1. Now What? Health Insurance 101
All You Need to Know Now That You’re Covered

3. Why is it so important?
Financial Protection
Keeps You Healthy

4. Insurance Sounds Complicated!
Private Insurance
Medicare
Preventative Care
Co-Pay
Network
Insurance Card
Preauthorization
Limitations
Specialist
Office Visit
Urgent Care
HMO
Deductible
PPO
Exclusions
Formulary
Health Savings Account
Co-Pay Card
Out-Of-Pocket Limit
Preferred Drug List
Actuarial Value
Primary Care Provider
Medicaid
Premium
Emergency Room
Co-Insurance
Prior Authorization
Gap Coverage
Marketplace

5. Relax and Take a Deep Breath!

7. By the end of this section you will:
Understand common insurance terms and how health insurance works
Know differences between types of health insurance plans
Be able to decode your insurance card

8. Common Insurance Terms
Karen Rubin
Community Engagement Coordinator

9. Payments
Premium
Co-Pay
Co-insurance

10. Premium Co-Pay Co-insurance Payments
Amount you pay each month for an insurance plan.
Co-Pay
Set amount you may have to pay at the time of your visit.
Co-insurance
Percentage of a medical service you need to pay after the deductible has been met.

11. Money, Money… Moneyyyyyy
Out-of-pocket limit
Actuarial Value
Deductible

12. Money, Money… Moneyyyyyy
Out-of-pocket limit
Most you’re allowed to pay per year before the plan covers 100%. Does not include premiums.
Actuarial Value
Percentage of the total costs for covered benefits.
Deductible
Amount you need to pay yearly before the plan starts paying.

13. Red Tape Exclusions and Limitations
Preauthorization/ Prior Authorization
Appeal/Grievance

14. Red Tape Exclusions and Limitations
Medical procedures and conditions the insurance plan will not cover.
Preauthorization/ Prior Authorization
Something that needs approval from your doctor and insurance company before it’s covered
Appeal/Grievance
Process you go through to try to get a decision by the insurance company reversed.

15. Doctors
Primary Care Provider
Specialist

16. Primary Care Provider Specialist Doctors
Your main doctor. He or she might refer you to other doctors. Required by some insurance plans.
Specialist
Doctor that focuses on a specific medical area. Generally more expensive to see. Might need a referral.

17. What is a Network?
Group of medical providers who agree to follow the plan’s rules and procedures
Contracts usually between medical practices/ organizations and insurance companies
Some models contract directly with medical providers
Providers get more clients, insurance companies get services at a reduced rate

18. What is Managed Care?
Uses a network, has explicit standards, formal review process, emphasizes preventative care, financial incentives to encourage efficiency
System designed to reduce costs and increase quality of care
Different types of plans, discussed later
Public and private plans
Others- fee-for-service
About 90% of insured Americans are enrolled in managed care plans.

19. Let’s Talk About Different Kinds of Insurance Plans!
HMO
EPO
PPO
POS
HSA

20. Health Maintenance Organization
HMO
All services in-network
Gatekeeper
Lower costs, more red tape

21. Exclusive Provider Organization
EPO
All services in-network
No Gatekeeper
Very similar to HMOs, generally less expensive

22. Preferred Provider Organization
PPO
Services in and out of network
No Gatekeeper!
Less red tape but higher premiums

23. POS Point of Service Services in and out of network Gatekeeper
HMO and PPO hybrid
Gatekeeper
Services in and out of network
Not as common as HMO or PPO

24. Health Savings Account
Tax-advantaged medical savings account
Unspent funds roll over year to year
Associated with plans with high deductibles
Limits on how much can be contributed

25. Decoding Your Insurance Card
Member name and number: Your name is printed along with your member number. If your spouse or children are on your insurance plan, your member numbers may look similar.
Coverage type: Type of insurance plan that you have.
Group number: Used to track the specific benefits of your plan. The group number and member number are used to identify you.
Co-pay and
co-insurance: Amounts you pay for some covered services
Phone numbers: Can be used to call your insurance company if you have any questions. May be on the back of your card.

26. Preventative Screenings
By: Erin Richardson

28. By the end of this section you will:
Know what a preventative screening is
Find out which screenings are right for you
Understand how to access preventative screenings
Create your own screening schedule

29. Preventative Health Screening
a cost-effective way to find and treat health problems before they start or get worse

30. Marketplace Plans and Preventative Screenings
All Marketplace plans and many other plans must cover certain preventive services
No charge of copayment or coinsurance.
Even if you haven’t met your yearly deductible
Applies only when services are delivered by a network provider.

31. Medicaid/Medicare and Preventative Screenings
Many preventive services are available without cost-sharing to individuals with new private health plans, Medicaid expansion plans, or Medicare

32. 5 Categories of Preventative Screenings/Services
Lifestyle Screenings
Sexual Health Screenings
General Health Screenings
Screenings for Women
Vaccines

33. Lifestyle Screenings Alcohol abuse screening and counseling
Depression screening for adults
Tobacco Use screening for all adults
help with quitting is available

34. Lifestyle Screenings (Marketplace Only)
Diet counseling
Obesity screening and counseling

35. Sexual Health Screenings
HIV screening for everyone ages 13 to 65
includes other ages at increased risk
Sexually Transmitted Infection (STI) prevention counseling
Syphilis, Gonorrhea, Hepatitis-C screening

36. General Health screenings
Blood Pressure screening
Cholesterol screening
Colorectal Cancer screening
for adults over 50
Diabetes (Type 2) screening

37. Screenings for Women Breast Cancer (Mammogram) screenings
every 1 to 2 years for women over 40
Cervical Cancer screening
Every 24 months
Domestic and interpersonal violence screening and counseling
Osteoporosis screening
for women over age 60 depending on risk factors

38. Vaccines What is a vaccine?
Treatment(s) that build up your body’s defenses against certain infections

39. Vaccines Your physician knows best when it comes to vaccines
Practices vary by physician and by individual case
Always consult you HIV doctor when it comes to getting vaccinated

40. How do vaccines work?

41. Vaccines Vaccines may cause more side effects for PLWHA
Vaccinations can increase viral load for a short period of time.
However, getting preventable diseases can be much worse.
Do not measure your viral load within 4 weeks of any vaccination.

42. Vaccines
People with low CD4 cell count should talk to their doctor before getting a “live” vaccine
Chicken Pox
Shingles
Measles, Mumps, and Rubella (MMR)

43. When to get Vaccinated CD4 count below 200 CD4 count above 200
Flu (Influenza)
Every year
Td/Tdap
Tetanus
Diphtheria
Pertussis
Tdap vaccine once
Td booster every 10 yrs
Chickenpox (Varicella)
Should not get
2 doses
HPV (human papillomavirus)
Women and Men
3 doses
(through age 26)
Shingles (Zoster)
No recommendation

44. When to Get Vaccinated CD4 count below 200 CD4 count above 200
Measles, mumps, rubella (MMR)
Should not get
1 or 2 doses
Pneumonia (Pneumococcal)
1 dose of Prevnar,
1 dose of Pneumovax every 5 years
Meningitis (meningococcal)
Hepatitis A
2 doses
Hepatitis B
3 doses
(Hib)
Haemophilus inluenzae typeB
1 or 3 doses

45. How to get screened or vaccinated
Talk with your HIV doctor
Schedule appointments as necessary
Keep a chart of screenings and vaccinations

46. Vaccines Your physician knows best when it comes to vaccines
Practices vary by physician and by individual case
Always consult you HIV doctor when it comes to getting vaccinated

47. Create a Screening Schedule
Within your packet there are two assessment sheets that will help you create a personalized screening schedule

48. Nueva Luz Urban Resource Center
Questions?
Erin Richardson
AmeriCorps Member
Nueva Luz Urban Resource Center
Phone: x 118

49. Picking Your Provider Matt Wovrosh
Senior Community Engagement Coordinator

51. By the end of this section you will:
Know how to find a doctor and be prepared for medical visits
Know when you should go to the emergency room and when to go to your primary care provider
Know what to do if you don’t like your doctor

52. Finding a Primary Care Doctor that works for you
Understand your Insurance
Find a Provider
Make an Appointment
Prepare for your Visit
Decide if you like your provider
Finding a Primary Care Doctor that works for you

53. How Do I Find a Doctor? Ask your friends and family
Internet- healthgrades. com
Check your insurance company’s provider network
If you’re assigned a doctor and want to change him or her, contact your insurance plan

54. Accepting new patients?
Things to Think About
Accepting new patients?
Close to home or work?
Office hours
Languages spoken
Other things to consider: Gender preference in your doctor, Doctor familiar with LGBT issues, if the doctor has a specialty that you might want to consider.

55. Making an Appointment Mention if you are a new patient
They will want your name DOB address Social Security Number and Insurance Information
Which Doctor do I want to see?
*As a new patient, I asked the receptionist on the phone which of the providers housed there had the best sense of humor. This (among other things, of course) helped inform my decision. Ask any questions you want, as this is YOUR choice and they will be YOUR doctor!
Might have to wait a bit for appointment depending on schedule
Write down any questions you have for them

56. Be Prepared for Your First Appointment
Show up early
Ask questions (make a list)
Have insurance card and ID
Bring list of medications
Money for co-pay*
Medical history
Don’t be shy!
*if you have one

57. So What’s the Difference?
Primary Care Provider
Emergency Department/Urgent Care
When you feel sick and when you feel well
When you are very sick or have a life-threatening situation
You will usually see the same person every time
Will see the person who is working that day
Will check all areas of your health, and may focus on areas that you weren’t concerned about
Will check mainly the problem/illness that brought you in
May have a shorter wait time in the office and a longer visit
May have a much longer wait time and a shorter visit
Will be able to access your complete health record and help you with your health over the long term
May or may not be able to access your full health record or health history
It’s important to remember that you may have a higher co-pay or co-insurance for visits to an emergency department or urgent care

58. Breakout Session

59. Picking out your Doctor
You’re not married to your doctor! “Date” a little bit. Not every doctor was created equal.
You should feel comfortable with your doctor—Not all docs are great!
Feel around for something that works
Someone who understands your health needs, culture, and language, and is respectful and convenient
If it’s not right, keep looking

60. After Your Appointment
Follow all the instructions your doctor gave you
If you need to, make a follow up visit
Keep in touch!
Take advantage of preventative care! You don’t have to be sick to see a doctor.

61. Exploring Your Options
Zach Reau
Community Engagement Coordinator

62. By the end of this section you will:
Know how OHDAP works in Health Marketplace plans
Understand your Medicaid eligibility
Be familiar with the purpose and eligibility of MyCare Ohio

64. Ryan White and the Marketplace
Tax credits and subsidies not sufficient to make plans affordable for all people living with HIV
Ryan White Part B (OHDAP) can be used to help cover insurance premiums, out-of-pocket costs for drugs on the OHDAP formulary, and out-of-pocket costs for HIV-related medical expenses
Not deductibles!
The Ohio Department of Health’s guidelines:
% FPL assess best silver plan
% FPL assess most cost-effective silver or gold plan
% FPL assess best gold plan

66. Documents and Forms
In order to receive premium and cost-sharing assistance from Ryan White:
Marketplace Eligibility Notice (from the IRS) showing amount of tax credit and plan information. Copy to OHDAP.
IRS Reconciliation Statement (starting Jan 31, 2015). Copy to OHDAP.

67. Where do you apply? *only during open enrollment
Apply online at healthcare.gov
Or call
Need help? ohioforhealth.org
**unless you qualify for a Special Enrollment Period
Qualifying life events like job loss, prison release, getting married, having a child, or anything that alters your tax status

68. What Is Medicaid Expansion?
Modernized and Simplified
MAGI (Managed Care) vs. Non-MAGI (ABD)
From 150 categories  2
New Eligibility
Individuals earning about $16,000/year for a household of one
Meet citizenship requirements
ROLLING ENROLLMENT
Resident of Ohio

69. Managed Care Medicaid
Begin with fee-for-service Medicaid (Medicaid card) before going into a Managed Care plan (15-60 days)
You choose a company to manage your plan (UHC, Molina, CareSource, etc.) but you STILL HAVE MEDICAID!
All must offer:
Unlimited mental health visits!
Additional benefits like 24-hour nurse advice lines, transportation to appointments, and care managers for folks with complex medical conditions
Companies may differ:
Incentives for services (Reward$), Preferred Drug Lists vs. “medically necessary” drugs

70. Where do you apply? Already receive Age, Blind or Disabled Medicaid?
Apply online at benefits.ohio.gov
Or call
County ODJFS—TIME SINK
Already receive Age, Blind or Disabled Medicaid?
remains the same
…unless you’re dual eligible

71. What Is MyCare? Integrated Care Delivery System
Coordinates Medicaid + Medicare into a Managed Care Plan
Simplifies use for consumer
“Pilot” Program
For those w/ Medicare Parts A, B & D and full Medicaid benefits - AND - live in one of the seven demonstration regions

72. MyCare Ohio
Single point of contact: managed care plans will be a single point of contact for all individuals enrolled in both Medicare and Medicaid.
Helps individuals better understand their health care needs and to more easily navigate various services and health care settings.
You choose: choose from at least two managed care plans in each region to provide your Medicaid and Medicare benefits.
Medicare opt-out: have the option for managed care plan to provide Medicare benefits or to opt out of the Medicare portion of the program and stay with current Medicare Advantage plan.
However, the chosen MyCare Ohio managed care plan will still provide and pay for all Medicaid services

73. Who can access?

74. Where do you apply? And if I’m not dual eligible? …
Auto-notified when eligible
Or call
And if I’m not dual eligible? …

75. Medicare APPLY Ohio Dept of Insurance
Various Parts
65+, eligible for Social Security, some people living with disabilities
Parts A-D cover different services
OHDAP
Part C & D Premium / Co-Pay Assistance Available
APPLY Ohio Dept of Insurance
Ohio Senior Health Insurance Information Program

77. Save $$ – Stay Healthy – Live Longer
Preventive Care
Use Generic Drugs
Follow Doctor’s Orders
Find a PCP
ER for Emergencies Only
Healthy Choices
Save $$ – Stay Healthy – Live Longer

78. Next Steps… Notify OAC with:
Enrollment issues in Marketplace, Medicaid & MyCare
Payment issues with OHDAP
Gaps in service or RW Provider network
Stay up-to-date by following our Marketplace Resources Page or follow OAC on Facebook
Report discriminatory practices to OAC or the Ohio Department of Insurance (online)
Questions or Feedback:
Zach Reau