Health Insurance 101 For 2015 Open Enrollment
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.
Basic Insurance Terms
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.
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!
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.
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.
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.
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.
Essential Health Benefits A set of health care service categories that must be covered by certain plans, starting in 2014. 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.
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.
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.)
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.
How to kynect Brochure
Other Resources http://www.cms.gov/cciio/resources/files/downloads/uniformglossary-final.pdf (uniform glossary) https://www.healthcare.gov/ http://marketplace.cms.gov/technical-assistanceresources/c2c.html (Coverage to care)
How To Read An SBC Or Other SSP Tools To Answer Insurance Questions.
SBC means: Statement of Benefits and Cost- Sharing? Summary of Benefit and Coverage? San Bernardino County? Somebody Better Call the Contact Center?
SBC
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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
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 2500 1500 ER physician 1200 600 Blood work 300 100 X-Ray 550 200 Hospital charges 4500 2000 Anesthesia 800 500 Surgery 1000 750 TOTALS $10,850 $5,650
10.0 Privacy & Security What does Meg Actually Pay? Service Billed Charge After Insurance Discount Co-pay or co-insurance ER 2500 1500 340 ER physician 1200 600 120 Blood work 300 100 $10 X-Ray 550 200 $50 Hospital charges 4500 2000 400 Anesthesia 800 500 100 Surgery 1000 750 150 TOTALS $10,850 $5,650 $1,170 10/22/2014 28
Plan Comparison Tools
Plan Comparison Tools
Plan Comparison Tools
Plan Comparison Tools
Plan Comparison Tools
Plan Comparison Tools
Plan Comparison Tools
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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
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
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.
Know The Differences In Dental Policies For 2015.
What s new for 2015
Dental insurance Includes 2015 Open Enrollment
Dental Shopping
Dental shopping
Dental plan comparison
Dental Plan Comparison
Dental Plan
Other Brief reminders
Enrollment Periods Open Enrollment 2015 November 15 to February 15 Continuous Open Enrollment For Medicaid or SHOP Special Enrollment For Qualifying Life Events
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