1. UNDERSTANDING HEALTH INSURANCE AND YOUR OPTIONS

2. HEALTH INSURANCE BASICS
Presented by
[insert organization’s name]

3. When shopping for a plan, ask:
What do I need?
What can I afford?
What is included in the plan?
How does the plan work?
Does the network of providers meet my needs? 1

4. Where can you get insurance?
Your employer.
On your own.
Groups associated with employment.
Membership organizations.
State or federal government.
On your own, or an ‘individual’ plan may be an option if you do not have access to employer-related insurance.
Groups associated with employment – trade unions or collective bargaining units will sometimes offer insurance.
Membership organizations such as a chamber of commerce or trade association may have association-sponsored plans. This is a good source if you are self-employed or a small business owner.
Pennsylvania offers PA Fair Care, Medicare, Medical Assistance and CHIP. 2

5. Health Plan Comparison3

6. Important Parts of the Plan to Review
Doctor Participation – Does your doctor participate in the plan?
Coverage – Does the plan provide coverage for both routine care and major medical coverage (catastrophic illness) or only major medical?
Premium – How much will the insurance cost you?
Co-pays – How much will you have to pay when you go to the doctor?
It is important to first check and see if your physician participates in the plan you have chosen. Be sure to call to receive the most up-to-date information.
Does your plan cover routine care? Major medical coverage? Prescription medication?
How much will this cost you on a bi-weekly or monthly basis?
Make sure you are aware how much you will have to pay when visiting – this is your copay. Many times, PCP, specialist and ER visit co-pays will be different.
Your deductible is the amount you pay each year toward medical expenses before insurance pays your claims.
Does the company need to approve your care or treatment before you receive it?
If you have a pre-existing condition, does your plan include an exclusion or waiting period for coverage?
Is there anything your plan doesn’t cover? Vision, dental and experimental procedures are some examples.
Some plans have limits on how much they will pay for services or over a certain period of time. 4

7. Important Parts of the Plan to Review (continued)
Deductible – How much will you have to pay each year toward medical expenses before the insurance begins paying claims?
Preauthorization – Does the health insurance company need to approve care or treatment before you receive it?
Pre-existing conditions – Does the plan cover your pre-existing condition?
Exclusions – Review what is not covered by the plan.
Limits – Is there a maximum dollar limit on how much the plan will pay? 5

8. 10 Questions to ask yourself before choosing a plan

9. Questions to Ask
Is the insurance company or agent selling the plan licensed by the Pennsylvania Insurance Department?
Is the company that offers the plan financially sound?
Will you be covered for care in an emergency situation or when you’re out of town?
Is it a discount health plan or an actual health insurance plan?
What degree of coverage will you receive?
#2 - Visit AM Best, Standard & Poor’s, Moody’s or other independent financial rating services to find out. 6

10. Questions to Ask (continued)
What are the real costs of the plan?
Are the doctors, hospitals, laboratories and other medical providers you use included in the network?
Do you have to choose a primary care physician?
Do you need to get a referral before you see a specialist?
Are the prescription medicines that you use covered by the plan?
#6 - Don’t be fooled by one or two low costs – take into account premiums, co-pays, deductible, coinsurance and other out-of-pocket expenses)
#7 - (If you want to use a doctor outside the network, will the plan permit it and, if so, at what cost?) 7

11. For more information on health insurance,
please visit 8

12. A Quick Guide to Medicare & Medigap9

13. What is Medicare? Federal health insurance program
Ages 65 & older.
Younger than 65 with certain disabilities.
Any age with permanent kidney failure (End-State Renal Disease).
Must be legal U.S. resident for five years
Two types of Medicare Coverage:
Original Medicare.
Medicare Advantage Plans.
Primarily an insurance program for those 65 and older, but can apply to those younger and at any age under certain conditions.
End-Stage Renal Disease is the proper term for permanent kidney failure
It isn’t a completely ‘free’ program – there are maximum benefits allowed and you must pay monthly premiums and can incur out-of-pocket deductibles and co-pays. 10

14. Original Medicare Medicare Part A Medicare Part B Hospital Insurance
- Hospital, skilled nurse facility, hospice or home healthcare.
You may be automatically enrolled, but sign up as soon as you are eligible.
Medicare Part B
Medical Insurance
- Doctors, healthcare providers, outpatient care, durable medical equipment, home healthcare and preventative services.
Sign up as soon as eligible – avoid late enrollment fee.
Original Medicare is broken down into two parts:
Part A assists with costs if you are in the hospital, skilled nursing facility, hospice or home healthcare.
Part B helps cover costs associated with doctors, healthcare providers, outpatient care, durable medical equipment, home healthcare and preventative services.
If you don’t sign up as soon as you are eligible, you may incur late enrollment fees. 11

15. Original Medicare (continued)
You will need to sign up on your own if:
You are not receiving Social Security or Railroad Retirement Board (RRB) benefits.
You qualify for Medicare because you have End-Stage Renal Disease (ESRD) 12

16. Original Medicare (continued)
You should apply for Medicare Part A and Part B three months before
your 65th birthday. You can apply:
Online at
In person at your local Social Security office.
By phone at (If you worked for a railroad, call the RRB at ) 13

17. Medicare Advantage Plans
Medicare plans that are run by private insurance companies.
Combine Medicare Part A and Part B in one plan.
Also called Medicare Part C.
Original Medicare is broken down into two parts:
Part A assists with costs if you are in the hospital, skilled nursing facility, hospice or home healthcare.
Part B helps cover costs associated with doctors, healthcare providers, outpatient care, durable medical equipment, home healthcare and preventative services.
If you don’t sign up as soon as you are eligible, you may incur late enrollment fees. 14

18. Medicare Part D Medicare Part D is prescription drug coverage.
Some Medicare Advantage plans include Part D.
If covered by Original Medicare, you may purchase Part D coverage through a Medicare-approved prescription drug plan (PDP). 15

19. Medicare Quick Recap Medicare Part A is hospital insurance.
Medicare Part B is medical insurance.
Medicare Part C is a Medicare Advantage Plan.
Medicare Part D is prescription drug coverage. 16

20. For more information on Medicare, please visit www.Medicare.gov.17

21. Medigap (Medicare Supplemental Insurance)
Private health insurance option that helps fill gaps in Medicare coverage
You must have Original Medicare to purchase Medigap
Medicare Advantage Plans (Part C) are ineligible
In order to purchase, you must have Original Medicare. Medicare Advantage Plan owners are not eligible to purchase Medigap.
Must be purchased individually. If you want to have your spouse covered, an additional policy must be purchased.
There are ten different plans available, labeled A-N. E, H, I and J are no longer available to be purchased. 18

22. Medigap Plans How to read the chart:
If a check mark appears in a column of this chart, the Medigap policy covers 100 percent of the described benefit. If a row lists a percentage, the policy covers that percentage of the described benefit. If a row is blank, the policy doesn’t cover that benefit. Note: The Medigap policy covers coinsurance only after you have paid the deductible (unless the Medigap policy also covers the deductible).
Policies typically will not cover vision, dental, long-term care, hearing aids, eyeglasses or private nursing.
Source: Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare, Developed jointly by the Centers for Medicare & Medicaid Services (CMS) and the National Association of Insurance Commissioners (NAIC), 2012.
*Plan F also offers a high-deductible plan. If you choose this option, this means you must pay for Medicare-covered costs up to the deductible amount before your Medigap plan pays anything.
**Plans K and L have out-of-pocket annual limits. After you meet your out-of-pocket yearly limit and your yearly Part B deductible, the Medigap plan pays 100 percent of covered services for the rest of the calendar year.
***Coinsurance is covered except copayments are required for certain office or emergency room visits. Review the plan carefully to understand the details. 19

23. Medigap. How much does it cost?
Each insurance company’s rates are different, but you’ll pay a monthly premium.
Policy pricing:
Community-rated
Not based on age
Same premium charged to everyone
Issue-age-related
Based on age when you buy policy
Attained-aged-related
Premium based on current age and rises with age
With the issue-age-related policy, those who purchase at a younger age will pay a lower premium.
Attained-aged-related can be inexpensive at first, but can be the most expensive option as you grow older. 20

24. Medigap: Open enrollment (continued)
Starts the first day of the month in which you began Medicare Part B benefits & lasts for six months
Different than Medicare Advantage Plan open enrollment
The insurance company can’t consider your health status (use medical underwriting) to:
Refuse to sell or charge you more
Make you wait for coverage to start
Likely to receive the best rates at this time
During the open enrollment period, the insurance company must offer ALL plans it sells and cannot use medical underwriting to refuse to sell you a plan, charge you more, or make you wait for coverage to begin. Pre-existing conditions may be excluded from this. 21

25. Medigap (continued)
For more information on Medigap, visit
to download Your Guide to Choosing a Medigap Policy. 22

26. If you’d like to learn more about health insurance, visit www
If you’d like to learn more about health insurance, visit