1. Health Insurance Literacy 101 Centers for Medicare and Medicaid Services July 2014 Understanding Health Insurance and the Marketplace & From Coverage to Care: Using the Roadmap & Discussion Guide

2. 2  Essential health benefits  The value of health insurance coverage Primary and/or specialty care Inpatient care Emergency care  Follow-up care Preventive care Explaining the Value in Having Health Insurance 2 Health Insurance Literacy for the Marketplace 2

3. 3 3 Understanding the Marketplace Preventive and wellness services and chronic disease management Pediatric services, including oral (dental) and vision care (pediatric oral (dental) services may be provided by stand-alone plan) Ambulatory patient 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 and devices Laboratory services  Essential health benefits include at least these 10 categories Qualified Health Plans Cover Essential Health Benefits

4. 4  Primary care  Pediatric health and dental care  Coverage for specialty services Women’s health, cardiologist, etc.  Prescriptions  Mental health care and substance use disorder services  Laboratory services Value: Immediate “Everyday” Care 44 Health Insurance Literacy for the Marketplace Health care, right when you need it, before a health problem gets worse

5. 5  Health insurance for preventive care Prevents illness or detect illness at an early stage, when treatment is likely to work best The health care law makes many of these free  Examples: Flu shots and screening mammograms Helps you become well and stay well  Manage chronic conditions Like diabetes or asthma Value: Preventive and Chronic Care Management 55 Health Insurance Literacy for the Marketplace https://www.healthcare.gov/what-are-my-preventive-care-benefits /

6. 6  Inpatient care, like for surgery  Emergency care Illness, injury, or condition so serious that a reasonable person would seek care right away to avoid severe harm No prior approval needed whether provider or hospital is in the plan (in the network) or not Value: Inpatient, Emergency and Follow-up Care 66 Health Insurance Literacy for the Marketplace The average cost for a 3-day hospital stay is $30,000. The average cost for fixing a broken leg is $7,500.

7. 7  Protection from high medical costs that could put you in debt, affect your credit, or cause bankruptcy  Insurance companies negotiate rates with providers so you pay a lower rate (generally a 40% saving from those not insured)  Peace of mind  Protecting your family’s health Value: Cost Savings 7 Health Insurance Literacy for the Marketplace 62.1% of all bankruptcies have a medical cause.

8. 8  You may pay a fee when you file your 2014 Federal tax return in 2015 (and thereafter) If you don’t have minimum essential coverage, and You don’t qualify for an exemption  You have to apply for an exemption, it isn’t automatic  Paying the fee doesn’t provide health coverage Value: Without Minimum Essential Coverage You May Pay a Fee 8 Health Insurance Literacy for the Marketplace Less than 2% of Americans are expected to have to pay the fee.

9. 9  Health insurance is a contract You compare plans You choose a plan and enroll You pay a monthly premium and other costs The insurance company pays a predetermined part of your healthcare expenses and you pay part You get access to health care Explaining How Health Insurance Works 9 Health Insurance Literacy for the Marketplace 9

10. 10  Health Maintenance Organizations (HMOs) Have networks Usually use primary care doctors Usually need referrals for specialists  Preferred Provider Organizations (PPOs) Have networks Can go out-of-network but pay more No referrals needed Explaining the Types of Marketplace Plans – HMOs and PPOs 10

11. 11 The Difference Between Getting Services In-Network and Out-of-Network 11 Health Insurance Literacy for the Marketplace In-Network Plan discounts Out-of-Network Possibly no discount May have to pay 100% out-of-pocket

12. 12  People will ask you “How much will it cost?” You will need to explain  Premiums  Deductibles  Copayments  Coinsurance  Out-of-Pocket Limit/ Maximum Explaining Costs Health Insurance Literacy for the Marketplace http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf 12

13. 13 Jane Pays 100% Her plan pays 0% Her plan pays 80% Her plan pays 100% Jane Pays 20% Jane Pays 0% Example of How to Explain Cost Sharing 13 Copayments – For certain services Jane pays a set amount, like $30 for a doctor visit. Jane has not reached her $1,500 deductible Jane reaches her $1,500 deductible, co-insurance begins Jane reaches her $5,000 out of pocket limit Her plan doesn’t pay anything: Office Visit cost $125 Jane pays $125 Her plan pays $0 Her plan pays some of the costs: Office visit cost: $75 Jane Pays 20% of $75 = $15 Her plan pays %80 of $75 = $60 Her plan pays the full cost: Office visit costs: $200 Jane pays: $0 Her plan pays: $200

14. 14  A list of prescription drugs covered by the plan  May have tiers that cost different amounts Explaining Formularies and Tiers 14 February 2014Health Insurance Literacy for the Marketplace Tier Structure Example TierCopayment You Pay Prescription Drugs Covered 1Most generics 2Preferred, brand-name 3Non-preferred, brand-name Specialty or high coinsurance Unique, very high-cost

15. 15  When you need care, call the doctor’s office Set up an appointment Confirm that they accept your insurance  Take insurance card to the doctor’s office  At your doctor’s visit, pay your share  Take advantage of preventive benefits  Call your insurance plan with coverage questions  Contact the plan if you want to change your primary care doctor Explaining How to Use Health Insurance 15 Health Insurance Literacy for the Marketplace

16. 16  You need to be informed Look for official government seals, logos, and navigator and assister certifications Navigators and assisters won’t ask for money  Protect your personal information  Ask questions and verify the answers you get  Report anything suspicious to the Marketplace consumer call center at 1-800-318-2596 (TTY users should call 1-855-889-4325) Explaining How to Protect Yourself From Fraud 16 Health Insurance Literacy for the Marketplace

17. From Coverage to Care: Using the Roadmap & Discussion Guide Training Guide

18. 1.What is From Coverage to Care (C2C)? 2.How to use the Roadmap and Discussion Guide 3.Step by Step: Walking Consumers Through the Roadmap 4.C2C Resources Presentation Overview

19. This session will help you:  Understand the goals of From Coverage to Care.  Talk to consumers about how to use new health coverage.  Explain key concepts to improve consumers’ health insurance literacy.  Teach consumers about using coverage to pay for preventive and primary health care services.  Locate resources for consumers, providers and assisters. Objectives

20.  Millions of Americans gained coverage through the Marketplace and Medicaid and CHIP during open enrollment, and this year more than 500,000 uninsured 64-year olds will become eligible for Medicare.  For many, this is the first time in a long time or they have never had coverage.  Unless we connect the newly insured to primary care and preventive services, we will not realize the other goals of the ACA – improving population health and reducing health care costs. Why From Coverage to Care?

21.  C2C is an effort to help educate consumers about their new coverage and to connect them with primary care and preventive services that are right for them so they can live long, healthy lives.  Resources online and in print include the Roadmap, Discussion Guide, videos, and more.  C2C builds on existing networks of community partners to educate and empower newly covered individuals. What is From Coverage to Care?

22.  Start the Conversation. Use the Roadmap and Discussion Guide as a tool to help people understand their new coverage and understand the importance of getting the right preventive services.  Help Consumers Understand. The Roadmap has a lot of information for consumers. You can help them use it as a resource to refer back to as they journey to better health and well-being.  Personalize it. You know your community. Consider adding local resources and information. How to Use the Roadmap

23. Coverage to Care Roadmap Online at marketplace.cms.gov/c2c

24. Step 1: Put Your Health First STEP 12345678 Key Points for Consumers Staying healthy is important for you and your family. Maintain a healthy lifestyle, get recommended health screenings, and manage chronic conditions. Keep health information in a safe place. Key Questions for Consumers Do you have questions about healthy habits, including eating and exercise? Do you know what free screenings and preventive care you should get to stay healthy?

25. Step 2: Understand Your Health Coverage Key Points for Consumers Check with your insurance plan or state Medicaid or CHIP program to see what services are covered. Be familiar with your costs (premiums, copayments, deductibles, coinsurance). Know the difference between in-network and out-of-network. Key Questions for Consumers Do you know how to find a provider in your network? Can you estimate how much you will pay when you see a provider? 1STEP 2345678

26. Key Terms On An Insurance Card Key terms 1) Member Name 2) Member Number 3) Group Number 4) Plan Type 5) Copayment 6) Phone Numbers 7) Prescription Copayment

27. Sample Cost Tables Cost scenarios like managing Type 2 Diabetes and having a baby help consumers understand what their care may cost, and how their plan may divide these costs. NOTE: These are not real costs.

28. 12STEP 345678 Step 3: Know Where To Go For Care Key Points for Consumers Only use the ER in a life-threatening situation. Primary care is preferred when it isn’t an emergency. Knowing the difference between primary care and care in the ER. Key Questions for Consumers Do you know how your costs would be different if you went to a primary care provider versus the Emergency Department? Do you know how your care would be different?

29. Primary Care vs. Emergency Care

30. Step 4: Find a Provider Key Points for Consumers Find providers your plan works with. Ask people you trust or do research on the Internet. Visit a provider to see if you like them. If you are assigned a provider, contact your plan to change. Key Questions for Consumers Were you assigned a provider by your plan or state Medicaid or CHIP program? Can you find the list of different provider types in your network – mental health, counselors, podiatrists, allergists? 123STEP 45678

31. Step 5: Make an Appointment Key Points for Consumers What to say when you call for an appointment. What questions to ask when scheduling your visit. Know how to make the most of your visit. Key Questions for Consumers Did you tell your provider what you want from your appointment – a wellness exam? screenings? help managing a chronic condition? Do you know your providers’ cancellation policy and when and how to pay? 1234STEP 5678

32. Step 6: Be Prepared for Your Visit Key Points for Consumers What health information to bring to your visit. How to use your health coverage for payment. Bring someone with you if you feel more comfortable. Key Questions for Consumers Do you have a list of the medications you take to share with your provider? Do you have information on your personal, and family, health history to share with your provider? 12345STEP 678

33. Step 7: Decide if the Provider is Right For You Key Points for Consumers Finding a provider you trust, and can communicate with, is important for your health. Is this provider someone you can work with over time? It is always okay to find another provider for any reason. Key Questions for Consumers Did you feel like you could talk with your provider? If you didn’t like your provider, what would have made it a better fit – language, culture, gender? 123456STEP 78

34. Step 8: Next Steps After Your Visit Key Points for Consumers Write down your providers’ instructions and healthy living tips so you can act on them every day. Schedule any follow-up or other visits and fill prescriptions so you don’t forget or get too busy. Review any documents or bills you receive and contact your plan or state Medicaid or CHIP program if you have questions. Key Questions for Consumers Do you know what to do now to keep yourself healthy? Do you know what number to call if you get sick and need to make an appointment or come back? 1234567STEP 8

35. Explanation of Benefits (EOB) It’s a summary of health care charges from the care you or those covered under your policy received. It is NOT A BILL!

36.  Glossary of health coverage terms.  Resource list.  Personal health tracking checklist.  Health information page for coverage and provider information. Other Information in the Roadmap

37.  Share C2C resources with others.  Continue to educate consumers.  Let us know what other resources would be useful.  Personalize it – you know your community. What Can You Do?

38. Visit http://marketplace.cms.gov/c2chttp://marketplace.cms.gov/c2c  Roadmap Poster Roadmap One-pagers: Insurance card, Primary care vs. emergency, and EOB Pull-out steps  Discussion Guide  Video vignettes …and more to come! Print copies available from the CMS Clearinghouse Available C2C Resources

39.  Chapter 1 – My New Health Plan Chapter 1 – My New Health Plan  Chapter 2 – Understand the Plan Chapter 2 – Understand the Plan  Chapter 3 – Words to Know Chapter 3 – Words to Know  Chapter 4 – Where to go for Care Chapter 4 – Where to go for Care  Chapter 5 – Finding a Provider Chapter 5 – Finding a Provider  Chapter 6 – Making an Appointment Chapter 6 – Making an Appointment  Chapter 7 – Almost Ready Chapter 7 – Almost Ready  Chapter 8 – My First Visit Chapter 8 – My First Visit  Chapter 9 – Like or Dislike Chapter 9 – Like or Dislike  Chapter 10 – The Day After Chapter 10 – The Day After  Chapter 11 – The Final Word Chapter 11 – The Final Word Videos 39