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What I need to know about health insurance.. Introduction to Health Insurance Basics Terms Scenario Mandated covered services Plans Identify Explain Pros.

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Presentation on theme: "What I need to know about health insurance.. Introduction to Health Insurance Basics Terms Scenario Mandated covered services Plans Identify Explain Pros."— Presentation transcript:

1 What I need to know about health insurance.

2 Introduction to Health Insurance Basics Terms Scenario Mandated covered services Plans Identify Explain Pros and Cons Metal tiers How to choose Other considerations

3 Basic Terms for Personal Cost Premium Deductible Coinsurance Copayment Out-Of-Pocket Max

4 What is a premium? Amount you pay to maintain insurance coverage. This is reflected in a monthly payment.

5 What is a deductible? Amount you are responsible for paying for a covered medical expense before the plan begins to pay for covered medical expenses per year.

6 What is Coinsurance? A shared cost between you and the plan. Either pay coinsurance or copayment.

7 What is a Copayment? AKA Copay A payment you will make each time you visit the doctor or fill a prescription. Some policies or plans have additional copays for Emergency and Urgent Care services.

8 What is an Out-of-Pocket Maximum? The most you will be required to pay for covered medical expenses during the plan year. Includes costs to meet deductible and coinsurance/copayments. Plan will pay at 100% once OOP has been reached.

9 How Does Health Insurance Work? Scenario: You have inpatient surgery to remove your gallbladder on January 1st. Your accumulated expenses total $40,000. Scenario Plan: Deductible: $3,000 Coinsurance: 10% Out-of-Pocket Max: $4,000 Scenario balance you are responsible for: $4,000. For the rest of the year, covered medical expenses will be covered at 100%.

10 What is health insurance mandated to cover in 2014? Ambulatory patient services (outpatient services) Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care

11 Types of insurance plans Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Point-Of-Service (POS)

12 HMO-Health Maintenance Organization PROS Plan pays for visits with out having to file a claim. Minimal OOP costs. All in-network providers clearly listed in plan. CONS Limited network of providers. Plan will not pay for specialty care with out pre-approval from gatekeeper (except in emergencies). No coverage for use of out of network providers. A type of health insurance plan that limits coverage to care from doctors who work for or contract with the HMO.

13 PPO-Preferred Provider Organization PROS Contracts with individual physicians, hospitals and providers in community. Contracts with providers for discounted fees. Can use out of network providers. Able to see specialists without a referral from gatekeeper. CONS Have to pay more to use out of network providers. Patient is responsible for a percentage of the discounted service fee. A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers.

14 POS-Point of Service plan PROS Functions like an HMO if primary care provider is in network. Option of using other physicians and self referrals. CONS Deductible and co- insurance apply if utilizing providers out of network/ non-participating plan providers. A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plans network.

15 Metal Tiers

16 How do I choose a plan? Review medical needs (self/family). Prescriptions, doctors, etc. Estimate total cost for the year with new plan. Total premium, anticipated deductible payments, coinsurance, copayments and other OOP expenses.

17 Help Paying for Insurance

18 Additional resources- VIDEO LINKS Cost Sharing and Advanced Premium Tax Credit (APTC) https://www.healthcare.gov/will-i- qualify-to-save-on-monthly-premiums/ https://www.healthcare.gov/will-i- qualify-to-save-on-monthly-premiums/ https://www.healthcare.gov/will-i- qualify-to-save-on-out-of-pocket-costs/ https://www.healthcare.gov/will-i- qualify-to-save-on-out-of-pocket-costs/

19 References /GETTINGSTARTED/Pages/Understa ndInsurance.aspx#works /GETTINGSTARTED/Pages/Understa ndInsurance.aspx#works -your-ppos-hmos-poss-straight/ -your-ppos-hmos-poss-straight/ g/blog/10-essential-health-benefits- insurance-plans-must-cover- starting-in g/blog/10-essential-health-benefits- insurance-plans-must-cover- starting-in-2014


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