Health Insurance Explained…

Who is ENROLL-Virginia!?

Why have health insurance? Ensure financial security

Obtain preventive services for FREE and stay healthy◦ Annual physical, check-ups◦ screenings ◦ prevention counseling◦ contraception.

A medical home

Manage health conditions, chronic diseases

Different Ways to Get Healthcare Health Insurance Marketplace Employer-based Coverage Medicaid/FAMIS Medicare TRICARE Clinics/Health Centers*

Understanding Your Health Coverage

Network◦ In-Network ◦ Out-of-Network

Deductible

Copay

Coinsurance

Premium

Out-of-Pocket Maximum◦ Worst-case scenario◦ Chronic diseases (diabetes, cancer, etc.)

Provider

Co-Pay and Co-Insurance

$ Co-Insurance

$Monthly Premium

$ Co-Pay

Consumer Patient

Different Types of InsurancesHMO POS**** PPO

Network Coverage In-Network only(limited choice of doctors)

In- & Out-of-Network(wider choice of doctors)

In- & Out-of-Network (wider choice of doctors; may cover multi-state)

Primary Care Doctor (PCP) Must select a PCP when you join Must select a PCP when you join Not required to select a PCP

Lab Services Must visit in-network lab only; typically only 1 available

May visit independent lab preferably in-network

May visit independent lab preferably in-network

Prescription Services Must visit in-network pharmacy; typically onsite

May visit any pharmacy May visit any pharmacy

Urgent Care Must visit in-network urgent care center(s)

Typically can visit any urgent care that accepts your insurance

Typically can visit any urgent care that accepts your insurance

Major Services Must visit in-network hospitals Any hospital* Any hospital*

Emergency Care (911) May visit any hospital May visit any hospital May visit any hospital

Claim Reimbursement for Out-of-Network

Not available Must file claim Must file claim

Facility Type Single building with all services on site

Generally independent offices for each doctor

Generally independent offices for each doctor

Examples Kaiser Permanente, Carefirst, Anthem HealthKeepers

Carefirst, Anthem HealthKeepers Carefirst, Innovation Health

Your Insurance Card

Explanation of Benefits (EOB) This is NOT A BILL

After you doctor visit, you may receive an EOB from your insurer

An EOB is an overview of the total charges for your visit and how much you and your health plan will have to pay.

If you need help understanding your EOB, you can call ENROLL-Virginia! at 1-888- OR visit our website at www.enroll-Virginia.com

Where to Go for Care? Primary Care Doctor (PCP)

Specialists◦ Referral from PCP may be necessary

Urgent Care Center◦ Non-life threatening events

Emergency Room◦ Dial 911 if you have an life-threatening situation

Preparing for Your Visit Make sure to schedule an appointment in advance

Arrive early to fill out registration forms

Bring your insurance card and ID

Pay your copay

At your Doctor Visit Be honest with your doctor about:

◦ Your lifestyle, family & medical history◦ Medications (request a refill if needed)

Ask Questions!◦ What is my main problem?◦ What do I need to do?◦ Why is it important for me to do this?◦ How do I see a specialist?

Not satisfied? Change your provider!

Next Steps After your Appointment

Schedule a follow-up appointment if needed

Fill prescription if needed

Call your doctor’s office:◦ If you experience any side effects or other problems with your medicines◦ If your symptoms get worse◦ To get results of any tests you’ve had◦ To explain your test results

Do You Need Help Paying For… Prescriptions

◦ Needymeds.org

Copays