Discuss the nature of health insurance coverage

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Discuss the nature of health insurance coverage
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Purpose and Objectives

• Purpose
• This presentation is to provide an overview on
  health insurance and what the Affordable Care Act
  (ACA) is changing within the structure of
  insurance plans

• Objectives
• Upon completion of this presentation you will
• Have a general understanding of health insurance
• Understand common health insurance terms
• Understand most common health insurance plans
• Understand the benefits of health insurance

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Explore Your Options
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Customer SupportField Level Help
Estimated Premium This is the amount of money
that you will pay monthly for your health
insurance coverage. This does not include any
out-of-pocket health care expenses.
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Cycle without Health Insurance
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Health Insurance Basics
Key Point

• What is Health Insurance

• The Value of Health Insurance

• The 10 Essential Health Benefits

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Ten Essential Health Benefit Categories

1. Ambulatory services 6. Prescription drugs
2. Emergency services 7. Rehabilitative and habilitative services and devices
3. Hospitalization 8. Laboratory services
4. Maternity and newborn care 9. Preventive and wellness services and chronic disease management
5. Mental health and substance use disorder services, including behavioral health treatment 10. Pediatric services, including oral and vision care
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Types of Commercial Health Insurance

• Health Maintenance HMOs
• Preferred Provider Organizations PPOs

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Health Maintenance Organizations (HMOs)

• Network providers and primary care physician
• Co-payment
• Lower out of pocket expenses

Key Point
In-Network
Individual must seek care from
Health Care Professionals Laboratory Medical
Facilities Pharmacy
In-Network Providers Only
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Preferred Provider Organization(PPO)

• Contracted Preferred Provider List
• More choice of providers
• Higher costs for using non-Preferred Providers

Key Point
Yes! My providers on this list!
Provider List
Choosing a provider from the list lower costs
Choosing a provider that is not on the list
higher costs
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Cost Sharing
Key Point

• Cost Considerations
• Maximum Out-of-Pocket
• Your choices determine your costs

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Understanding Health Insurance Cost Sharing
http//www.dol.gov/ebsa/pdf/SBCUniformGlossary.pd
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Things to Consider about Health Insurance
Key Point

• Commercial private insurance

HMO limited to In-Network Providers
PPO Your choice of contracted Providers.

• Coinsurance or copayment

• Plan or calendar year deductible

To find out if a provider is contracted with a
specific health care plan either contact the
providers office or the health care plan and
ask.

• Contracting

• Protection

Cost Sharing
Deductible
Coinsurance a percentage
Copayment a predetermined amount
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Questions to ask Yourself

• What is the premium? Monthly? Annually?
• What is the deductible?
• What is the maximum amount of money my customer
  might have to pay out of pocket during a policy
  year?
• My customer has specific health care needs. Are
  these needs covered by the Qualified Health Plans
  were looking at?
• Are there any services that are limited in this
  policy?
• What services are excluded in this policy?

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What are the Benefits of Health Insurance?

• Better Health
• Peace of mind
• Financial protection
• Control in health care options
• Ability to shop, compare and enroll online
  through the Washington Healthplanfinder

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Types of Health Insurance Plans

• Fee For Service Plans- A health insurance plan
  that allows the holder to make almost all health
  care decisions independently. The plan holder
  pays for a service, submits a claim to the
  insurance company, and, if the service is covered
  in the policy, receives reimbursement.
  Fee-for-service plans often have higher
  deductibles or copay than managed care plans.
• Government Sponsored Insurance

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Government-sponsored health insuranceplans

• Medicaid - Medicaid and CHIP provide free or
  low-cost health coverage to millions of
  Americans, including some low-income people,
  families and children, pregnant women, the
  elderly, and people with disabilities. Both
  programs are run jointly by federal and state
  governments, and details vary somewhat between
  states. You qualify for these programs based on
  your household size, income, and other factors,
  like age and disability
• Medicare - Medicare is our countrys health
  insurance program for people age 65 or older.
  Certain people younger than age 65 can qualify
  for Medicare, too, including those who have
  disabilities

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Government-sponsored health insuranceplans

• State Childrens Health Insurance Program is a
  partnership between the Federal and state
  governments that provides health coverage to
  uninsured children whose families earn too much
  to qualify for Medicaid, but too little to afford
  private coverage

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Cobra Insurance Coverage

• Cobra gives workers and their families who lose
  their health benefits the right to choose to
  continue group health benefits provided by their
  group health plan for limited periods of time
  under certain circumstances such as voluntary or
  involuntary job loss, reduction in the hours
  worked, transition between jobs, death, divorce,
  and other life events.
• (Consolidated Omnibus Budget
  Reconciliation Act)

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Key Terms

• Indemnity - Undertaking given to compensate for
  (or to provide protection against) injury, loss,
  incurred penalties, or from a contingent
  liability
• Coinsurance - Your share of the costs of a
  covered health care service, calculated as a
  percent (for example, 20) of the allowed amount
  for the service. You pay coinsurance plus any
  deductibles you owe. For example, if the health
  insurance or plans allowed amount for an office
  visit is 100 and youve met your deductible,
  your coinsurance payment of 20 would be 20. The
  health insurance or plan pays the rest of the
  allowed amount.

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Lets Review

• Health insurance terms
• Benefits of health insurance
• Health insurance plan types

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Knowledge Check

• What is the definition of Estimated Premium?
• The percentage owed for each visit to a provider
  until the deductible is met.
• The co-payment required until the maximum out of
  pocket expenses are met.
• A deductible.
• The amount of money paid monthly for health
  insurance coverage. This does not include any
  out-of-pocket health care expenses.
• All of the above.

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Knowledge Check

• What is health insurance?
• Health insurance is a contract between an
  individual and an insurance company.
• Health insurance is something bought to protect
  against fire.
• Health insurance can be sold by a Navigator or
  In-person Assister.
• Health insurance is required for all dogs and
  cats.

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Knowledge Check

• This is the amount you and/or your family pay
  each policy period before your health plan starts
  to pay for covered services.
• Co-Insurance
• Co-Payment
• Premium
• Deductible

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Knowledge Check

• In a HMO an individual must seek care from
• Any provider they wish.
• An In-Network provider.
• A provider theyve seen in the past.
• The provider that is closest to the individuals
  home.

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Knowledge Check

• Which of the following is not a characteristic of
  a PPO?
• They provide a Contracted Preferred Provider List
• Out of pocket costs are lower when an insured
  individual uses providers from the Contracted
  Preferred Provider list.
• Insured must use In-Network providers.

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Knowledge Check

• An individual policy has a 200 yearly deductible
  and a 30 coinsurance. This individual is not
  eligible for any cost sharing reductions. The
  individual has not been feeling well and decides
  to go to the Dr. for the first time. Will the
  individual have any out of pocket costs and if
  so, what will they be?
• This individual is responsible for the first 200
  of the bill.
• This individual is responsible for the first 200
  of the bill plus 30 of anything over 200.
• Nothing. This is what they bought health care
  coverage for.

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Knowledge Check

• Which of the following is not included in cost
  sharing reductions?
• Co-payments
• Co-insurance
• Premiums
• Deductibles

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Performance Activity

• Should the government force you to have insurance?