1 ALPHA-1 FOUNDATION. Private Insurance: Virtual Support Group Telecall and Webinar
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1 1 ALPHA-1 FOUNDATION Open Enrollment for Medicare and Private Insurance: How to choose the plan that will work for you Virtual Support Group Telecall and Webinar
2 Prepare Yourself Know your healthcare needs by accessing this year s usage of your healthcare insurance. Make note of any benefits, providers or excessive costs to help you find a plan that better suits you requirements. Items to Consider Are my physicians, home health care, DME (durable medical equipment) providers, hospitals, etc covered? Are there annual limits? Are out-of-network of benefits available? What percentage of cost will be your responsibility if you receive out-of-network benefits? Am I covered if I get sick while out of state? t
3 What Benefits are Provided? Is augmentation therapy covered? If so, is it under major medical or pharmacy benefits? Do I have a choice of more than one specialty pharmacy provider? Is augmentation therapy covered in the home setting? Are there annual limits on nursing visits? Is durable medical equipment covered? Look at your specific needs. Is pulmonary rehab and physical therapy covered? Do I need a referral to see a specialist? Is my pulmonologist in network? What services require prior authorization?
4 Where can I find the answers? Answers for many of these, both relative to cost and benefits, can be found by reviewing gyour plan s summary of benefits and coverage, drug formulary list (with tiers) and provider network directory. It is one of fthe most timportant tsteps you can take to insure that a plan meets your needs.
5 What do I need? Benefit Summary that gives an overview of the benefits provided by health insurance plans. It shows current rates for all benefit programs offered including health, dental and life insurance. Drug Formulary with a list of tiered prescription p drugs, g, both generic and brand name that are available through your health plan; one that defines the plan s co payment or co insurance levels. Gather the materials you need! Provider Network kbooklet containing a list of providers (such as physicians, pharmacies, hospitals and others) who are contracted to provide health care services to plan members. Health Savings Account or Flexible Spending Account if your employer provides either of these programs have printed copies of the details available.
6 Premium Discounts Ask about possible premium discounts you may qualify for in the plan(s) you are considering: Wellness Incentives Health Assessment Survey Non-smokers For coverage in the Health Insurance Marketplace, you may be able to get a premium tax credit that lowers what you pay in monthly premiums. You can apply part or all of this tax credit each month to your premium payments. The Marketplace will send your tax credit directly to your insurance company, so you pay less for your premiums each month. This is called advance payment of the premium tax credit.
7 It is important to remember- ONCE YOU CHOOSE A PLAN, YOU CANNOT CHANGE UNTIL THE NEXT OPEN ENROLLMENT PERIOD
8 Patient Services, Inc. Private Health Insurance Today Arm yourself with Information!
9 Choosing A Health Plan Open Enrollment Typically once a year Allows you to choose from one or more available plans Once chosen, no change in coverage until the next open enrollment date Exception: a qualifying event Death, termination of employment, divorce, terminal illness
10 What to look for in a plan Make an informed decision in choosing healthcare plan Look at cost vs. benefit what s covered at what price?
11 Typical Questions to Consider What are the plan benefits? Prescriptions? Hospitalization? Specialists? How much does it cost? Monthly Premium Deductible, Co Insurance, & Co Pays In Network vs. Out of Network
12 Getting Started Chart your family s Personal Health Experience Utilize resources like insurance checklists and information on the Alpha 1 and PSI websites. Know the meaning of the terms in your policy Get the following documents for each plan offered: Benefit Summary Drug Formulary Provider Network Booklet
13 The Affordable Care Act No pre existing condition exclusion for children <19 (All in 2014) Dependant coverage for adult children up to age 26 No rescission by insurance plans except for fraud No Lifetime Limits on coverage for essential benefits (defined by HHS, Spring 2012?) Restriction on Annual Limits until removed in 2014 Every American (with notable exceptions) is required to maintainminimumessential minimum health insurance coverage for themselves and their dependents
14 Who is Exempt From the Mandate? Those whose contribution exceeds 8% of income An income under 100% of the FPL Indian tribe members Those who qualify for hardship waiver
15 State Exchanges Establishes Health Insurance Benefit Exchanges Premium tax credits for state exchange plans Cost sharing subsidies and caps for state exchange plans Ensureyou review the plansandutilizeand resources to compare
16 To Learn More. Kelly at Visit Visit Alpha 1 website Contact InsuranceCommissioner
17 Annual Open Enrollment Period
18 What is OEP? The opportunity, each year, for Medicare recipients to enroll in, or make changes to, their Medicare Advantage or Prescription Drug policies for the coming year When is OEP? October 15 December 7 When do Changes take effect? January 1
19 Consider the entire picture! Monthly premium Out of pocket expenses Medical Hospital Prescription Deductible(s) Available financial assistance CVC Copayment assistance Premium assistance State programs Federal programs
20 Medicare Prescription Drug Plan (Part D) Offers coverage for prescription drugs only Nationwide coverage Medicare Advantage with Prescription (Part C) Offers coverage for hospital, medical, and prescription needs Coverage area may be limited Medicare Advantage without prescription i Offers coverage for hospital and medical needs only Medicare Supplemental Plan (Medigap) Most comprehensive secondary coverage for medical and hospital needs Limited guaranteed enrollment periods
21
22 Everyone has different prescriptions needs
23 What is a drug formulary? A listing, specific to each insurance company, of which prescription medications are covered by the plan Determines copayment responsibility Determines restrictions for each drug Prior Authorization (PA) Quantity Limit (QL) Step Therapy (ST) Why is a drug formulary important? Lets you know what to expect Are there any restrictions to overcome? Drugs that are not on formulary = full cost of drug
24 All Part D plans have very similar costs Standard benefit structure Initial coverage level 33% of the total cost Coverage gap (Donut Hole) 47.5% of the total cost Catastrophic coverage level 5% of the total cost Some plans have a deductible Maximum $310/year
25 Offers both prescription needs and additional health benefits
26 Part A and Part B benefits Lower copayments to visit Primary care physician Specialist Emergency room Out-of-pocket maximum $6,700 is highest allowable May offer additional supplemental benefits Dental Vision hearing Part D Benefits Standard structure Deductible Initial coverage level Coverage gap Catastrophic coverage levell No Out of pocket maximum for prescription benefits
27 Health Maintenance Organization (HMO) Strict network of providers and hospitals Must have referral from PCP to see specialist Preferred Provider Organization (PPO) Open network of providers and hospitals No referrals required Point of Service (POS) or Preferred Fee for Service (PFFS) Specific network of doctors with some exceptions Special Needs Plan (SNP) Must meet specific health/mental condition requirements to qualify for plan
28 Need more medical coverage than Part C offers?
29 Private insurance providers offer a variety of plans to pay for costs left behind by Medicare Part A and Part B Plans are lettered based on specific services covered A, B, C, D, F, G, K*, L*, M, N All plans cover the 20% coinsurance responsibility for hospital and medical services Some plans cover the Part A or Part B deductible Ideal for those with very high medical costs or anticipated costs (transplant)
30 Age65orover over Guaranteed right to purchase plan 6 months following 65 th birthday Cannot be denied during this period All states sell Medigap policies to age 65 and over All plan options (letters) sold in that area are availableailable Under age 65 Not federally required for policies i to be sold to those under 65 Some states require plans to be sold Not all plan options must be made available
31 Access to Care and Reimbursement 2014 Private Health Insurance Toolkit Addresses the concerns encountered when choosing a healthcare plan that t best fits you and your family. Order your copy at: Or call (877) ext 323 Reimbursement Resource Barbee Bennington, Support Group & Program Coordinator bbennington@alpha1.org or call (855)
32 Contacts Barbee Bennington, Support Group & Program Coordinator, Alpha-1 Foundation: Lauren Ruiz, Senior Case Manager, Alternate Coverage & Premium Assistance, Caring Voice Coalition: 1-(888) Kelly Fitzgerald, Associate Director of Donor & Government Relations, Patient Services, Inc:
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