Now What? Health Insurance 101. All You Need to Know Now That You re Covered

Transcription

1 Now What? Health Insurance 101 All You Need to Know Now That You re Covered

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3 Why is it so important? Financial Protection Keeps You Healthy

4 Insurance Sounds Complicated! Medicare Private Insurance Co-Pay Preventative Care Insurance Card Network Limitations Preauthorization Specialist Urgent Care Office Visit PPO Exclusions HMO Deductible Formulary Health Savings Account Co-Pay Card Out-Of-Pocket Limit Preferred Drug List Actuarial Value Primary Care Provider Premium Medicaid Emergency Room Co-Insurance Prior Authorization Gap Coverage Marketplace

5 Relax and Take a Deep Breath!

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7 By the end of this section you will: Understand common insurance terms and how health insurance works Know differences between types of health insurance plans Be able to decode your insurance card

8 Common Insurance Terms Karen Rubin Community Engagement Coordinator

9 Payments Premium Co-Pay Coinsurance

10 Payments Premium Amount you pay each month for an insurance plan. Co-Pay Set amount you may have to pay at the time of your visit. Coinsurance Percentage of a medical service you need to pay after the deductible has been met.

11 Money, Money Moneyyyyyy Out-ofpocket limit Actuarial Value Deductible

12 Money, Money Moneyyyyyy Out-ofpocket limit Most you re allowed to pay per year before the plan covers 100%. Does not include premiums. Actuarial Value Percentage of the total costs for covered benefits. Deductible Amount you need to pay yearly before the plan starts paying.

13 Red Tape Exclusions and Limitations Preauthorization/ Prior Authorization Appeal/Grievance

14 Red Tape Exclusions and Limitations Medical procedures and conditions the insurance plan will not cover. Preauthorization/ Prior Authorization Something that needs approval from your doctor and insurance company before it s covered Appeal/Grievance Process you go through to try to get a decision by the insurance company reversed.

15 Doctors Primary Care Provider Specialist

16 Doctors Primary Care Provider Your main doctor. He or she might refer you to other doctors. Required by some insurance plans. Specialist Doctor that focuses on a specific medical area. Generally more expensive to see. Might need a referral.

17 What is a Network? Group of medical providers who agree to follow the plan s rules and procedures Providers get more clients, insurance companies get services at a reduced rate Contracts usually between medical practices/ organizations and insurance companies Some models contract directly with medical providers

18 What is Managed Care? System designed to reduce costs and increase quality of care Uses a network, has explicit standards, formal review process, emphasizes preventative care, financial incentives to encourage efficiency Public and private plans Different types of plans, discussed later About 90% of insured Americans are enrolled in managed care plans. Others- fee-for-service

19 Let s Talk About Different Kinds of Insurance Plans! PPO

20 Health Maintenance Organization Gatekeeper All services in-network Lower costs, more red tape HMO

21 Exclusive Provider Organization All services in-network No Gatekeeper Very similar to HMOs, generally less expensive EPO

22 Preferred Provider Organization No Gatekeeper! Services in and out of network Less red tape but higher premiums PPO

23 Point of Service Gatekeeper Services in and out of network HMO and PPO hybrid POS Not as common as HMO or PPO

24 Health Savings Account Unspent funds roll over year to year Associated with plans with high deductibles Tax-advantaged medical savings account HSA Limits on how much can be contributed

25 Decoding Your Insurance Card Group number: Used to track the specific benefits of your plan. The group number and member number are used to identify you. Member name and number: Your name is printed along with your member number. If your spouse or children are on your insurance plan, your member numbers may look similar. Coverage type: Type of insurance plan that you have. Co-pay and co-insurance: Amounts you pay for some covered services Phone numbers: Can be used to call your insurance company if you have any questions. May be on the back of your card.

26 Preventative Screenings By: Erin Richardson

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28 By the end of this section you will: Know what a preventative screening is Find out which screenings are right for you Understand how to access preventative screenings Create your own screening schedule

29 Preventative Health Screening a cost-effective way to find and treat health problems before they start or get worse

30 Marketplace Plans and Preventative Screenings All Marketplace plans and many other plans must cover certain preventive services No charge of copayment or coinsurance. Even if you haven t met your yearly deductible Applies only when services are delivered by a network provider.

31 Medicaid/Medicare and Preventative Screenings Many preventive services are available without cost-sharing to individuals with new private health plans, Medicaid expansion plans, or Medicare

32 5 Categories of Preventative Screenings/Services 1. Lifestyle Screenings 2. Sexual Health Screenings 3. General Health Screenings 4. Screenings for Women 5. Vaccines

33 Lifestyle Screenings Alcohol abuse screening and counseling Depression screening for adults Tobacco Use screening for all adults help with quitting is available Domestic and interpersonal violence screening and counseling (local hotline)

34 Lifestyle Screenings (Marketplace Only) Diet counseling Obesity screening and counseling

35 Sexual Health Screenings HIV screening for everyone ages 13 to 65 includes other ages at increased risk Sexually Transmitted Infection (STI) prevention counseling Syphilis, Gonorrhea, Hepatitis-C screening

36 General Health screenings Blood Pressure screening Cholesterol screening Colorectal Cancer screening for adults over 50 Diabetes (Type 2) screening

37 Screenings for Women Breast Cancer (Mammogram) screenings every 1 to 2 years for women over 40 Cervical Cancer screening Every 24 months Osteoporosis screening for women over age 60 depending on risk factors *certain individuals may be more at-risk, including men and trans men with a genetic predisposition*

38 Vaccines What is a vaccine? Treatment(s) that build up your body s defenses against certain infections

39 Vaccines Your physician knows best when it comes to vaccines Practices vary by physician and by individual case Always consult you HIV doctor when it comes to getting vaccinated

40 How do vaccines work?

41 Vaccines Vaccines may cause more side effects for PLWHA Vaccinations can increase viral load for a short period of time. However, getting preventable diseases can be much worse. Do not measure your viral load within 4 weeks of any vaccination.

42 Vaccines People with low CD4 cell count should talk to their doctor before getting a live vaccine Chicken Pox Shingles Measles, Mumps, and Rubella (MMR)

43 When to get Vaccinated CD4 count below 200 CD4 count above 200 Flu (Influenza) Every year Every year Td/Tdap Tetanus Diphtheria Pertussis Tdap vaccine once Td booster every 10 yrs Tdap vaccine once Td booster every 10 yrs Chickenpox (Varicella) Should not get 2 doses HPV (human papillomavirus) Women and Men 3 doses (through age 26) 3 doses (through age 26) Shingles (Zoster) Should not get No recommendation

44 When to Get Vaccinated CD4 count below 200 CD4 count above 200 Measles, mumps, rubella (MMR) Should not get 1 or 2 doses Pneumonia (Pneumococcal) 1 dose of Prevnar, 1 dose of Pneumovax every 5 years 1 dose of Prevnar, 1 dose of Pneumovax every 5 years Meningitis (meningococcal) 1 or 2 doses 1 or 2 doses Hepatitis A 2 doses 2 doses Hepatitis B 3 doses 3 doses (Hib) Haemophilus inluenzae typeb 1 or 3 doses 1 or 3 doses

45 How to get screened or vaccinated Talk with your HIV doctor Schedule appointments as necessary Keep a chart of screenings and vaccinations

46 Vaccines Your physician knows best when it comes to vaccines Practices vary by physician and by individual case Always consult you HIV doctor when it comes to getting vaccinated

47 Create a Screening Schedule Assessment sheets within your packet will help you create a personalized screening schedule

48 Questions? Erin Richardson Or Contact OAC

49 Picking Your Provider Matt Wovrosh Senior Community Engagement Coordinator

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51 By the end of this section you will: Know how to find a doctor and be prepared for medical visits Know when you should go to the emergency room and when to go to your primary care provider Know what to do if you don t like your doctor

52 Finding a Primary Care Doctor that works for you Decide if you like your provider Prepare for your Visit Make an Appointment Find a Provider Understand your Insurance

53 How Do I Find a Doctor? Ask your friends and family Internethealthgrades. com Check your insurance company s provider network If you re assigned a doctor and want to change him or her, contact your insurance plan

54 Things to Think About Accepting new patients? Close to home or work? Office hours Languages spoken

55 Making an Appointment Mention if you are a new patient They will want your name DOB address Social Security Number and Insurance Information Which Doctor do I want to see? Write down any questions you have for them

56 Be Prepared for Your First Appointment Show up early Ask questions (make a list) Have insurance card and ID Bring list of medications Money for co-pay* Medical history Don t be shy!

57 Primary Care Provider So What s the Difference? When you feel sick and when you feel well You will usually see the same person every time Will check all areas of your health, and may focus on areas that you weren t concerned about May have a shorter wait time in the office and a longer visit Will be able to access your complete health record and help you with your health over the long term Emergency Department/Urgent Care When you are very sick or have a lifethreatening situation Will see the person who is working that day Will check mainly the problem/illness that brought you in May have a much longer wait time and a shorter visit May or may not be able to access your full health record or health history It s important to remember that you may have a higher co-pay or co-insurance for visits to an emergency department or urgent care

58 Breakout Session

59 Picking out your Doctor You should feel comfortable with your doctor Not all docs are great! Feel around for something that works Someone who understands your health needs, culture, and language, and is respectful and convenient If it s not right, keep looking

60 After Your Appointment Follow all the instructions your doctor gave you If you need to, make a follow up visit Keep in touch! Take advantage of preventative care! You don t have to be sick to see a doctor.

61 Exploring Your Options Zach Reau Community Engagement Coordinator

62 By the end of this section you will: Know how OHDAP works in Health Marketplace plans Understand your Medicaid eligibility Be familiar with the purpose and eligibility of MyCare Ohio

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64 Ryan White and the Marketplace Tax credits and subsidies not sufficient to make plans affordable for all people living with HIV Ryan White Part B (OHDAP) can be used to help cover insurance premiums, out-of-pocket costs for drugs on the OHDAP formulary, and out-of-pocket costs for HIV-related medical expenses Not deductibles! The Ohio Department of Health s guidelines: % FPL assess best silver plan % FPL assess most cost-effective silver or gold plan % FPL assess best gold plan

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66 Documents and Forms In order to receive premium and cost-sharing assistance from Ryan White: Marketplace Eligibility Notice (from the IRS) showing amount of tax credit and plan information. Copy to OHDAP. IRS Reconciliation Statement (starting Jan 31, 2015). Copy to OHDAP.

67 Where do you apply? *only during open enrollment Apply online at healthcare.gov Or call Need help? ohioforhealth.org **unless you qualify for a Special Enrollment Period Qualifying life events like job loss, prison release, getting married, having a child, or anything that alters your tax status

68 What Is Medicaid Expansion? Modernized and Simplified New Eligibility From 150 categories 2 MAGI (Managed Care) vs. Non-MAGI (ABD) Individuals earning about $16,000/year for a household of one Resident of Ohio Meet citizenship requirements ROLLING ENROLLMENT

69 Managed Care Medicaid Begin with fee-for-service Medicaid (Medicaid card) before going into a Managed Care plan (15-60 days) You choose a company to manage your plan (UHC, Molina, CareSource, etc.) but you STILL HAVE MEDICAID! All must offer: Unlimited mental health visits! Additional benefits like 24-hour nurse advice lines, transportation to appointments, and care managers for folks with complex medical conditions Companies may differ: Incentives for services (Reward$), Preferred Drug Lists vs. medically necessary drugs

70 Where do you apply? Apply online at benefits.ohio.gov Or call County ODJFS TIME SINK Already receive Age, Blind or Disabled Medicaid? remains the same unless you re dual eligible

71 Medicare Various Parts OHDAP Parts A-D cover different services 65+, some people living with disabilities, ESRD Part C & D Premium / Co-Pay Assistance Available

72 Medicare Option 1 Original Medicare (A + B) Secondary Insurance (GHI, MesSup, Medicaid Rx Coverage (D or GHI)* Option 2 Medicare Advantage (C)* Hospitalization, Medical, Rx Offered through private companies

73 Where do you apply? Must apply with Social Security during your 7 month Initial Enrollment Period 3 months before 65 th Month of 65 th 3 months after 65 th May delay enrollment to B in some cases, but penalties possible with late enrollments Ohio Dept of Insurance Ohio Senior Health Insurance Information Program

74 What Is MyCare? Integrated Care Delivery System Coordinates Medicaid + Medicare into a Managed Care Plan Simplifies use for consumer Pilot Program For those w/ Medicare Parts A, B & D and full Medicaid benefits - AND - live in one of the seven demonstration regions

75 Who can access?

76 MyCare Ohio Single point of contact: managed care plans will be a single point of contact for all individuals enrolled in both Medicare and Medicaid. Helps individuals better understand their health care needs and to more easily navigate various services and health care settings. You choose: choose from at least two managed care plans in each region to provide your Medicaid and Medicare benefits. Medicare opt-out: have the option for managed care plan to provide Medicare benefits or to opt out of the Medicare portion of the program and stay with current Medicare Advantage plan. However, the chosen MyCare Ohio managed care plan will still provide and pay for all Medicaid services

77 Where do you apply? Auto-notified when eligible Or call

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79 Preventive Care Healthy Choices Use Generic Drugs Save $$ Stay Healthy Live Longer ER for Emergencies Only Follow Doctor s Orders Find a PCP

80 Next Steps Notify OAC with: Enrollment issues in Marketplace, Medicaid & MyCare Payment issues with OHDAP Gaps in service or RW Provider network Stay up-to-date by following our Healthcare and You page or follow OAC on Facebook Report discriminatory practices to OAC or the Ohio Department of Insurance (online) insurance.ohio.gov Quick Links > File a Complaint Questions or Feedback: Zach Reau

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