligible to buy an insurance product of their own choosing in the Marketplace

34 The Patient Experience: PAF s Front Line View Patients are making decisions on plans simply based on their premium, after subsidy Example: A patient selects the plan because the tax credit lowers the premium to what is affordable, but they find later that their providers do not participate with the plan or they selected a plan with limited coverage Patients fall under the 100% FPL and cannot document their current income, therefore they are not qualifying for premium tax subsidy. Their state did not expand Medicaid, therefore they are unable to afford/obtain insurance due to high premium costs We are noticing that there is, at times, a disconnect between the insurance companies and the Marketplace. We are having to facilitate calls between the patients, plans and the Marketplace in order to collaborate to resolve enrollment and coverage issues patients are facing. This can take a lot of time time and increases frustration and stress for patients

35 Tips from the PAF Professional Case Managers Open Enrollment If this is the first time you have had coverage, familiarize yourself with insurance terms what is a co-pay, what is co-insurance, etc.? What does it mean for your budget? Open enrollment only occurs annually, you need to review your coverage every year because the plan you currently have now, may no longer be relevant or working for your in your current situation

36 Tips from the PAF Professional Case Managers Plan Selection (Continued) Make sure your current physicians and medical facilities are in-network with any insurance product that you select. Does the insurance product allow any out of network options? Also, making sure your current medications are on formulary and consider the tiers these medications are on? Don t pick a plan with limited coverage or lower premiums simply because you currently have no or limited health issues. You never know what you many run into tomorrow and need to be prepared as open enrollment is only yearly A lower premium probably means higher Out of Pocket (OOP) costs, so it may be best to weigh your options with that in mind. You may end up paying more in the long run if you pick the policy with the lowest monthly premium

37 Tips from the PAF Professional Case Managers Plan Selection Catastrophic Health Plans are NOT recommended for patients with ongoing treatment or surveillance needs as they are designed to cover major medical episodes only Patient diagnosed with and being treated for cancer should consider at least a Gold Plan. We recommend a platinum plan as that is likely to be the most affordable over the course of the year, if this is an available option in your state

38 Tips from the PAF Professional Case Managers Financial Assistance Make sure you evaluate whether you may be eligible for financial assistance Have a solid idea of your current household income when applying for the tax subsidy. When you file your taxes at the end of the year, there could be a discrepancy in the stated income vs. actual income filed on your taxes. If this occurs, you may owe more money on your premiums due to a decrease in your subsidy If your HH income changes during the course of the year, notify the Marketplace of the income change so the tax subsidy can be adjusted

39 Tips from the PAF Professional Case Managers Final Reminders Do not wait to the last minute to complete and finalize enrollment Pay your premium on time. Your policy will cancel if you do not pay premium, and this will not qualify you for re-enrollment or special enrollment period Be thoughtful and intentional in decisions made during open enrollment If you need it, Help is available

40 Plan Vocabulary to Know During Enrollment Premium the amount that must be paid for your health plan benefits to be active. Usually paid monthly Out-of-pocket costs Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered Out-of-pocket maximum/limit the most you could pay during a plan year for covered service Deductible- the amount you owe for health services before your plan begins to pay. During this period you pay 100% of all costs for care that is received Copayment a defined fixed amount you pay for covered health care services, for example $15 for office visit. This amount can vary by type of covered service Coinsurance your share of the cost of a covered health service, calculated as a percent of the allowed amount Formulary a list of approved drugs covered by a prescription drug program Excluded Services Services that your health insurance will not pay for or cover Covered Services the healthcare services that your insurance agrees are eligible for reimbursement under your plan language

41 2016 Open Enrollment Information and Resources Get Covered: A One-Page Guide to the Health Insurance Marketplace: Cancer Insurance Checklist: Patient Advocate Foundation Patient Empowerment Series-Preparing for Open Enrollment - Changing Plans and/or Enrolling in New Insurance: Automatic re-enrollment: Keeps you covered, but without updated savings: Enrollment Toolkit: Sample Summary of Benefits & Coverage Document: osed.pdf

42 2016 Open Enrollment Information and Resources Marketplace Checklist for Enrollment: FAQ on Marketplaces from Kaiser Family Foundation: What Small Business Employees Should Know about the SHOP Exchange: Subsidy Calculator by Kaiser Family Foundation for Marketplace: Healthcare.gov for Marketplace Enrollment:

43 Cancer Insurance Checklist Hundreds of thousands of people with cancer or a history of cancer will use Marketplaces to shop for coverage CSC led a coalition to develop a tool to help people with cancer navigate insurance decisions. Launched September 25, 2013 Goals of the tool: Provide a resource Make the Checklist widely available Monitor patient experiences on Marketplaces to inform policy discussions

44 Cancer Insurance Checklist The Checklist contains 3 worksheets: My Care: list your providers, sites of care and medications to see if they are covered by the plan Treatment & Health Services: identify whether a list of common treatments and health services that people with cancer may need is covered by the plan My Costs: analyze the costs associated with a plan and the subsidies you might be able to get

45 Cancer Insurance Checklist The Checklist contains 3 worksheets: My Care: list your providers, sites of care and medications to see if they are covered by the plan Treatment & Health Services: identify whether a list of common treatments and health services that people with cancer may need is covered by the plan My Costs: analyze the costs associated with a plan and the subsidies you might be able to get

46 Cancer Insurance Checklist The Checklist contains 3 worksheets: My Care: list your providers, sites of care and medications to see if they are covered by the plan Treatment & Health Services: identify whether a list of common treatments and health services that people with cancer may need is covered by the plan My Costs: analyze the costs associated with a plan and the subsidies you might be able to get

47 CancerInsuranceChecklist.org

48 Spanish Cancer Insurance Checklist: Guía de Cobertura Médica para Personas con Cáncer SegurosMedicosYCancer.org

49 Cancer Insurance Checklist Partner Organizations Contact Information The Assistance Fund - Phone: Association of Community Cancer Centers - Phone: Avalere Health - Phone: Cancer Support Community - Phone: Chronic Disease Fund - Phone:

50 Cancer Insurance Checklist Partner Organizations Contact Information Cutaneous Lymphoma Foundation - Phone: International Myeloma Foundation Phone: or The Leukemia & Lymphoma Society - Phone: Living Beyond Breast Cancer - Phone: Lung Cancer Alliance - Phone:

51 Cancer Insurance Checklist Partner Organizations Contact Information Melanoma Research Foundation - Phone: Men s Health Network - Phone: ext. 101 National Coalition for Cancer Survivorship - Phone: National Patient Advocate Foundation - Phone: Oncology Nursing Society - Phone:

52 Cancer Insurance Checklist Partner Organizations Contact Information Ovarian Cancer National Alliance - Phone: Patient Advocate Foundation - Phone: Patient Services, Inc.- Phone: Prevent Cancer Foundation - Phone:

53 Patient s Perspective VJ Sleight, Cancer Survivor VJ Sleight, Cancer Survivor Sleight is a two cancer thrivor, being first diagnosed in 1987 at the age of 32 and had a recurrence in She has firsthand knowledge of the discrimination of patients with pre-existing conditions and the loopholes insurance companies used to deny coverage. She gained health coverage under the ACA through the PCIP and then through the California exchange. Sleight was trained at the Mayo Clinic as a Tobacco Treatment Specialist and helps smokers quit and educates health care professionals on effective counseling techniques. She is the author of "How to Win at Quitting Smoking." She is a legislative ambassador for the American Cancer Society Cancer Action Network, the chairperson for the Coalition for Tobacco Free Communities serving Riverside County, a volunteer with Family Hospice and Gilda's Club, a cancer support community. She lives in La Quinta, CA with her dog Joey.

54 Questions & Answers Please type your questions in the Q&A field on the bottom right We will answer as many of your questions as possible

55 THANK YOU! On behalf of the Cancer Insurance Checklist Partners: The Assistance Fund, Association of Community Cancer Centers, Avalere Health, Chronic Disease Fund, Cutaneous Lymphoma Foundation, International Myeloma Foundation, The Leukemia & Lymphoma Society, Living Beyond Breast Cancer, Lung Cancer Alliance, Melanoma Research Foundation, Men s Health Network, National Coalition for Cancer Survivorship, Oncology Nursing Society, Ovarian Cancer National Alliance, Patient Services, Inc., Prevent Cancer Foundation This webinar was made possible thanks to an educational grant from Novartis