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Now What? Health Insurance 101
All You Need to Know Now That You’re Covered
Financial Protection
Keeps You Healthy
Why is it so important?
Insurance Sounds Complicated!
Premium
Deductible
Co-Pay
Co-Insurance
HMOPPO
Network
Prior Authorization
Out-Of-Pocket Limit
Limitations
Exclusions
Preauthorization
Primary Care Provider
Specialist
Actuarial Value
Health Savings Account
Preventative Care
Preferred Drug ListFormulary
Insurance Card
Emergency Room
Urgent Care Office Visit
Medicaid
Medicare Private Insurance
Marketplace
Co-Pay Card
Gap Coverage
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
Karen RubinCommunity Engagement Coordinator
Common Insurance Terms
Payments
Premium
Co-Pay
Co-insurance
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.
Co-insurance
Percentage of a medical service you need to pay after the deductible has been met.
Money, Money… Moneyyyyyy
Out-of-pocket limit
Actuarial Value
Deductible
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.
DeductibleAmount 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/GrievanceProcess 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.
SpecialistDoctor 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
• 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
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.
Let’s Talk About Different Kinds of Insurance Plans!
HMO
EPOPPO POS
HSA
Health Maintenance Organization
HMO
All services in-network
Gatekeeper
Lower costs, more
red tape
Exclusive Provider Organization
EPO
All services in-network
No Gatekeeper
Very similar to HMOs,
generally less expensive
Preferred Provider Organization
PPO
Services in and out of network
No Gatekeeper!
Less red tape but higher premiums
Point of Service
POSHMO and
PPO hybrid
GatekeeperServices in and out of network
Not as common as
HMO or PPO
Health Savings Account
HSA
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
Decoding Your Insurance CardMember 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.
Group number: Used to track the specific benefits of your plan. The group number and member number are used to identify you.
Co-pay andco-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.
Coverage type: Type of insurance plan that you have.
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. Lifestyle Screenings2. Sexual Health Screenings3. General Health Screenings4. Screenings for Women5. 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 onceTd booster every 10 yrs
Tdap vaccine onceTd 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 RichardsonAmeriCorps Member
Nueva Luz Urban Resource Center
Phone: 216-651-8236 x 118Email: [email protected]
Matt WovroshSenior Community Engagement Coordinator
Picking Your Provider
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
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
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
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
CareWhen 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
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.
Zach ReauCommunity Engagement Coordinator
Exploring Your Options
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
• 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.
Documents and Forms
In order to receive premium and cost-sharing assistance from Ryan White:
Where do you apply?
Apply online at healthcare.govOr call 800-318-2596Need help? ohioforhealth.org
*only during open enrollment
Qualifying life events like job loss, prison release, getting married, having a child, or anything that alters your tax status
**unless you qualify for a Special Enrollment Period
What Is Medicaid Expansion?
Modernized and SimplifiedFrom 150 categories 2
MAGI (Managed Care) vs. Non-MAGI (ABD)
New EligibilityIndividuals earning about $16,000/year for a household of
oneResident of Ohio
Meet citizenship requirementsROLLING ENROLLMENT
Managed Care Medicaid
• Begin with fee-for-service Medicaid (Medicaid card) before going into a Managed Care plan (15-60 days)
• You choose a company to manage your plan (UHC, Molina, CareSource, etc.) but you STILL HAVE MEDICAID!
• All must offer:– Unlimited mental health visits!
– Additional benefits like 24-hour nurse advice lines, transportation to appointments, and care managers for folks with complex medical conditions
• Companies may differ:– Incentives for services (Reward$), Preferred Drug Lists vs. “medically
necessary” drugs
Where do you apply?
Apply online at benefits.ohio.govOr call 800-324-8680County ODJFS—TIME SINK
Already receive Age, Blind or Disabled Medicaid?
remains the same…unless you’re dual eligible
What Is MyCare?
Integrated Care Delivery SystemCoordinates Medicaid + Medicare
into a Managed Care PlanSimplifies use for consumer
“Pilot” ProgramFor 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 eligibleOr call 800-324-8680
And if I’m not dual eligible? …
Medicare
Various PartsParts A-D cover different services65+, eligible for Social Security,
some people living with disabilities
OHDAP Part C & D Premium / Co-Pay Assistance Available
APPLY Ohio Dept of InsuranceOhio Senior Health Insurance Information Program
800-686-1578
Preventive Care
Use Generic Drugs
Follow Doctor’s Orders
Find a PCP
ER for Emergenci
es Only
Healthy Choices
Save $$ – Stay Healthy – Live Longer
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
