Dan Trzos, Christy Watrous October 30, 2013 Insurance 101.pdf · medical and pharmacy deductible....
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HEALTH INSURANCE 101 Dan Trzos, Christy Watrous October 30, 2013
Transcript of Dan Trzos, Christy Watrous October 30, 2013 Insurance 101.pdf · medical and pharmacy deductible....
HEALTH INSURANCE 101
Dan Trzos, Christy Watrous
October 30, 2013
New Medical Resources/ACA
• Getting to know Insurance terms
• Familiarizing yourself with carriers, plans and networks
• Meeting new carrier account representatives
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• Insurance Terms 1
• Carriers, Plans and Networks 2
• Meet your new colleagues 3
Today’s Overview
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Learning Objectives
• Define and explain five major terms used in insurance plans
• Identify carriers and network by region, plan designs by carrier
• Develop resource and relationship with carrier account managers
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NEW TERMS
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Basic Standards for All Marketplace Plans
• Essential health benefits
– Basic standards for the benefits that plans must cover
• Cost-sharing Standards
– Protect enrollees from very high out-of-pocket costs for covered, in-network benefits
– Help organize plans to make them easier for people to compare
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Types of Cost-Sharing Charges
• Deductible – Enrollee must pay the deductible before the plan
begins to pay for most benefits – Set on a yearly basis
• Copayments – Dollar amount for an item or service that enrollees
must pay
• Coinsurance – Percentage of the cost of an item or service that
enrollees must pay
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Maximum Out-of-Pocket Limit (OOP)
• Puts a cap on what the enrollee pays in cost-sharing charges each year
– Set on a yearly basis
– Applies to in-network services
• 2014 amounts: $6,350 individual/$12,700 family
• OOP limit is not the amount that an enrollee must spend each year
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TERM DEFINITION IMPACT
PREMIUMS Amount paid for monthly coverage
Based on plan selected
COST SHARING Shared expense between individual and medical service provider
Total cost is adjusted based on contracted amount
DEDUCTIBLE First dollar paid by insured for non-routine services
2014 maximum $2000 individual $4000 family
CO-PAYMENT Amount paid for routine office visits to primary and specialty care physicians
Typically limited to services in physician office
CO-INSURANCE
Insured persons share of cost after deductible is met
Metal Levels determine co-insurance %
OUT-OF-POCKET LIMIT
Individual $6350.00 Family $12,750
Includes all but premium costs
COMMON TERMS
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Types of Marketplace Plans (“Metal Levels”)
Plan Level Actuarial Value
Platinum 90%
Gold 80%
Silver 70%
Bronze 60%
Lower enrollee cost-sharing
Higher enrollee cost-sharing
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Kaiser Permanente Deductible Catastrophic KP GA Catastrophic 6350/01
The KP GA Catastrophic 6350/0 plan has a $6350 individual combined medical and pharmacy deductible. Most services are paid out-of-pocket until the deductible is met. Once the deductible is met, all covered services are at no charge. The first three primary care visits are covered at no charge and are not subject to the deductible. All covered services contribute to the out-of-pocket maximum. Preventive care services, such as routine physical exams and mammogram screenings, are at no charge.
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Annual Deductible $6,350 Max Out-of-Pocket $6,350 Primary Care Office Visit: First 3 office visits no charge.2 Additional visits no charge after deductible. Available for people age 29 and under when the plan goes into effect. If you're 30 and over, you must prove financial hardship or lack of affordable coverage with a certificate from the Health Insurance Marketplace in order to purchase this plan. Federal financial assistance is not available if you choose this plan.
Kaiser Permanente Deductible Catastrophic
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Key Considerations in Plan Selection
• What health care expenses are likely
• Upfront cost-sharing (the deductible), “as-you-go” cost-sharing (like copayments)
• Other aspects of the plan, such as provider network and covered drugs
• What benefits are covered under various plans
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Carrier and Plan Considerations
Plans by Actuarial Value
• 5 Catastrophic
• 22 Bronze
• 23 Silver
• 14 Gold
• 3 Platinum
• 67 Total
• 5 Carriers
• 5 Networks (State-wide)
• Networks within Carrier
Plan Combinations
• HMO
• POS
• HSA
• Direct Access
• Multi State
• Dental
• Vision
• Cost per Subsidy
• + / - 50 years old
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Same Actuarial Value, Different Charges
Key Takeaway: Cost-sharing charges can differ even if the
plans have the same actuarial value.
Silver Plan #1
(enrollee pays)
Silver Plan #2
(enrollee pays)
Deductible
(Indiv) $2,000 $2,500
Maximum OOP limit
(Indiv) $5,500 $6,350
Inpatient hospital
(After deductible)
$1,500 /
admission 30%
Office visit
(After deductible) $30 $35
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KP GA Bronze 5000/30%/HSA Kaiser Foundation Health Plan of Georgia HMO | Bronze Estimated monthly premium for Only you $299.00 Health Savings Account – www.irs.gov Network rates No co-pays Separate deposit to personal HSA for medical expenses
Humana National Preferred Gold 2500/3500 Plan Humana Insurance Company POS | Gold Estimated monthly premium for Only you $401.57 Point of Service – In/Out of Network costs
4 plans – 4 topics (50+ y.o. from GA Marketplace Options)
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Ambetter Bronze 1 + Vision + Adult Dental Ambetter from Peach State Health Plan HMO | Bronze Estimated monthly premium for Only you $404.37 Vision – Network – 12/12/24 $120CL 25% Dental – Network – 100/80/50 50/1000
Blue Cross and Blue Shield Healthcare Plan of Georgia Silver DirectAccess, a Multi-State Plan Anthem Blue Cross and Blue Shield HMO | Silver Estimated monthly premium for Only you $466.31 Direct Access – Does not require primary Physician referral Multi- State – as long as HMO network in location you need, can go in-network
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New Resources
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Blue Cross – Blue Shield
BC/BS offers plans to fit your consumers health coverage needs – and budget. To make it easy to compare and choose a plan they are split into three different levels – Bronze, Silver and Gold. Also offered are Health Savings Account plans (HDHP). You set up the account through a bank and fund it with post-tax dollars. That money can be used to pay for your qualified healthcare expenses, including prescriptions. FIND A PHYSICIAN www.bcbsga.com Useful Tools “Find a Doctor”
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Blue Cross – Blue Shield
The 2014 networks names are branded by market segment below •ON-EXCHANGE - Pathway X (Individual)
•OFF EXCHANGE - Pathway (Individual)
•SHOP Network - Pathway X Enhanced (Small Group Exchange) •Small Group Networks – Off Exchange
•Pathway Enhanced •Blue Open Access POS •Blue Choice PPO •Blue Choice Healthcare Plan (HMO or POS)
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Blue Cross/Blue Shield
Georgia's insurance exchange regions
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Alliant Health Plans and The Federal Health Insurance Marketplace (aka: The Exchange) As a Qualified Health Plan, Alliant Health Plans will be offering individual and small group products on the Health Insurance Marketplace. Alliant is marketing these products in 32 Georgia counties (see map). Members electing one of these products will access our traditional Alliant network. Beginning October 1, 2013, The Marketplace will enable individuals to purchase coverage online, over the phone, by mail and potentially in person. Small employers may select plans starting November 1, 2013. For more information, please visit www.healthcare.gov.
Alliant
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Updated Provider Directory – Changes to Come Health One and Alliant Health Plans are in the process of updating our current online Provider Directory in order to make it easier for you to locate an in network provider. The new enhanced directory’s design has been simplified, which has resulted in more efficient searches and easy to understand advanced options. Individuals will be able to have quick access to provider listings which include details such as a provider’s gender, language, provider group name, hospital privileges and board certification status. Other improvements include a map feature to assist with locating a specific provider office and also the ability to pull office hours for a specific provider location. Look for these enhancements within the next few weeks!
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Kaiser Permanente Availability of Health Insurance Marketplace plans: 28 Georgia counties, including all of metro Atlanta Plan type: HMO Details: Kaiser is a well-established health maintenance organization with 450 doctors who care exclusively for members of the Kaiser plan at its 30 medical offices in metro Atlanta and Athens. Kaiser has contracts to provide hospital care at Piedmont Hospital and Northside Hospital
The information in this online directory is updated periodically. The availability of physicians, hospitals, providers, and services may change. Before receiving care at a facility, click on the link for that location and verify the accepted plan types under "About this facility" to make sure it is available in your plan. If no plan types are listed, the facility is available for all plan types.
www.kp.org Find a Doctor or Locate a Facility
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Humana www.humana.com Find a Healthcare Provider Start your search • 83 Georgia counties, including all of metro Atlanta
• Plan types: HMO and POS
• Humana, one of the nation’s largest insurers, is offering a “point of service” plan in addition to an
HMO plan
• The plans are dramatically different and the HMO is not available in every county. The HMO requires members to get care within a small network of doctors and hospitals. For Atlanta that network includes Northside Hospital and its satellites in Cherokee and Forsyth counties
• The POS plan offers a more extensive network including these hospitals and hospital systems: Atlanta Medical Center, DeKalb Medical Center, Eastside Medical Center, Emory Healthcare, Grady Health System, Gwinnett Medical Center, North Fulton Hospital, Northside Hospital, Piedmont Healthcare, Rockdale Medical Center, Southern Regional, St. Josephs of Atlanta, WellStar Health System.
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AmBetter (Peach State)
Ambetter Peach State Health Plan
www.pshpgeorgia.com/provider-directory/
Availability of Health Insurance Marketplace plans: 16 Georgia counties, including Fulton, Fayette and Henry in metro Atlanta
Plan type: HMO
Peach State is expanding beyond its business of managing care for Medicaid participants with its new health plan for individuals. The plan is available in only a few metro Atlanta counties; the hospital network includes Atlanta Medical Center system and North Fulton Medical Center
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Ambetter (Peach State)
Columbus, Athens, Atlanta
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New Colleagues
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Who’s Who
Lead Contact information
Marc Capogrossi Sales Account Consultant
[email protected] Blue Cross
Monica Moultrie Mgr., Provider Relations
[email protected] Peach State Health Plan
Mavis [email protected]
Doug [email protected]
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New Resources
The carrier plan learning curve
NewEmployee
1 yr 2 yr 3 yr
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Case Study Thank you for your assistance. I turned 62 on July 14 this year, am a white male , average height and build. Currently I am added to my wife’s policy from her employer (United Healthcare), along with our 20yr old son who is in college full time. Unlike stories we have heard, our premiums are going up by 200% , co-pays as well. We have to make a decision before the end of October about maintaining or changing coverage. We are not able to afford the increase for all three of us. 1.) At what age am I available to enroll in Medicare/Medicaid ? 2.) Will the lack of Medicare/Medicaid 'expansion' in GA prevent me from getting on those programs ? 3.) I am in good health, no meds.
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Case Study Discussion Items
• Ignore what is not pertinent i.e. race, gender, physical description • Focus on important points i.e. currently on group plan, dependent is on
plan • Begin to formulate questions
1. Is the group plan considered affordable (9.5% of household income)? 2. What is the tax filing status of husband and wife? 3. What is the current plan design? 4. How much does the employer contribute?
Response: A. Consider getting individual plan with son through 12.31.13 B. Enroll in Marketplace to compare APTC with private plan C. May want to work with agent instead of Navigator D. www.nahu.org to assist with finding agent E. Not eligible for Medicare until age 65
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Resources
Blue Cross Blue Shield East Region (GA, VA HN, ME) FFM 800-318-2596 www.bcbsga.com
Humana Telesales Department 877-877-4388 Local 800-986-9527 www.humana.com Kaiser 800-518-3769 www.kp.org
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Resources
AmBetter – Peach State Health Plan GA
877-687-1180
http://ambetter.pshpgeorgia.com
Alliant
No distinct number or contact established to date
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QUESTIONS?
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