1. Navigating the Health Insurance Marketplace
Randy Oates (PSC patient) IronHealth Chief Operating Officer (retired)

2. Sources of Coverage Employer Sponsored Plans
Approximately 45% of Americans receive their health insurance coverage through an employer sponsored plan
Employers typically pay about 75% of the employee premium and a much smaller portion of dependent coverage
Employer selects plan design (co-pays, deductibles, covered services, etc.) as well as the type of plan(s) offered (PPO, HMO, EPO)

3. Sources of Coverage (continued)
Medicare
Administered by the Federal Government
Provides coverage for citizens age 65+ as well as certain disabled citizens
Funded via payroll taxes on the employee as well as the employer
Providers (hospitals and doctors) must agree to accept Medicare reimbursement rates which are typically lower than regular commercial reimbursements

4. Sources of Coverage (continued)
Medicaid
Administered by each State with funding provided by the Federal Government
Provides coverage for lower income and/or disabled adults and children
Providers must agree to accept Medicaid reimbursement rates which are typically lower than Medicare reimbursement rates

5. Sources of Coverage (continued)
Health Insurance Exchange Plans
(“the individual market”)
Commonly referred to as “Obamacare”
Requires participating insurance companies to provide coverage on a guaranteed issue basis with a preset list of minimum coverages
Insurance companies are not required to participate and must have rates approved in advance of open enrollment periods
Potential changes on the horizon (discussed later in this presentation)

6. What Impacts the Cost We Pay for Coverage?
Who is offering the plan
Size of the network (participating hospitals and doctors)
Out of network coverage (if available)
Benefits offered
Cost sharing mechanisms (co-pays, deductibles, out-of-pocket limits, etc.)
Drug formulary (approved drugs, tiered drugs, mail order drugs)
Centers of Excellence
Select group of specialty hospitals for procedures like organ transplants that have agreed to reduced charges in exchange for patient flow.
Fortunately, these are normally the best facilities in terms of quality and outcomes

7. Potential Landmines When Selecting a Plan
Your provider(s) are not in the network
Drug formulary doesn’t cover your medication(s) or considers them Tier 3 medications
No out of network coverage available
Your covered child will soon reach age 26 and can no longer be covered under your plan
Lower premium may be a result of significantly higher cost sharing

8. Exception Requests Examples
Medication not covered by formulary
Out of network provider
Who is funding your plan will determine the path you need to follow
Employer plan exception requests will vary based on how the plan is funded
Self insured employer plans are administered by an insurance company but the employer must approve any exceptions
Fully insured plans are managed by the insurance company and they will approve/decline exceptions
Medicare and Medicaid requests driven by your provider to Medicare/Medicaid Administration
Individual plan requests will be determined by the insurance company

9. Potential Healthcare Reforms Coming This Fall For Individual Market
Individual mandate has been repealed so people are no longer required to buy insurance (only those who need it will buy)
Costs will most likely increase as a result
Pre-existing conditions limitations may be reinstated
Could result in reduced or no coverage for pre-existing conditions
Current 3x premium maximum may increase to as much as 9x
Maximum premium charge for the oldest person cannot exceed 3x the lowest premium currently
More carriers may exit the market
Fewer or no options available for coverage