Transcript Document

Now What? Health
Insurance 101
All You Need to Know Now That You’re
Covered
Why is it so important?
Financial
Protection
Keeps You
Healthy
Insurance Sounds Complicated!
Medicare Private Insurance
Preventative Care
Co-Pay Network
Insurance Card
Limitations Preauthorization
Specialist Urgent Care
Office Visit
Deductible
HMO
Exclusions
PPO
Formulary Health Savings Account
Co-Pay Card Out-Of-Pocket Limit
Preferred Drug List Actuarial Value
Primary Care Provider Premium Medicaid
Emergency Room
Co-Insurance
Prior Authorization
Gap Coverage
Marketplace
Relax and Take a Deep Breath!
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
Common Insurance Terms
Karen Rubin
Community Engagement
Coordinator
Payments
Premium
Co-Pay
Coinsurance
Payments
Premium
Amount you pay each month
for an insurance plan.
Co-Pay
Set amount you may have to
pay at the time of your visit.
Coinsurance
Percentage of a medical
service you need to pay after
the deductible has been met.
Money, Money… Moneyyyyyy
Out-ofpocket limit
Actuarial
Value
Deductible
Money, Money… Moneyyyyyy
Out-ofpocket 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.
Red Tape
Exclusions and
Limitations
Preauthorization/
Prior
Authorization
Appeal/Grievance
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.
Doctors
Primary
Care
Provider
Specialist
Doctors
Primary
Care
Provider
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.
What is a Network?
Group of medical providers who agree to follow
the plan’s rules and procedures
Providers get more clients, insurance companies
get services at a reduced rate
• Contracts usually between medical practices/
organizations and insurance companies
• Some models contract directly with medical providers
What is Managed Care?
System designed to reduce costs and increase quality of care
• Uses a network, has explicit standards, formal review process,
emphasizes preventative care, financial incentives to encourage
efficiency
Public and private plans
• Different types of plans, discussed later
About 90% of insured Americans are enrolled in managed care plans.
• Others- fee-for-service
Let’s Talk About Different Kinds of Insurance
Plans!
PPO
Health Maintenance Organization
Gatekeeper
Lower
costs, more
red tape
All services
in-network
HMO
Exclusive Provider Organization
No
Gatekeeper
Very similar
to HMOs,
generally less
expensive
All services
in-network
EPO
Preferred Provider Organization
No
Gatekeeper!
Services in
and out of
network
Less red tape
but higher
premiums
PPO
Point of Service
Gatekeeper
Services in
and out of
network
HMO and
PPO hybrid
POS
Not as
common as
HMO or PPO
Health Savings Account
Unspent funds
roll over year
to year
Tax-advantaged
medical savings
account
Associated
with plans with
high
deductibles
HSA
Limits on how
much can be
contributed
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
Co-pay and
of your plan.
co-insurance:
The group
Amounts you pay
number and
for some covered
member number
services
are used to
identify you.
Phone numbers: Can be used to call your
insurance company if you have any
questions. May be on the back of your card.
Preventative Screenings
By: Erin Richardson
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
Preventative Health Screening
a cost-effective way to find and treat health
problems before they start or get worse
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.
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
5 Categories of Preventative
Screenings/Services
1.
2.
3.
4.
5.
Lifestyle Screenings
Sexual Health Screenings
General Health Screenings
Screenings for Women
Vaccines
Lifestyle Screenings
• Alcohol abuse screening and counseling
• Depression screening for adults
• Tobacco Use screening for all adults
– help with quitting is available
Lifestyle Screenings
(Marketplace Only)
• Diet counseling
• Obesity screening and
counseling
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
General Health screenings
• Blood Pressure screening
• Cholesterol screening
• Colorectal Cancer screening
– for adults over 50
• Diabetes (Type 2) screening
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
Vaccines
• What is a vaccine?
– Treatment(s) that build up your body’s defenses
against certain infections
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
How do vaccines work?
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.
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)
When to get Vaccinated
CD4 count below 200
CD4 count above 200
Flu (Influenza)
Every year
Every year
Td/Tdap
• Tetanus
• Diphtheria
• Pertussis
Tdap vaccine once
Td booster every 10 yrs
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)
3 doses
(through age 26)
Shingles (Zoster)
Should not get
No recommendation
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
1 dose of Prevnar,
1 dose of Pneumovax
every 5 years
Meningitis (meningococcal)
1 or 2 doses
1 or 2 doses
Hepatitis A
2 doses
2 doses
Hepatitis B
3 doses
3 doses
(Hib)
Haemophilus inluenzae typeB
1 or 3 doses
1 or 3 doses
How to get screened or vaccinated
• Talk with your HIV doctor
• Schedule appointments as
necessary
• Keep a chart of screenings
and vaccinations
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
Create a Screening Schedule
Within your packet there are two assessment
sheets that will help you create a personalized
screening schedule
Questions?
Erin Richardson
AmeriCorps Member
Nueva Luz Urban Resource Center
Phone: 216-651-8236 x 118
Email: [email protected]
Picking Your Provider
Matt Wovrosh
Senior Community
Engagement Coordinator
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
Decide if you like your
provider
Finding a Primary
Care Doctor that
works for you
Prepare for your Visit
Make an
Appointment
Find a Provider
Understand your
Insurance
How Do I Find a Doctor?
Ask your
friends and
family
Internethealthgrades.
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
Things to Think About
Accepting
new
patients?
Close to
home or
work?
Office
hours
Languages
spoken
Making an Appointment
Mention if you
are a new
patient
Which Doctor
do I want to
see?
They will want your name
DOB address Social
Security Number and
Insurance Information
Write down any
questions you
have for them
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!
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 lifethreatening 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
Breakout Session
Picking out your Doctor
• 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
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.
Exploring Your Options
Zach Reau
Community Engagement
Coordinator
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
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:
– 138-200% FPL assess best silver plan
– 201-250% FPL assess most cost-effective silver or gold plan
– 251-300% FPL assess best gold plan
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.
Where do you apply?
*only during open enrollment
Apply online at healthcare.gov
Or call 800-318-2596
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
What Is Medicaid Expansion?
Modernized
and
Simplified
New
Eligibility
From 150 categories  2
MAGI (Managed Care) vs.
Non-MAGI (ABD)
Individuals earning about
$16,000/year for a household
of one
Resident of Ohio
Meet citizenship requirements
ROLLING ENROLLMENT
Managed Care Medicaid
• Begin with fee-for-service Medicaid (Medicaid card) before going
into a Managed Care plan (15-60 days)
• You choose a company to manage your plan (UHC, Molina,
CareSource, etc.) but you STILL HAVE MEDICAID!
• All must offer:
– Unlimited mental health visits!
– Additional benefits like 24-hour nurse advice lines, transportation to
appointments, and care managers for folks with complex medical
conditions
• Companies may differ:
– Incentives for services (Reward$), Preferred Drug Lists vs. “medically
necessary” drugs
Where do you apply?
Apply online at benefits.ohio.gov
Or call 800-324-8680
County ODJFS—TIME SINK
Already receive Age, Blind or Disabled
Medicaid?
 remains the same
…unless you’re dual eligible
What Is MyCare?
Integrated
Care Delivery
System
“Pilot”
Program
Coordinates Medicaid +
Medicare into a Managed
Care Plan
Simplifies use for
consumer
For those w/ Medicare
Parts A, B & D and full
Medicaid benefits - AND live in one of the seven
demonstration regions
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
Who can access?
Where do you apply?
Auto-notified when eligible
Or call 800-324-8680
And if I’m not dual eligible? …
Medicare
Various
Parts
65+, eligible for Social
Security, some people
living with disabilities
OHDAP
Part C & D Premium /
Co-Pay Assistance
Available
Parts A-D cover
different services
APPLY Ohio Dept of Insurance
Ohio Senior Health Insurance Information Program
800-686-1578
Preventive
Care
Healthy
Choices
Use Generic
Drugs
Save $$ – Stay Healthy – Live Longer
ER for
Emergencies
Only
Follow
Doctor’s
Orders
Find a PCP
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
[email protected]
614.340.6752