Washington Health Benefit Exchange

Insurance 101Summer 2013

Purpose and ObjectivesPurpose

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

2

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

Today’s Agenda

▪ Health Insurance Basics▪ The ACA Individual Mandate

▪ Types of Commercial Health Insurance

▪ Things to consider about health insurance

▪ Understanding health insurance cost-sharing

▪ Benefits of health insurance

▪ Let’s review

▪ Health Insurance Terms

Explore Your Options

4

Customer SupportField Level Help

5

Estimated PremiumThis 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.

Key Point

Cycle without Health Insurance

6

Health Insurance Basics

▪ The Value of Health Insurance

7

▪ What is Health Insurance

▪ The 10 Essential Health Benefits

Key Point

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

8

The ACA Individual Mandate

▪ What is the Individual mandate?

9

▪ How does the mandate work?

▪ What is Qualifying Health Coverage?

▪ What if someone cannot afford insurance? ▪ Are there Exemptions?

Key Point

Individual Mandate

▪ Require all citizens and legal residents (there are some exceptions) to have health coverage in 2014.

▪ What happens if someone does not meet this deadline?

▪ Will they go to jail? NO!

10

What is the penalty?

2014: $95 per adult and $47.50 per child (up to $285 for a family) or 1% of income, whichever is greater

2015: $325 per adult and $162.50 per child (up to $975 for a family) or 2%, whichever is greater

2016: $695 per adult and $347.50 per child (up to $2,085 for a family) or 2.5% of family income, whichever is greater

11

Key Point

the Mandate IS SATISFIED WHEN

You were insured for the whole year through a combination of any of the following sources:

▪Medicare

▪TRICARE

▪The veteran’s health program

▪A plan offered by an employer

▪Medicaid or the Children’s Health Insurance Program (CHIP)

▪Insurance bought on your own that is at least at the Bronze level

▪A grandfathered health plan in existence before the health reform law was enacted

12

No Penalty. The requirement to

have health insurance is

satisfied

Types of Commercial Health Insurance

▪ Health Maintenance – HMO’s

▪ Preferred Provider Organizations – PPO’s

13

Health Maintenance Organizations (HMO’s)

▪ Network providers and primary care physician

▪ Co-payment

▪ Lower out of pocket expenses

14

Individual must seek care from

Individual must seek care from

In-NetworkProviders Only

In-NetworkProviders Only

“In-Network”“In-Network”

Health Care ProfessionalsLaboratory

Medical FacilitiesPharmacy

Key Point

Preferred Provider Organization(PPO)

▪ Contracted Preferred Provider List

▪ More choice of providers

▪ Higher costs for using non-Preferred Providers

15

“Yes! My provider’s on this list!”

Provider List

Choosing a provider from the list = lower costs $$

Choosing a provider that is not on the list = higher costs $$$$$

Key Point

Cost Sharing

▪ Cost Considerations

▪ Maximum Out-of-Pocket

▪ Your choices determine your costs

16

Key Point

Understanding Health Insurance Cost Sharing

17

http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf

Things to Consider about Health Insurance

18

▪ Commercial private insurance

▪ Coinsurance or copayment

▪ Plan or calendar year deductible

▪ Contracting

▪ Protection

Coinsurance = a percentage Copayment = a predetermined amount

Cost Sharing Deductible

HMO limited to “In-Network Providers

PPO – Your choice of contracted Providers.

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

Key Point

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 we’re looking at?

▪ Are there any services that are limited in this policy?

▪ What services are excluded in this policy?

19

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

20

Let’s Review

▪ Health insurance terms

▪ Benefits of health insurance

▪ Health insurance plan types

21

Knowledge Check

What is the definition of Estimated Premium?

A.The percentage owed for each visit to a provider until the deductible is met.

B.The co-payment required until the maximum out of pocket expenses are met.

C.A deductible.

D.The amount of money paid monthly for health insurance coverage. This does not include any out-of-pocket health care expenses.

E.All of the above.

22

Knowledge Check

What is health insurance?

A.Health insurance is a contract between an individual and an insurance company.

B.Health insurance is something bought to protect against fire.

C.Health insurance can be “sold” by a Navigator or In-person Assister.

D.Health insurance is required for all dogs and cats.

23

Knowledge Check

Starting ____________, all individual and small employer health plans must include 10 essential health benefit categories.

January 1, 2014

October 1, 2013

March 31, 2013

December 15, 2014

24

Knowledge Check

What is the Individual Mandate?

A.Every United State’s citizen and legal resident (with no exceptions) must have qualifying health care coverage or pay a penalty.

B.Every United State’s citizen and legal resident (with some exceptions) must have qualifying health care coverage or pay a penalty.

C.Individuals are mandated to have fire insurance.

25

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.

A.Co-Insurance

B.Co-Payment

C.Premium

D.Deductible

26

Knowledge Check

It’s the end of the year, 2014. I am an individual adult that decided not to get qualifying health care coverage. What is the minimum penalty I will be assessed.

A.The cost of one year’s worth of premiums based on a bronze level plan.

B.The cost of one year’s worth of premiums based on a silver level plan.

C.$95

D.The cost of one year’s worth of premiums based on a gold level plan.

27

Knowledge Check

In a HMO an individual must seek care from…

A.Any provider they wish.

B.An In-Network provider.

C.A provider they’ve seen in the past.

D.The provider that is closest to the individual’s home.

28

Knowledge Check

Which of the following is not a characteristic of a PPO?

A.They provide a Contracted Preferred Provider List

B.Out of pocket costs are lower when an insured individual uses providers from the Contracted Preferred Provider list.

C.Insured must use In-Network providers.

29

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?

A.This individual is responsible for the first $200 of the bill.

B.This individual is responsible for the first $200 of the bill plus 30% of anything over $200.

C.Nothing. This is what they bought health care coverage for.

30

Knowledge Check

In the previous scenario the maximum out of pocket expense the insured is responsible for is $2000. The insured has been very ill and needs to go back to the Dr. for further treatment. The insured has paid $1900 out of pocket to date. They have already met their $200 deductible. This Dr. visit is $200. How much will this visit cost the insured?

A.$100

B.$60

C.$40

D.$200

31

Knowledge Check

The insured has met their Maximum Out of Pocket expense. They go to the Dr. and receive treatment that is not a covered service. What amount of the bill will they be responsible for?

A.$200

B.30%

C.All of it. The service was not covered

D.None of it. This is why they purchased health care coverage

32

Knowledge Check

The insured has met their Maximum Out of Pocket expense. They go to a Dr. and receive treatment for a covered service. The bill is $173.50. How much of this bill is the insured responsible for?

A.$17.35

B.$52.05

C.$173.50

D.Nothing

33

Knowledge Check

Which of the following is not included in cost sharing reductions?

A.Co-payments

B.Co-insurance

C.Premiums

D.Deductibles

34

Questions

35

Thank you!

Congratulations! You have completed Insurance 101 course!

37