Transcript Health Insurance Literacy

Health Insurance Literacy 101
Understanding Health Insurance and the Marketplace
& From Coverage to Care:
Using the Roadmap & Discussion
Guide
Centers for Medicare and Medicaid Services
July 2014
Explaining the Value in
Having Health Insurance
 Essential health benefits
 The value of health insurance coverage
• Primary and/or specialty care
• Inpatient care
• Emergency care
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Follow-up care
• Preventive care
Health Insurance Literacy for the Marketplace
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Qualified Health Plans Cover
Essential Health Benefits
 Essential health benefits include at least these 10 categories
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Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services,
including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral (dental) and vision care (pediatric
oral (dental) services may be provided by stand-alone plan)
Understanding the Marketplace
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Value: Immediate “Everyday” Care
 Primary care
 Pediatric health and dental care
 Coverage for specialty services
• Women’s health, cardiologist, etc.
 Prescriptions
 Mental health care and
substance use disorder services
 Laboratory services
Health Insurance Literacy for the Marketplace
Health care, right
when you need it,
before a health
problem gets worse
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Value: Preventive and Chronic
Care Management
 Health insurance for preventive care
• Prevents illness or detect illness at an early stage,
when treatment is likely to work best
• The health care law makes many of these free
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Examples: Flu shots and screening mammograms
• Helps you become well
and stay well
 Manage chronic conditions
• Like diabetes or asthma
https://www.healthcare.gov/what-are-my-preventive-care-benefits/
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Value: Inpatient, Emergency
and Follow-up Care
 Inpatient care, like for surgery
 Emergency care
• Illness, injury, or condition so
serious that a reasonable person
would seek care right away to
avoid severe harm
• No prior approval needed
whether provider or hospital is in
the plan (in the network) or not
The average cost for a 3-day hospital stay is $30,000.
The average cost for fixing a broken leg is $7,500.
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Value: Cost Savings
 Protection from high medical costs
that could put you in debt, affect
your credit, or cause bankruptcy
 Insurance companies negotiate
rates with providers so you pay a
lower rate (generally a 40% saving
from those not insured)
 Peace of mind
 Protecting your family’s health
Health Insurance Literacy for the Marketplace
62.1% of all
bankruptcies
have a
medical
cause.
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Value: Without Minimum Essential
Coverage You May Pay a Fee
 You may pay a fee when you file your 2014
Federal tax return in 2015 (and thereafter)
• If you don’t have minimum essential coverage, and
• You don’t qualify for an exemption
 You have to apply for an exemption,
it isn’t automatic
 Paying the fee doesn’t provide health coverage
Less than 2% of Americans are expected to have to pay the fee.
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Explaining How
Health Insurance Works
 Health insurance is a contract
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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
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Explaining the Types of Marketplace
Plans – HMOs and PPOs
 Health Maintenance Organizations (HMOs)
• Have networks
• Usually use primary care doctors
• Usually need referrals for specialists
 Preferred Provider Organizations (PPOs)
• Have networks
• Can go out-of-network but pay more
• No referrals needed
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The Difference Between Getting Services
In-Network and Out-of-Network
In-Network
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Plan discounts
Out-of-Network
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Possibly no discount
May have to pay
100% out-of-pocket
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Explaining Costs
 People will ask you
“How much will it cost?”
• You will need to explain
Premiums
 Deductibles
 Copayments
 Coinsurance
 Out-of-Pocket Limit/
Maximum
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http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf
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Example of How to Explain Cost Sharing
Jane has not reached her
$1,500 deductible
Jane Pays
100%
Her plan pays
0%
Her plan doesn’t pay anything:
Office Visit cost $125
Jane pays $125
Her plan pays $0
Jane reaches her $1,500 deductible,
co-insurance begins
Jane Pays
20%
Jane reaches her $5,000
out of pocket limit
Her plan pays
80%
Her plan pays some of the costs:
Office visit cost: $75
Jane Pays 20% of $75 = $15
Her plan pays %80 of $75 = $60
Jane Pays
0%
Her plan pays
100%
Her plan pays the full cost:
Office visit costs: $200
Jane pays: $0
Her plan pays: $200
Copayments – For certain services Jane pays
a set amount, like $30 for a doctor visit.
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Explaining Formularies and Tiers
 A list of prescription drugs covered by the plan
 May have tiers that cost different amounts
Tier Structure Example
Tier
Copayment You Pay
Prescription
Drugs Covered
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Most generics
2
Preferred, brand-name
3
Non-preferred, brand-name
Specialty
February 2014
Unique, very high-cost
or highHealth
coinsurance
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Explaining How to Use Health Insurance
 When you need care, call the doctor’s office
• Set up an appointment
• Confirm that they accept your insurance
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Take insurance card to the doctor’s office
At your doctor’s visit, pay your share
Take advantage of preventive benefits
Call your insurance plan with coverage questions
Contact the plan if you want to change your
primary care doctor
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Explaining How to Protect
Yourself From Fraud
 You need to be informed
• Look for official government seals, logos, and
navigator and assister certifications
• Navigators and assisters won’t ask for money
 Protect your personal information
 Ask questions and verify the answers you get
 Report anything suspicious to the Marketplace
consumer call center at 1-800-318-2596
• (TTY users should call 1-855-889-4325)
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From Coverage to Care:
Using the Roadmap & Discussion Guide
Training Guide
Presentation Overview
1. What is From Coverage to Care (C2C)?
2. How to use the Roadmap and Discussion Guide
3. Step by Step: Walking Consumers Through the
Roadmap
4. C2C Resources
Objectives
This session will help you:
 Understand the goals of From Coverage to Care.
 Talk to consumers about how to use new health
coverage.
 Explain key concepts to improve consumers’ health
insurance literacy.
 Teach consumers about using coverage to pay for
preventive and primary health care services.
 Locate resources for consumers, providers and
assisters.
Why From Coverage to Care?
 Millions of Americans gained coverage through the
Marketplace and Medicaid and CHIP during open
enrollment, and this year more than 500,000 uninsured
64-year olds will become eligible for Medicare.
 For many, this is the first time in a long time or they have
never had coverage.
 Unless we connect the newly insured to primary care and
preventive services, we will not realize the other goals of
the ACA – improving population health and reducing
health care costs.
What is From Coverage to Care?
 C2C is an effort to help educate consumers about their
new coverage and to connect them with primary care
and preventive services that are right for them so they
can live long, healthy lives.
 Resources online and in print include the Roadmap,
Discussion Guide, videos, and more.
 C2C builds on existing networks of community partners
to educate and empower newly covered individuals.
How to Use the Roadmap
 Start the Conversation. Use the Roadmap and
Discussion Guide as a tool to help people understand
their new coverage and understand the importance
of getting the right preventive services.
 Help Consumers Understand. The Roadmap has a lot
of information for consumers. You can help them use
it as a resource to refer back to as they journey to
better health and well-being.
 Personalize it. You know your community. Consider
adding local resources and information.
Coverage to Care Roadmap
Online at marketplace.cms.gov/c2c
Step 1: Put Your Health First
Key Points for Consumers
• Staying healthy is important for you and your family.
• Maintain a healthy lifestyle, get recommended
health screenings, and manage chronic conditions.
• Keep health information in a safe place.
Key Questions for Consumers
• Do you have questions about healthy habits, including eating
and exercise?
• Do you know what free screenings and preventive care you
should get to stay healthy?
STEP 1
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Step 2: Understand Your Health
Coverage
Key Points for Consumers
• Check with your insurance plan or state Medicaid
or
CHIP program to see what services are covered.
• Be familiar with your costs (premiums, copayments,
deductibles, coinsurance).
• Know the difference between in-network and out-of-network.
Key Questions for Consumers
• Do you know how to find a provider in your network?
• Can you estimate how much you will pay when you see a provider?
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STEP 2
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Key Terms On An Insurance Card
Key terms
1) Member Name
2) Member
Number
3) Group Number
4) Plan Type
5) Copayment
6) Phone Numbers
7) Prescription
Copayment
Sample Cost Tables
Cost scenarios like
managing Type 2
Diabetes and having a
baby help consumers
understand what
their care may cost,
and how their plan may
divide these costs.
NOTE: These are not real costs.
Step 3: Know Where To Go For Care
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STEP 3
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Key Points for Consumers
• Only use the ER in a life-threatening situation.
• Primary care is preferred when it isn’t an emergency.
• Knowing the difference between primary care and care in the
ER.
Key Questions for Consumers
• Do you know how your costs would be different if you went to
a primary care provider versus the Emergency Department?
• Do you know how your care would be different?
Primary Care vs. Emergency Care
Step 4: Find a Provider
Key Points for Consumers
• Find providers your plan works with.
• Ask people you trust or do research on the Internet.
• Visit a provider to see if you like them.
• If you are assigned a provider, contact your plan to change.
Key Questions for Consumers
• Were you assigned a provider by your plan or state
Medicaid or CHIP program?
• Can you find the list of different provider types in your
network – mental health, counselors, podiatrists, allergists?
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STEP 4
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Step 5: Make an Appointment
Key Points for Consumers
• What to say when you call for an appointment.
• What questions to ask when scheduling your visit.
• Know how to make the most of your visit.
Key Questions for Consumers
• Did you tell your provider what you want from your
appointment – a wellness exam? screenings? help
managing a chronic condition?
• Do you know your providers’ cancellation policy and when
and how to pay?
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STEP 5
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Step 6: Be Prepared for Your Visit
Key Points for Consumers
• What health information to bring to your visit.
• How to use your health coverage for payment.
• Bring someone with you if you feel more comfortable.
Key Questions for Consumers
• Do you have a list of the medications you take to share with
your provider?
• Do you have information on your personal, and family,
health history to share with your provider?
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STEP 6
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Step 7: Decide if the Provider is Right
For You
Key Points for Consumers
• Finding a provider you trust, and can communicate
with, is important for your health.
• Is this provider someone you can work with over time?
• It is always okay to find another provider for any reason.
Key Questions for Consumers
• Did you feel like you could talk with your provider?
• If you didn’t like your provider, what would have made it a
better fit – language, culture, gender?
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STEP 7
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Step 8: Next Steps After Your Visit
Key Points for Consumers
• Write down your providers’ instructions and healthy
living tips so you can act on them every day.
• Schedule any follow-up or other visits and fill
prescriptions so you don’t forget or get too busy.
• Review any documents or bills you receive and contact your plan
or state Medicaid or CHIP program if you have questions.
Key Questions for Consumers
• Do you know what to do now to keep yourself healthy?
• Do you know what number to call if you get sick and need to
make an appointment or come back?
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STEP 8
Explanation of Benefits (EOB)
It’s a summary
of health care
charges from
the care you or
those covered
under your
policy received.
It is NOT A
BILL!
Other Information in the Roadmap
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Glossary of health coverage terms.
Resource list.
Personal health tracking checklist.
Health information page for coverage and
provider information.
What Can You Do?
 Share C2C resources with others.
 Continue to educate consumers.
 Let us know what other resources would be
useful.
 Personalize it – you know your community.
Available C2C Resources
Visit http://marketplace.cms.gov/c2c
 Roadmap
• Poster Roadmap
• One-pagers: Insurance card, Primary care vs. emergency,
and EOB
• Pull-out steps
 Discussion Guide
 Video vignettes
…and more to come!
Print copies available from the CMS Clearinghouse
Videos
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Chapter 1 – My New Health Plan
Chapter 2 – Understand the Plan
Chapter 3 – Words to Know
Chapter 4 – Where to go for Care
Chapter 5 – Finding a Provider
Chapter 6 – Making an Appointment
Chapter 7 – Almost Ready
Chapter 8 – My First Visit
Chapter 9 – Like or Dislike
Chapter 10 – The Day After
Chapter 11 – The Final Word
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