Health Insurance 101 For 2015 Open Enrollment
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1 Health Insurance 101 For 2015 Open Enrollment
2 Objectives: Understand and Explain Basic Insurance Terms. How To Read An SBC Or Other SSP Tools To Answer Insurance Questions. Understand Your Part In The QHP Renewal Process. Know The Differences In Dental Policies For 2015.
3 Basic Insurance Terms
4 Premium vs. individual contribution Premium = The total amount that must be paid for an individual or family s health insurance plan. You and/or your employer usually pay it monthly, quarterly or yearly. Premium Individual or family contribution: The individual or family s portion of the premium that must be paid for an individual or family s health insurance plan. You usually pay it monthly, quarterly or yearly. Premium APTC or Employer Contribution = Individual/Family Contribution.
5 APTC Payment assistance: A tax credit that can help you afford coverage bought through the Marketplace. Unlike tax credits you can only claim when you file your taxes, these tax credits can be used right away to lower your monthly premium costs. Payment assistance is also called Advance Premium Tax Credits (APTC). Special Discounts lower the amount you have to pay for out-of-pocket costs like deductibles, coinsurance, and copayments. Special Discounts are also called Cost-Sharing Reductions (CSR). Payment Assistance and Special Discounts are only available on kynect!
6 Providers and Networks Provider: A health care professional or health care facility that is licensed, certified or accredited, as required by state law. Network: The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. In-Network Provider : A provider who has a contract with your health insurer or plan to provide services to you at a discount. (Sometimes called participating or preferred provider). Out of Network Provider : A provider who doesn t have a contract with your health insurer or plan to provide services to you. You ll pay more to see an out of network provider. (Sometimes called a non-preferred or non-participating provider). Primary Care Provider (PCP): Medical Doctor or D.O. (Doctor of Osteopathic Medicine), advanced practice registered nurse or physician assistant who provides, coordinates or helps individuals access most healthcare services.
7 Type of Plans: Health Maintenance Organization (HMO) A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness. Preferred Provider Organization (PPO) A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan s network. You can use doctors, hospitals, and providers outside of the network for an additional cost. Point of Service (POS) Plans A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.
8 In-Network vs. Out-of-Network Deductible: The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. The deductible may not apply to all services. (Innetwork; Medical; Pharmacy; Integrated) Maximum Out-of-pocket (MOOP) Limit: The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This amounts never include your premium, balancebilled charges or health care your health insurance or plan doesn t cover. Some health insurance or plans don t count all of your co-payments, deductibles, co-insurance payments, out-ofnetwork payments or other expenses toward the maximum out of pock limit.
9 In-Network vs. Out-of-Network COINSURANCE: An amount you may be required to pay as your share of the cost for services after* you pay any deductibles. Coinsurance is usually a percentage of the cost of the service (for example, 20%). COPAYMENT: An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor s visit, hospital outpatient visit or prescription drug. A co-payment is usually a set amount, rather than a percentage of the total cost.
10 Essential Health Benefits A set of health care service categories that must be covered by certain plans, starting in Health plans offered in the individual and small group markets offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
11 Other Insurance Terms Appeal: A formal request to your health plan to reconsider a decision to deny coverage for healthcare. Excluded Services: Healthcare services that your health insurance plan doesn t pay for or cover(for example, cosmetic surgery) External Review: A formal independent review of a disagreement between you and your health plan about coverage for healthcare that was denied because your plan considered it to be either experimental or not medically necessary. Pre-Authorization: A decision by your health insurer or plan that the service requested for you is medically necessary. This is also called prior approval or precertification.
12 HSA/HRA/FSA Health Savings Accounts (HSAs) An account established so that individuals covered by high-deductible health plans could receive taxpreferred treatment of money saved for medical expenses. Generally, an adult who is covered by a high-deductible health plan (and has no other first-dollar coverage) may establish an HSA. Health Reimbursement Arrangement (HRA) is an employerfunded, tax advantaged plan that reimburses employees for out of pocket medical expenses and individual health insurance premiums. Flexible Spending Account(FSA) (also known as a flexible spending arrangement) is a special account you put money into that you use to pay for certain out-of-pocket health care costs (Copayments and deductibles for certain medical and dental expenses.)
13 More Insurance Terms Catastrophic Health Plan Health plans that meet all of the requirements applicable to other Qualified Health Plans (QHPs) but that don't cover any benefits other than 3 primary care visits per year before the plan's deductible is met. To qualify for a catastrophic plan, you must be under 30 years old OR get a "hardship exemption. Formulary A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a Prescription Drug List.
14 How to kynect Brochure
15 Other Resources (uniform glossary) (Coverage to care)
16 How To Read An SBC Or Other SSP Tools To Answer Insurance Questions.
17 SBC means: Statement of Benefits and Cost- Sharing? Summary of Benefit and Coverage? San Bernardino County? Somebody Better Call the Contact Center?
18 SBC
19 10/22/
20 10/22/
21 10/22/
22 10/22/
23 10/22/
24 10/22/
25 10/22/
26 An example how to use the SBC How does her plan work: Meg had a horrible pain in her stomach and it did not go away. She finally went to ER at 3 am. They ordered bloodwork and an x-ray. It turned out to be appendicitis so she was admitted to the hospital and had her surgery the following morning. She was released from the hospital the following day. Thankfully, the hospital and all the providers who saw Meg were innetwork participating providers and prior to this episode, she had $450 applied to her deductible. Before Meg s insurance information was added her bill would look like this: Service Billed Charge After Insurance Discount Co-pay or co-insurance ER 2500 ER physician 1200 Blood work 300 X-Ray 550 Hospital charges 4500 Anesthesia 800 Surgery 1000 TOTALS $10,850
27 An example how to use the SBC Now Let s look at Meg s Bill After insurance Discount: Service Billed Charge After Insurance Discount Co-pay or coinsurance ER ER physician Blood work X-Ray Hospital charges Anesthesia Surgery TOTALS $10,850 $5,650
28 10.0 Privacy & Security What does Meg Actually Pay? Service Billed Charge After Insurance Discount Co-pay or co-insurance ER ER physician Blood work $10 X-Ray $50 Hospital charges Anesthesia Surgery TOTALS $10,850 $5,650 $1,170 10/22/
29 Plan Comparison Tools
30 Plan Comparison Tools
31 Plan Comparison Tools
32 Plan Comparison Tools
33 Plan Comparison Tools
34 Plan Comparison Tools
35 Plan Comparison Tools
36 10/22/
37 Open Enrollment Timeline 11/01/14* Open Enrollment Notices sent 11/15/14 Open Enrollment begins 12/15/14 Last day to enroll with an effective date of 1/1/15 01/01/15 Effective Date of Coverage if enrolled by 12/15/14 02/01/15 Effective Date of Coverage if enrolled by 1/15/15 02/15/15 Open Enrollment ends 03/01/15 Effective Date of Coverage if enrolled by 02/15/15
38 Open Enrollment Notices 1. Notice of Open Enrollment for those who will be automatically (passively) reenrolled in their current plan for the 2015 Plan Year. This notice will provide general information about open enrollment such as dates and allowed changes. 2. Notice of Open Enrollment for those who cannot be automatically (passively) reenrolled due various reasons. 3. Notice of Open Enrollment for those who have not authorized data checks with the federal hub for the upcoming year
39 Renewal Process A qualified individual enrolled in a QHP that remains eligible for coverage will remain in the QHP selected in the previous year unless: The individual terminates coverage from QHP The individual enrolls in another QHP (if available) The QHP is no longer available in 2015.
40 Know The Differences In Dental Policies For 2015.
41 What s new for 2015
42 Dental insurance Includes 2015 Open Enrollment
43 Dental Shopping
44 Dental shopping
45 Dental plan comparison
46 Dental Plan Comparison
47 Dental Plan
48 Other Brief reminders
49 Enrollment Periods Open Enrollment 2015 November 15 to February 15 Continuous Open Enrollment For Medicaid or SHOP Special Enrollment For Qualifying Life Events
50 6.3 SHOP Enhancements SHOP Amnesty Period kynect will produce a report on the number of Employers who utilize the Amnesty Period in order to participate in SHOP. Employer creates enrollment (Contribution is turned back on 11/15) (Open Enrollment closes 12/15) (Contribution/Participation is turned off) Employees are notified and may enroll Coverage is effective 1/1/15 10/15 11/14 11/15 12/15 10/15/14 11/15/14 12/15/14 01/01/15
51
MCHO Informational Series
MCHO Informational Series Glossary of Health Insurance & Medical Terminology How to use this glossary This glossary has many commonly used terms, but isn t a full list. These glossary terms and definitions
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.westernhealth.com or by calling 1-888-563-2250. Important
More informationHealthKeepers, Inc. Anthem HealthKeepers University of Virginia Physicians Group Anthem HealthKeepers- $750/$1,500 deductible
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.tcsig.com or by calling Delta Health Systems at 1-800-464-7627.
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Anthem BlueCross BlueShield Premier Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2013-01/01/2014 Coverage For: Individual/Family Plan Type: PPO This is
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Anthem BlueCross BlueShield Blue Access PPO Option 20 / Rx Option 7 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage For: Individual/Family
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Anthem BlueCross Value HMO 25/40/20% Select Plus HMO / $10/$30/$45/20% Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage For: Individual/Family
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Anthem BlueCross BlueShield Blue Access PPO Option D54 / Rx Option 7 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 04/01/2013-03/31/2014 Coverage For: Individual/Family
More informationAnthem Blue Cross Placentia-Yorba Linda USD Custom Premier PPO 500/30/10 (500/30/90/60) High Option Coverage Period: 07/01/ /30/2017
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Wittenberg University: Blue Access (PPO) Option 2 Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type:
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BlueCross BlueShield Healthcare Plan of Georgia Premier Plus POS Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2013-01/01/2014 Coverage For: Individual/Family
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.uhc.com/calpers or by calling 1-877-359-3714. Important
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Molina Healthcare of Texas, Inc.: Molina Choice Bronze Plan Coverage Period: 01/01/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.chpbenefits.com or by calling 1-800-633-7867. Important
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Anthem BlueCross BlueShield Blue Access PPO Option 14 / Rx Option AE Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage For: Individual/Family
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.mdwise.org/marketplace or by calling 1-855-417-5615 Important
More informationWhat is the overall deductible?
Molina Healthcare of California: Molina Silver 70 HMO Coverage Period: 01/01/2014 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan
More informationCoverage for: Individual and Family Plan Type: POS. Important Questions Answers Why this Matters: $250 member / $500 two-person /
Blue Choice New England Plan 2 Berkshire Health Group Coverage Period: on or after 07/01/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.myiuhealthplans.com or by calling 1.866.895.5975. Important
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Anthem BlueCross Anthem Elements Choice PPO 6000 / Generic Premium $15/$35/30% 500 Deductible Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015
More informationYou can see the specialist you choose without permission from this plan.
Northwest Laborers-Employers Health & Security Trust: Coverage Period: 04/01/2013 03/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.capitalhealth.com or by calling 1-850-383-3311. Important
More informationNo You don t have to meet deductibles for specified services, but see the chart starting on page 2 for other costs for services this plan covers.
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