Transcript educating our peers on assister roles

Educating Consumers and Peers about
Health Insurance and Assister Roles
Learning Objectives
I.
Identify and examine the health insurance literacy
problem in the U.S.
II. Define common health insurance terms and procedures
III. Identify effective strategies for educating peers about the
Navigator’s role, building workplace and community
support, and advocating for health insurance literacy
The Washington Post
Survey: Americans Have Low Health Insurance
Literacy
• Only 12 percent of adults have proficient health literacy,
according to the National Assessment of Adult Literacy.
• More than HALF of Americans cannot correctly define at
least one of these common financial terms related to health
insurance:
– Premium
– Deductible
– Copay
Source: HHS; Kaiser Health News
Health Literacy Matters
People of all ages, races, incomes and education levels struggle
with limited health literacy, but the groups who struggle the most
are:
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Older adults
Recent immigrants
People with low incomes
Those enrolled in Medicare
or Medicaid
Health Literacy Matters
• Poor health literacy is a huge barrier standing between
uninsured American and enrollment in health coverage
– More than HALF of the American public find it difficult to understand
and use information written above an eighth-grade level. Most healthrelated materials are written at a tenth-grade reading level or higher.
Source: Enroll America
Health Literacy Matters
• Jargon and technical language make it harder for consumers
to enroll and retain health coverage
• Many people also face linguistic and cultural barriers
• These factors are a recipe for missed deadlines and
appointments, misunderstood instructions, and poor
understanding and management of chronic diseases
• Low health literacy is associated with reduced use of
preventive services and management of chronic conditions,
unnecessary ER visits, and higher mortality.
– This costs the US Economy between $106 billion and $236 billion
annually!
Source: Center for Health Care Strategies, Inc.
TERMS TO KNOW
Minimum Essential Coverage (MEC)
• The type of coverage an individual needs to have to meet the
individual responsibility requirement (individual mandate)
under the Affordable Care Act (ACA).
– The individual mandate requires that ALL eligible Americans have at
least basic health coverage
– If they don’t have coverage, then they are subject to the individual
shared responsibility fee for each month they are without health
insurance or do not have an exemption
Minimum Essential Coverage (MEC)
• If you have coverage from any of the following, you’re
covered and don’t have to do anything.
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Employer-sponsored coverage, including COBRA and retiree
Individual coverage/Marketplace Coverage
Medicare (Part A) and Medicare Advantage plans
Most Medicaid coverage, including CHIP
Certain Veterans health coverage (from the VA)
Most types of TRICARE coverage
Coverage provided to Peace Corp volunteers
Refugee Medical Assistance (ACF)
Self-funded health coverage offered to students through schools
State high risk pools
Coverage under the Nonappropriated Fund Health
Benefit Program
Essential Health Benefits (EHBs)
• Marketplace plans MUST include essential health benefits in
at least these 10 categories:
1. Ambulatory patient
services
2. Emergency
services
3. Hospitalization
4. Maternity and
newborn care
5. Mental health and
substance use disorder
services
6. Prescription drugs
7. Rehabilitative and
habilitative services and
devices
8. Laboratory services
9. Preventive and wellness
services and chronic
disease management
10. Pediatric services
including oral and vision
Premium
• The amount that must be paid for health insurance or plan.
You and/or your employer usually pay it monthly, quarterly or
yearly.
• You must pay the first month’s premium by the insurer’s
deadline to avoid plan termination
– Consumers receiving APTC who timely pay their first premium are
eligible for the three-month grace period
• Insurers must accept payments by:
– Paper check, cashier’s check, money order, EFT, Pre-paid debit card
– Some issuers may also accept online, credit card, or debit card
payments (check with plan)
Premium
• Monthly premiums are based on several factors including:
 Age
 Smoking status
 Location
 How many people are enrolling on the same plan
 The insurance company
• Consumers between 100 and 400% of the federal poverty
level qualify for the Premium Tax Credit
 Available only through the Marketplace
Premium Tax Credit
Choose to Get It Now: Advanced Payments of the Premium Tax Credit
• All or some of the premium tax credit is paid directly to the plan on a monthly
basis
• Consumer pays the difference between the monthly premium and advance
payment
• Consumer reconciles when they file their tax return for the coverage year*
Choose to Get it Later
• Don’t request any advance payments
• Consumer pays the entire monthly plan premium
• Consumer claims the full amount on the tax return they file for the coverage
year
Cost-Sharing Reduction (CSR)
• A discount that lowers the amount you have to pay out-of-pocket for
deductibles, coinsurance, and copayments
• CSR subsidies are automatically applied on the federal Marketplace
for individuals/families with income between 100 and 250% of the
federal poverty level ($11,670-$29,175 for an individual)
– A silver plan must be selected to take advantage of CSR
Copayment
• A fixed amount you pay for a covered health care service,
usually when you receive the service.
• The amount can vary by the type of covered health care
service.
– For example, Jane pays $15 to see her primary care physician, $25
for her cardiologist and $20 for her brand-name prescriptions
Deductible
• The amount you owe for health care services your health
insurance or plan covers before your health insurance or plan
begins to pay.
• For example, Jane’s deductible is $1000, her plan won’t pay
for anything until she’s met her $1000 deductible for covered
health care services subject to the deductible.
– This deductible may not apply to all services.
Coinsurance
• Percentage of allowed charges for covered services that you
are required to pay after you have fulfilled the deductible.
• For example, Jane’s health insurance or plan’s allowed
amount for an office visit is $115, and she’s met her
deductible–her coinsurance payment of 20% would be $23.
– The health insurance or plan pays the rest of the allowed amount—
$92.
Out-of-Pocket Maximum
• The most you pay during a policy period (usually a year)
before your health insurance or plan begins to pay 100% of
the allowed amount.
• This limit never includes your premium, balance-billed
charges or health care your health insurance or plan doesn’t
cover.
• Some health insurance or plans don’t count all of your
copayments, deductibles, coinsurance payments, out-ofnetwork payments of other expenses toward this limit.
Explanation of Benefits (EOB)
• Summary of health care charges that your health plan sends
you after you see a provider or get a service.
• It is not a bill—it is a record of the health care you or
individuals covered on your policy got and how much your
provider is charging your health plan. If you have to pay
more for your care, your provider will send a separate bill
Health Maintenance Organization (HMO)
• A type of health insurance plan that usually limits coverage
to care from doctors who work for or contract with the
HMO. It generally won’t cover out-of-network care except
in an emergency. An HMO may require you to live or work
in its service area to be eligible for coverage
Preferred Provider Organization (PPO)
• A type of plan that contracts with medical providers, such as
hospitals and doctors, to create a network of participating
providers.
• You pay less if you use providers that belong to the plan’s
network, and you can use doctors, hospitals and providers
outside of the network for an additional cost
Explaining Appeals: Insurance Company
• Insurers must tell consumers why they’ve denied any claim
or ended coverage, and they must inform about the appeals
process
• There are two ways to appeal a health plan decision:
1. Internal Appeal: a consumer may ask their insurance company to
conduct a full and fair review of its decision. If the case is urgent,
the insurance company must speed up this process.
2. External Review: a consumer has the right to take their appeal to
an independent third party for review. The insurance company no
longer gets the final say over whether to pay a claim
Explaining Appeals: Marketplace
• A consumer may file an appeal for the following types of
Marketplace decisions:
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Eligibility to buy a Marketplace plan
Eligibility for a special enrollment period
Eligibility for lower costs based on income
The amount of savings the consumer is eligible for
Eligibility for Medicaid or CHIP
Eligibility for an exemption from the individual responsibility
requirement
• He or she can write a letter to the Marketplace or use an
appeal request form for Indiana
• Appeal decisions are made within 90 days
Explaining How to Report Life Changes
• It is extremely important to remind consumers that they must
report changes such as:
– Marriage, divorce or death of a spouse
– Birth, adoption or placement of a child
– A permanent move outside the current insurer’s
coverage area
– Involuntarily losing health coverage from events
such as end of job-based coverage, losing eligibility
for Medicaid or CHIP, aging off a parent’s policy,
COBRA expiration, decertification of a health plan
– A change in income or household status that opens up eligibility for
premium tax credits or CSRs
– Change in citizenship status
Explaining How Health Insurance Works
• 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 to Choose a Health Plan
• Compare plans based on the coverage you need
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What is covered and your needs
Your preferences (doctors, hospital, etc.)
The costs
Marketplace plan categories—actuarial value
Higher
Premiums
Lower
Premiums
Higher Consumer Cost-Sharing
BRONZE
60%
SILVER
Lower Consumer Cost-Sharing
GOLD
PLATINUM
70%
80%
Percent of Total Cost of Care Covered
90%
Explaining How to Choose a Health Plan
• Deciding which plan can be a challenge, so it is important to
help the consumer consider health and financial situations
when comparing plans on the Marketplace
– Someone expecting to have a lot of health care visits or regular
prescriptions may be better off with a Gold or Platinum plan that
pays a higher percentage of the costs
– On the other hand, a healthy individual who does not expect to have
many health care bills may be comfortable choosing a Bronze or
Silver plan
Comparing Health Plans—Important Checklist
• Review plan information
– See if their doctor is in the plan (in-network)
– See what prescription drugs are covered (plan
formulary or list of covered drugs)
• What is the cost?
• Does the plan have a convenient pharmacy?
• Check plan rules
– Does a consumer need a referral (primary care
doctor refers you or pre-authorization (plan’s
permission) before they see a specialist, or can they
go to one directly)
Explaining How to Use Health Insurance
• Use familiar language, and limit the amount of information
you provide to a manageable amount
• Check for understanding
– Make sure the consumer walks away knowing what their next steps
are
– Continue working with consumer if you sense hesitation or confusion
• Utilize visuals and keep the conversation interactive
– KFF’s YouToons or Healthcare.gov’s YouTube channel for helpful
explanation videos—many individuals learn better visually or through
interactive activities or tutorials
• Facilitate healthy decision-making by asking questions and
explaining in detail
Improving Health Insurance Literacy
• Know the terms and how to explain them in clear, concise
ways
• Use materials that are accessible, user-friendly and easy to
navigate
– Organize your information so that the most important points come first
– Use translations that are adapted for readers with limited literacy skills
• Hold educational events open to the public at your local
library, public space or health center in nontraditional hours
• Remember that everyone’s health care needs and health
literacy levels are different, and it is your job to help them find
a plan that meets their needs!
EDUCATING OUR PEERS ON
ASSISTER ROLES
Explaining What a Navigator Is
Tell your consumers and peers that you
are:
• A trained and certified professional through
the Indiana Department of Insurance and
Centers for Medicare and Medicaid Services
• Prepared and capable to determine coverage
eligibility, assist with coverage applications,
answer questions about health insurance, and
plan or participate in outreach events
• Willing to connect individuals to different
resources and information in the healthcare
system and your community
Educating Your Health Center Staff
• Both clinical and non-clinical staff in your health center can
benefit from knowing more about your position and
responsibilities as a Navigator and CAC
• Identify the stakeholders in your organization—anyone who
touches consumers via the written word, spoken word, or the
web
– It is important to let your colleagues know how low health literacy
impacts your community and how you can work together to improve
access to affordable health care
– Capitalize on individual staff expertise by building an internal referral
system for consumer questions and concerns—know who to ask!
Advocating for Health Literacy in Your Health Center
• You can advocate for health literacy in your organization
– Use this information to make the case for health literacy
improvement—most staff members are in a position to educate and
encourage patients to enroll
– Incorporate health literacy into mission and planning
• Convene a work group or committee to develop a health literacy agenda
for your organization
• Include health literacy in grants, contracts, and memorandums of
understanding
– Establish accountability for health literacy activities
– Include health literacy in staff training and orientation
• Make a presentation on health literacy at your next staff meeting
• Circulate relevant research and reports on health literacy to colleagues
• Post and share health literacy resources
Advocating for Health Literacy in Your Health Center
• Host a workshop or panel discussion about health insurance
literacy
• Create informative, flashy bulletin boards or posters in an
area with a lot of foot traffic
• Promote a contest for developing a catchy phrase for
encouraging consumers to enroll in coverage
• Involve the entire health center in planning a health literacy
outreach event with agenda like:
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ACA and health coverage outreach
Free blood pressure checks and other health screenings
“Ask a nurse/physician” booth
Flu shots
Games and activities for children
Advocating for Health Literacy in Your Community
• October is Health Literacy Month
• Use this month to build awareness
about the open enrollment period,
educate about health coverage options,
and encourage consumers to commit to
enrolling
 There are many community festivals and events during
October as well as other health-related holidays to partner
with such as National Breast Cancer Awareness month,
National Disability Employment Awareness Month, National
School Lunch Week (11-15th), Mental Illness Awareness
Week (4-10th), and National Child Health Day (4th)
Advocating for Health Literacy in Your Community
• Consumers who understand health care information may:
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Follow more fully instructions on medications
Call back less often
Visit less often
Have fewer hospitalizations
Have better health outcomes
Have increased patient satisfaction
Start being a health literacy hero now!