Health Insurance Literacy Understanding Basic Health Insurance Terms Massachusetts Health Care Training Forum April 2015 Presented by: Debi Lang Debbie Raymond
Objectives: After this presentation you will be able to: Define health insurance literacy Discuss the importance of health insurance literacy Explain the meaning of some basic health insurance terms to your clients Recognize appropriate resources and tools to assist with health literacy challenges 2
What is Health Insurance Literacy? The Health Insurance Literacy Expert Roundtable defines health insurance literacy as the degree to which individuals have the knowledge, ability, and confidence to find and evaluate information about health plans, select the best plan for their own (or their family s) financial and health circumstances, and use the plan once enrolled. Health Insurance Literacy, CMS National Training Program, 3
Why is Health Insurance Literacy Important? Individuals that understand health insurance terms: Are able to compare and choose an insurance plan that fits their healthcare needs Are able to compare and choose insurance plans that better fit their budget and avoid unnecessary high cost medical bills Use their benefits wisely resulting in improved health and disease prevention 4
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How Do I Decide? http://healthpopuli.com/2010/09/27/blondie-and-dagwood-on-thehealth-economy/ 6
Knowing how to explain basic health insurance terms to your clients is important! Shopping for health insurance can be: 7
Premium: The cost to purchase a health insurance plan. 8
Network: Doctors, Nurses, Specialists, Physical and Occupational Therapists, Mental Health providers Hospitals, Nursing Homes Labs Pharmacies 9
In Network: Out of Network: 10
Deductible: The amount you must pay for most covered services before the plan begins to pay. Jane s health insurance coverage just began. She has not met her annual $1500 deductible yet. She visits her doctor for a sick visit (e.g. sore throat and cough). The cost of the covered service is $125. Jane pays = $125 Her plan pays = $0 11
Certain in-network expenses may not be subject to the deductible, which means your insurance may cover all or part of the cost. Prescription medication, immunizations, screenings, office visits..always check with your plan if you are not sure. 12
A family may meet their annual family deductible without each person having to meet their individual deductible. $1500 $1500 $1500 $500 = Family Deductible $5000 13
Out-of-Pocket Limit The most you pay during a 12 month policy period. This limit doesn t include the premium, or payments for services your plan doesn t cover. 14
Summary of Benefits CMS: Summary of Benefits & Coverage & Uniform Glossary 15
Using Benefits 16
Covered Service: A healthcare provider s service or medical supplies covered by your health plan. Benefits will be given for these services based on your plan. (Medical Mutual 2014) 17
Co-Pay: The fixed amount your plan requires you to pay when you receive a covered service (a co-pay is usually paid at the time you receive the service). YOUR CO-PAYMENT Is due at the time of your visit. Thank You 18
Co-insurance: The amount you pay for your share of a covered service, calculated as a percent. Coinsurance starts once you ve met your deductible. You also may have a co pay. 19
Summary of Benefits CMS: Summary of Benefits & Coverage & Uniform Glossary 20
CMS: Summary of Benefits & Coverage & Uniform Glossary 21
The Insurance Card: Center for Health Guidance ACA-Consumer-Guide-2014 22
The Insurance Card: Center for Health Guidance ACA-Consumer-Guide-2014 23
Suppose that under your health insurance policy, hospital expenses are subject to a $1,000 deductible and $250 per day copay. You get sick and are hospitalized for 4 days, and the bill (after insurance discounts are applied) comes to $6,000. How much of that hospital bill will you have to pay yourself? $0 $1,000 $2,000 $4,000 Don t know From: The Henry J. Kaiser Family Foundation 24
True or false: If you receive inpatient care at a hospital that participates in your health plan s provider network, all the doctors who care for you while you re in the hospital will also be in network? True False Don t know From: The Henry J. Kaiser Family Foundation 25
Suppose your health plan covers lab tests in full if you go to an in-network lab, but only pays 60% of allowed charges if you go out of network. You forget to check and go get your blood test at a lab that turns out to be out of network. The lab bills you $100 for the blood test. Your health insurance allows only a $20 charge for that test. How much would you have to pay out of pocket for that lab test? $0 $40 $80 $88 Don t know From: The Henry J. Kaiser Family Foundation 26
Stay Tuned! The Health Connector, based on feedback from this year s Open Enrollment events, is working on a Health Plan Shopping Guide for consumers and a Health Plan Shopping Training for assisters The assister training is focused on shopping for an unsubsidized QHP on the Health Connector website Training will be held at the end of May and an invite for the training will go out through the MTF listserv The Health Plan Shopping Guide for consumers will be available for download from MAhealthconnector.org 27
Resources for Assisters Massachusetts Health Care Training Forum (MTF) www.masshealthmtf.org MassHealth http://www.mass.gov/eohhs/consumer/insurance/masshealth member info/ Massachusetts Health Connector https://www.mahealthconnector.org US Department of Health and Human Services www.healthfinder.gov Center for Medicare and Medicaid Services (CMS) http://marketplace.cms.gov Glossary of Health Coverage and Medical Terms http://marketplace.cms.gov/help us/2partner with us.html From Coverage to Care http://marketplace.cms.gov/help us/c2c.html Institute of Medicine Roundtable on Health Literacy http://iom.edu/global/perspectives/2013/letsask4.aspx 28