HEALTH INSURANCE 101. Finding the Right Plan

Transcription

1 HEALTH INSURANCE 101 Finding the Right Plan

2 HEALTH CARE 101: FINDING THE RIGHT PLAN Introduction... 2 Common Health Insurance Terms and Definitions... 3 Health Care Reform: What You Need to Know... 7 Important Questions to Ask Before Choosing a Plan... 8 Types of Plans to Consider Discover EmblemHealth

3 INTRODUCTION Congratulations! If you re reading this book you re ready to take the first step needed to guarantee a more secure future for yourself, your family and/or your business. Indeed, the decision to purchase a health insurance plan is no small matter. There s much you ll need to know in order to explore your options and eventually put whatever insurance plan you purchase to best use. The good news is that this guide and other resources are available to help you. In the pages to come we ve outlined some important information that will help you: Understand common health insurance-related terms. Sort out the various health insurance options. See how certain provisions of the health reform law apply to you. Find a plan that meets your specific lifestyle and budget. Purchasing health insurance is a practical and important decision. This guide will make your decision easier by giving you the information you need to get coverage that fits your unique lifestyle, needs and budget. COMMON HEALTH INSURANCE TERMS AND DEFINITIONS Finding a plan that s right for you begins with understanding the basics. With this in mind, here are a number of terms you should know: Ambulatory Care: All types of health services provided on an outpatient basis. Amount Allowed By Your Plan: The maximum amount your plan will pay for the service(s) you received. This amount may be less than the amount submitted. Consumer-Directed Health Plans: Consumer-directed health plans (CDHPs) generally refer to plans designed to make consumers more active and aware purchasers of health care by giving them a greater stake in their care (and in their spending for health care). Because CDHPs are often High-Deductible Health Plans, premiums are lower than those for normal managed plans. If used with a health savings account (HSA) or a health reimbursement account (HRA), a CDHP can be used to pay for routine health costs with tax-deferred funds. Unused funds can be rolled over to the next plan year. Co-payment: A fixed dollar amount you must pay a provider each time you obtain care for a covered service. Continuation of Coverage: Procedure by which individuals transferring from one insurance plan to another are allowed uninterrupted coverage from the date of original enrollment. Cost-Sharing: A comprehensive term for the deductible, copayment and coinsurance provisions in your plan. This guide will make your decision easier by giving you the information you need to get the right coverage. Covered Services: The services for which your plan provides benefits under the terms of your contract. 2 Make an Informed Decision: Call EmblemHealth s Insurance Experts 3 at

4 Deductible: The amount you must pay each year before your provider will begin to pay for covered services. Direct Payment: Individual subscribers who are billed and pay premiums directly to the insurer or managed care organization. Drug Formulary: A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality. Exclusive Provider Organization (EPO): A managed care plan where services are covered only if you go to doctors, specialists or hospitals in the plan s network (except in an emergency). Explanation of Benefits (EOB): A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment or the claims appeal process. Family Deductible: The dollar amount of the member s health benefit coverage that must be met each calendar year before payment can be made on claims. There is a maximum out-of-pocket amount that will satisfy the family deductible. Once that deductible is reached, all claims for the family are then paid at 100 percent of allowable charges. Generic Drug: A drug which is the pharmaceutical equivalent to one or more brand-name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand-name drug. 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. Health Savings Account (HSA): A medical savings account available to taxpayers who are enrolled in a High-Deductible Health Plan. The funds contributed to the account aren t subject to federal income tax at the time of deposit. Funds must be used to pay for qualified medical expenses. Unlike a Flexible Spending Account (FSA), funds roll over year to year if you don t spend them. High-Deductible Health Plan (HDHP): A plan that features higher deductibles than traditional insurance plans. HDHPs can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis. Mail-Order Pharmacy Program: A program that offers drugs ordered and delivered through the mail to plan members. Member: A person, including a covered dependent (a child or spouse insured on your plan) who has health coverage. Network: The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members. Network Provider: A doctor, hospital or other health care provider who has entered into an agreement with EmblemHealth to provide health care services to members for a negotiated rate of reimbursement. Out-of-Network Benefits: Reimbursement for covered services provided by out-of-network providers and suppliers. Out-of-network benefits are generally subject to a deductible and coinsurance and, therefore, have higher out-of-pocket fees. Depending on your contract, out-of-network services may not be covered. 4 Explore Your Coverage Options: Call EmblemHealth s Insurance 5 Experts at

5 Point of Service (POS): A type of health benefit plan that allows enrollees to go outside the health plan s provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Preferred Provider Organization (PPO): A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket fees than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Premium: A prepaid payment or series of payments made to a health plan by purchasers and often plan members for health insurance coverage. Referral: A recommendation by a physician that an enrollee receive care from a specialty physician or facility. Finding a plan that s right for you begins with understanding the basics. HEALTH CARE REFORM: WHAT YOU NEED TO KNOW As a result of Health Care Reform (the Affordable Care Act), you ll have more options to consider when choosing a health care plan. Even though the law passed in 2010, most changes will take effect in 2014, and more changes will come over the course of its 10-year implementation. To help make health care reform more understandable for you, we ve explained some of the key changes that might affect you, your family and/or your business. 1. Health insurance may be required for all Americans by This means that each person or business would have to maintain a minimum level of health insurance or pay a tax penalty. New health insurance exchanges, as well as tax credits for families that qualify, will make it easier for people to afford health insurance. 2. Children can remain on their parents health plan until age 26. Under the Affordable Care Act, children can be insured under their parents plan up to 26 years of age, as long as they do not have their own job-based coverage. 3. Small Businesses: Tax credits and new programs will be available to businesses with less than 25 employees, making care more affordable for employers, their employees and early retirees. 4. Pre-existing conditions: Under the new law, you can no longer be denied coverage due to a pre-existing condition. New York currently has a plan to cover people with pre-existing conditions. It s called the New York Bridge Plan. GHI, an EmblemHealth company, was selected to administer this plan on behalf of the state. 5. Preventive Care: The Affordable Care Act will give you access to preventive care with no cost-sharing, encouraging people to stay healthy and reduce their health care needs. 6. Annual and Lifetime Dollar Limits: Health Care Reform will remove the cap (or maximum) on annual and lifetime coverage for individuals and families for essential treatments. This is an important change for people with chronic conditions and diseases that are expensive to treat. 6 Get Answers to Your Questions: Call EmblemHealth s Insurance Experts * For more information on health reform, 7 at visit

6 IMPORTANT QUESTIONS TO ASK BEFORE CHOOSING A PLAN When choosing health coverage, you want to find the plan that has your best interests in mind. Here are a few key questions about your coverage needs that you should think about in deciding which type of plan is right for you: 1. How often do I see a doctor or receive health care services? Generally, if you see your doctors or receive health care services frequently, you should consider plans with low copays and coinsurance for services, like HMO and PPO plans. If you see the doctor less often, you may prefer a plan that has a low monthly premium, like a high-deductible plan or EPO plan. 2. Am I flexible about the doctors I want to see? Network size and benefits for out-of-network coverage can vary widely from plan to plan. If you are flexible about the doctors you want to see and cost is a consideration, look at plans with smaller networks and low service fees. If you prefer to have access to more doctors and providers, consider plans with larger networks and out-of-network benefits. Keep in mind that under most plans, seeing a doctor in network will be less costly than seeing a doctor out of network. So if there are certain doctors that you prefer to see, it s a good idea to check if they are accepted by a plan first. 8 Neep Help Choosing Coverage? Call EmblemHealth s Insurance Experts at Do I take prescription drugs regularly? If you regularly take prescription drugs to help you manage your health, you will want to choose a plan that includes prescription drugs as a covered benefit. Not all plans use the same formulary, so you should also make sure that the plan you want covers the medications you take. You will also want to look at the amounts the plan charges for generic, brand and non-formulary medications. 4. Do I need individual or family coverage? If you are looking for coverage for yourself and a dependent or family, you will need to consider all of the above questions not only for yourself, but for your dependents. Here are a few key questions to ask yourself when considering health coverage. 9

7 TYPES OF PLANS TO CONSIDER When it comes to health insurance, most people have clear expectations: A plan that s there when they need it. Thankfully, individuals and sole proprietors have a number of health insurance options to choose from in today s marketplace. The information on these pages will help you sort out your options: PLAN HIGHLIGHTS PPO insurance plans EPO insurance plans HMO insurance plans HDHP insurance plans PPO insurance plans contract 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. EPO insurance plans are managed care plans where services are covered only if you go to doctors, specialists or hospitals in the plan s network (except in an emergency). HMO insurance plans provide coverage for care received only from a network of doctors who contract with the HMO. These plans 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. HDHP insurance plans feature higher deductibles than traditional insurance plans. HDHPs can be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis. PLAN FEATURES PPO insurance plans: EPO insurance plans: HMO insurance plans: HDHP insurance plans: Offer the highest level of coverage. Allow for referral-free choice of physicians both in and out of network. May require pre-approval for some services. Don t require referrals for specialist visits. May require pre-approval for some services. Are typically a lower-cost option. May require referrals for specialty care. Have services provided by individual providers or by physician group practices that offer multiple services in one convenient location. Offer cost-conscious shoppers lower premiums based on higher-than-customary member deductibles. Typically offset member costs with tax-saving Health Savings Accounts (HSAs). 10 Learn About Our Flexible Benefit Designs: Call EmblemHealth s Insurance Experts 11 at

8 We are committed to giving you access to the kind of care and service that you and your family deserve. DISCOVER EMBLEMHEALTH At EmblemHealth, we are committed to giving you access to the kind of care and service that you and your family deserve, with plans that fit your budget and lifestyle. We are proud of our roots and the many qualities that helped make our trusted HIP and GHI plans a New York mainstay and familiar names to New Yorkers like you. Why EmblemHealth? Our plans are designed with New Yorkers in mind. EmblemHealth is New York health insurance. Some 2.8 million people depend on our plans from small business owners, labor union members and higher education professionals to public workers. And we re growing and expanding our reach to cover more New Yorkers than ever, with plans that offer a range of coverage options for many different needs and budgets. Thoughtful and Accessible Health Care. We want our EmblemHealth members to stay healthy, get well and live better. You can count on the health care professionals, hospitals and facilities in our network to be where you need them, when you need them. And new innovative online tools make managing your health care experience fast, easy and convenient. Our goal is simple: to help you get the care you need at a price you re comfortable with. Stay healthy, get well and live better with EmblemHealth. 12 Find Budget-Friendly Health Insurance: Call EmblemHealth s Insurance Experts 13 at

9 Let Us Help You Choose the Right Plan Now that you have an understanding of the basics, the next step is to choose a plan. We offer plans that help you get the care you need, when you need it. Here are some of the plans EmblemHealth offers:* ConsumerDirect EPO GHI Direct Pay PPO GHI Healthy NY EPO High Deductible Health Plan HIP Healthy NY HMO High Deductible Health Plan HIP Direct Pay HMO GHI Healthy NY HMO High Deductible Health Plan *Rates may vary according to family size and where you live. Let us show you what care feels like. Call our insurance experts at , Monday through Friday from 8:30 to 5:00. If you have a hearing or speech impairment and use a TDD, please call Monday through Friday from 8:30 to 5:

10 16 17 NOTES: NOTES:

11 55 Water Street, New York, New York Group Health Incorporated (GHI), GHI HMO Select, Inc. (GHI HMO), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies EMB_MP_BRO_10234_Info_Kit_Response 8/12