700 E. Jefferson Street, Suite 100 Phoenix, AZ (602) Understanding Health Insurance

Making Sense from Confusion

Would You Take This Deal? “I’ll give you $6,000, if you agree to pay 70% of my medical bills for the next 12 months”.

What If It Was... 20,000 people X $6,000 = $120,000,000 & you pay 70% of their medical bills?

1.What would you want to know before you agreed? 2. What conditions or requirements would want to protect all that money?

What Is Insurance? “ A small known loss to protect you from a large unknown loss”

Insurance Provides Protection Money Home Health “Bankruptcies resulting from unpaid medical bills will affect nearly 2 million people this year—making health care the No. 1 cause of such filings”. Source: NerdWallet Health, a division of the price-comparison website

Insurance Is A Contract I will give you $XXX and you promise to pay $YYY. And, we have agreed to the following conditions or details.

Premium The amount you pay each month to have health insurance.

Deductible

A Relationship Big Premium Small Deductible

Copay A fixed amount (for example, $25) you pay for a covered health care service, usually when you get the service.

The amount you pay after you have met the deductible amount for a covered service, calculated as a percent (for example, 20%) of the allowed amount for the service. Co-Insurance

Levels of Coverage Premium $ $$ $$$ $$$$ When you get care $$$$ $$$ $$ $ Co-Insurance

Out of Pocket Limit The most you pay during a policy period (usually a year) before your health insurance begins to pay 100% of the allowed amount. The maximum out-of-pocket costs for any Marketplace plan for 2016 are $6,850 for an individual plan and $13,700 for a family plan.

Claim A request for payment that you or your health care provider submits to your insurance company when you get items or services you think are covered.

Free Preventive Care Preventive care is care you receive when you're healthy and symptom- free, such as routine check-ups, screenings and immunizations. All Marketplace plans and many other plans must cover preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible.

Mixed Family Status Coatzacoalcos, Mexico Brooklyn, New York If Salma and Jimmy were married and had kids

Review

Progress Progress Check Terms 1.____ Premium Definitions A. B. C. Handout: Match the Definition to the Term by writing the letter of the correct definition in front of the correct term.

Provider Network  Insurance plans do not include all doctors and hospitals.  Providers that are contracted with your insurance plan are said to be in network.  If you use a provider outside of your network you will pay more.  If you use a provider outside of your network the insurance company will pay less of the bill.

Know Your Network If you use a provider outside your “Provider Network” you will pay more.

Using Your Insurance Primary Care Provider Urgent Care Emergency Room

Where to Get Care Primary Care Provider Understand your history, conditions and prescriptions They know your insurance $$$ Urgent Care Open more hours No appointments Don’t know you $$$ Emergency Room Open 24/7 No appointments Don’t know you $$$$$

Important Tools

Marketplace Financial Assistance AHCCCS Three Affordability Programs 3. Premium Tax Credits 400% FPL $79,160 (3 people) 250% FPL $49,475 (3 people) 138% FPL $27,310 (3 people) 2. Cost Sharing Reduction 1. Medicaid AHCCCS

Be Careful!

Summary of Benefits and Coverage

Do It Your Self AHCCCS Marketplace

Key Ideas 1.The amount I pay each month - premium 2.The amount I pay before the insurance company starts to pay - deductible 3.The amount I pay when I see a provider - copay 4.The amount I pay before the insurance company pays 100% - out of pocket limit 5.Providers who are contracted with my insurance plan – are in my provider network 6.Where I find information - healthcare.gov, summary of benefits and coverage, provider directory and list of covered drugs 7.Where can I find local help?

Finding Help Talk with a Navigator or English or Spanish

Allen Gjersvig Director Healthcare Innovation Q & A