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S H I B A HelpLineStatewide Health Insurance

Benefits Advisors

Health Insurance 101: Health Insurance 101: Taking the “Huh?” out of health care coverageTaking the “Huh?” out of health care coverage

Especially for those with Traumatic Brain Injury, their families, friends, caregivers, and supporters

Sponsored by the

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Hello and welcome!Hello and welcome!

Who are we?

Audrey Pitchford, Curriculum Writer AudreyP@oic.wa.gov 360-725-7107

JoAnn Ehlers, Regional TrainerJoAnnE@oic.wa.gov 509-633-3788

We welcome your questions!

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What is the What is the SHIBA HelpLine?SHIBA HelpLine?

Statewide Health Insurance Benefits Advisors (SHIBA)

Free service of the Consumer Protection Division at the Washington State Office of the Insurance Commissioner (OIC)

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What is the What is the SHIBA HelpLine?SHIBA HelpLine?

Network of folks around the state: 15 staff 20 sponsors About 450 volunteers Multiple partner agencies

Unbiased – not part of an insurance company, not selling any product

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What does the What does the SHIBA HelpLine do?SHIBA HelpLine do?

Helps folks of all ages, from all walks of life: Understand health care coverage

options, benefits and bills

Access coverage and apply for some programs that may help with costs

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What does the What does the SHIBA HelpLine do?SHIBA HelpLine do?

Helps folks know what steps to take if a bill is denied

Reports complaints and possible fraud for review and investigation

Provides information so folks can make the best decisions for themselves

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Why do folks contact Why do folks contact SHIBA?SHIBA?

Uninsured or underinsured

Problem with insurance or want to change coverage – such as during Medicare Part D open enrollment

Questions about how insurance works

And so on!

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Real SHIBA case:Real SHIBA case: Divorced dad called SHIBA – his

minor-age son fell while visiting from out-of-state Concussion + broken leg

Surgery on leg + overnight in hospital for head injury observation

Dad thought son’s mother had coverage for kids but she did not

Bill: Over $17,400

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Real SHIBA case (cont’d):Real SHIBA case (cont’d): Dad’s on Medicare due to disability

and has a fixed income, can’t pay

SHIBA helped identify options: DSHS/state Medicaid (denied)

Charity care (granted)

Provider reduced bill to $3,300

Dad was able to set up an affordable payment plan for balance

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How do folks contact How do folks contact SHIBA?SHIBA?

Toll-free: 1-800-562-6900 (ask for SHIBA!)

Web: www.insurance.wa.gov

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How do folks contact How do folks contact SHIBA?SHIBA?

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Our sponsors, volunteers Our sponsors, volunteers and partners here today:and partners here today:

Many folks make SHIBA happen!

We couldn’t do it without our sponsors and volunteers!

We also have partners in the community who help us out.

Let’s take a moment and meet everyone!

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How you can help us!How you can help us! Please complete the pink Optional

Comments Page! We are not experts on Traumatic

Brain Injury (TBI)! We will learn from you today as well!

We always need more partners and volunteers, especially folks with a specialty or area of focus.

Want to join us?

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Today’s agenda:Today’s agenda:

Explain what SHIBA is/what we do

Presentation: How insurance works and preventing problems; health care coverage options available

Time for individual counseling

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How is health insurance How is health insurance supposed to work?supposed to work?

Folks pay a monthly amount (premium) to have health insurance.

If folks with health insurance have a medical need or problem, they usually do not have to pay all costs for their medical care.

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Insurance and serious Insurance and serious conditions such as TBIconditions such as TBI

Some diagnoses (medical conditions) cause insurers to look for other sources of payment (such as homeowners, drivers, job, liability, etc.).

Insurers may investigate whether other sources will pay first.

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Case studies: Case studies: We want to hear from you!We want to hear from you!

What insurance, if any, was there for the injury?

Were there problems with getting care or getting bills paid?

What was the financial impact?

What were or are the impacts on or issues for family or caregivers?

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How is health insurance How is health insurance supposed to work?supposed to work?

Often, understanding how health insurance works can help you avoid unnecessary bills.

Let’s talk about this next.

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How is health insurance How is health insurance supposed to work?supposed to work?

Many times health insurance doesn’t pay the full amount the doctor’s office bills.

Most folks want to know: Who pays the leftover amount? It depends!

Let’s learn about: Allowable Charges

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Allowable ChargesAllowable Charges Goal: Save insurance plans and

patients $$$!

Insurance plans enter contracts with providers. All contracts vary!

Contracts set Allowable charge for every medical service – the maximum dollar amount/percent: Plan pays provider, and

Provider may collect from patient

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Allowable ChargesAllowable Charges

Providers in contracts with the plan are Participating Providers

Plans often pay most of the Allowable Charge

Patients often must pay a smaller share of the Allowable Charge Copay = Fixed amount (Example: $25)

Coinsurance = Percent (Example 20%)

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Allowable Charge ExampleAllowable Charge Example Doctor bills plan = $100

Plan contract says Allowable Charge = $60

Who pays what on that bill? Doctor writes off (can’t collect) = $40

Plan pays 80% of AC = $48

Patient’s coinsurance 20% = $12

Bill is considered “paid in full”

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Participating ProvidersParticipating Providers

Providers who sign a contract with the insurance plan

Going to them saves you money!

Before you get care, Rx’s, etc., ask providers if they take your plan: Including Medicare and Medicaid

Not all providers take all plans!

If not, you could be stuck with the bill!

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Who has ultimate Who has ultimate responsibility for the bill?responsibility for the bill?

The Guarantor, who is usually: The patient (if age 18+)

The parent or guardian (for minors)

Sometimes, other sources (see next slide)

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Who has ultimate Who has ultimate responsibility for the bill?responsibility for the bill?

The Guarantor may be: L&I: on-the-job injuries

L&I: Crime Victims Comp. Program

Auto policy: motor vehicle accidents

Homeowners, business, etc: other injuries (such as slips/falls, etc.)

Employer: job-required exams (such as hearing tests, CDL, etc.)

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Who has ultimate Who has ultimate responsibility for the bill?responsibility for the bill?

If it is not you, be sure your doctors have information about Guarantor: Full legal name and address

Birth date and Social Security No.

Claim number and policy number

Name of employer and billing info

If info is missing or the other source doesn’t pay, bills may go to you!

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Who has ultimate Who has ultimate responsibility for the bill?responsibility for the bill?

If you have more than one plan or type of coverage: Tell your plans about each other!

Complete and turn in to your plan the plan’s Coordination of Benefits forms (which coverage pays 1st or 2nd)

If info is missing, you may get bills or delays in coverage!

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We suggest you know for We suggest you know for each plan you have:each plan you have:

Plan billing address and phone

For each person your plan covers: Full name and date of birth

Policy number and group number

Social Security Number

Current address and phone number

Employer’s name, address and phone

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We suggest you know for We suggest you know for each plan you have:each plan you have:

Who is the: Guarantor: responsible for the bill

Subscriber: person who carries the insurance (example: person with insurance through their job)

Patient: receiving the health care

This may be one person, or several people!

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We suggest you know for We suggest you know for each plan you have:each plan you have:

If you have more than one plan: Primary: which pays first?

Secondary: which pays second?

Rules vary! There are exceptions!

Let’s see some examples….

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Primary or secondary?Primary or secondary?

Medicare: May be primary or secondary to other insurance

Medicaid: Always secondary to private or employer plans

Crime Victims Compensation Program: Always secondary

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Primary or secondary?Primary or secondary?

Children covered by both parents: Parent with first birthday in the year has the primary insurance

Couples: If both partners cover each other, their own insurance is primary and their spouse’s is secondary

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We suggest you know for We suggest you know for each plan you have:each plan you have:

Premium: Your plan’s monthly cost

Deductible: What you must pay out-of-pocket before the plan pays May be for one person or the family Usually per calendar year Medicare hospital: per benefit period

(restarts after 60 days out of hospital)

These may change every year!

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We suggest you know for We suggest you know for each plan you have:each plan you have:

Copayment (copay) or coinsurance: Usually one or the other Copay: usually a flat fee per service or

appointment (such as $25) – you pay when you check in

Coinsurance: Usually a percentage (such as 20%) of the Allowable Charge

These may change every year!

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Short exerciseShort exercise If you wish, and you have your plan

card or cards with you, you may take them out now.

You don’t have to show them to anyone!

In fact, please keep them private to protect your personal information!

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Short exerciseShort exercise Does your card have the

information we’ve talked about? Full name and date of birth?

Subscriber name (if not you)?

Policy number and group number?

Name of plan? Billing address? Customer service phone number?

Premium, deductible, copays, or coinsurance?

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Short exerciseShort exercise Your card likely does not have all

this information on it!

We suggest you know information from the last slide, in case there are issues or problems.

Also, do you get a new card every year? When you do, destroy last year’s card!

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We suggest you know for We suggest you know for each plan you have:each plan you have:

Plan-covered services (what the plan will pay for)

Non-covered or excluded services (what the plan won’t pay for)

Your plan benefits booklet or Certificate of Coverage lists these

These may change every year!

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Placeholder – benefits booklet page on covered services

Sample

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Placeholder – benefits booklet page on excluded services

Sample

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We suggest you know for We suggest you know for each plan you have:each plan you have:

Which providers you may go to, such as participating providers

Whether the plan covers care with non-participating providers (not contracted with the plan)

How do you get these bills paid?

These may change every year!

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We suggest you know for We suggest you know for each plan you have:each plan you have:

Timelines that affect you: When can you access your benefits?

When can you make changes to your benefits?

These may change every year!

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Places to find answers:Places to find answers:

Your plan benefits booklet or Certificate of Coverage

Your plan benefits card, customer service phone or plan website

Your plan administrator or for job-based plans, the HR office

Coming up next: Billing cycle

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Billing cycle of a Billing cycle of a doctor visit:doctor visit:

1. Make your appointment. Tell scheduler what you need – don’t assume doctor sees this! Put the date and time in your calendar.

2. Get ready. Write down questions or invite a support person. If you need a specific service, bring your benefits book or other information.

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Billing cycle of a Billing cycle of a doctor visit:doctor visit:

3. Check in. Ensure front counter staff have your current insurance (they may copy your plan card and ID). If needed, pay copayment (copay).

4. Nurse calls you in. Tell the nurse why you’re there – don’t assume the doctor sees this! Nurse takes your vital signs.

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Billing cycle of a Billing cycle of a doctor visit:doctor visit:

5. See the doctor. Make sure the doctor knows what you need. Ask your questions. Take notes if needed.

6. Doctor decides diagnosis, treatment and level of care provided in today’s visit.

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Billing cycle of a Billing cycle of a doctor visit:doctor visit:

7. Medical records staff and billing staff convert diagnoses and treatment into billing codes.

8. Office staff bill insurance using the codes.

“Errors” in some steps may cause your plan to deny the bill!

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Things to know about Things to know about billing codes:billing codes:

Some diagnoses (for certain injuries and accidents) trigger insurance plans to send you a form.

The form may ask questions to verify who is the guarantor, which insurance is the primary payer, etc.

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If everything goes right in If everything goes right in the billing process:the billing process:

Your plan will determine the Allowable Charges.

The plan pays their part of the bill.

The plan sends you an Explanation of Benefits (EOB). Not a bill – don’t pay yet!! Shows what plan paid States your share of costs

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Sample

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If everything goes right in If everything goes right in the billing process:the billing process:

Your provider sends you a bill.

The bill should show: Original charge for service or services What your insurance paid What you owe

If the bill matches your EOB, now it’s okay to pay. (Unless you disagree – we’ll cover that soon!)

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Sample

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What can go wrong in the What can go wrong in the billing process?billing process?

Billing codes wrong, transposed, etc.

Provider doesn’t bill your insurance plan or doesn’t have plan info.

Provider sends you a bill before you get an EOB.

Provider bills wrong insurance

And so on!

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When you get your bill:When you get your bill:

Wait to get an EOB before you pay!

If the bill is due so soon you feel you can’t wait, call your provider’s office to find out: Did they bill your insurance? If no, can they do it now? Do they need your insurance info or

any other info you can provide?

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If you think your bill is If you think your bill is wrong…wrong…

After you get the EOB, look for a denial reason or reduced payment reason. If needed: Call your provider and ask them to

correct and re-process the bill Look for plan appeal rights (phone

number or address with deadline to disagree with plan denial)

Check your benefits booklet

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If you think your bill is If you think your bill is wrong…wrong…

You may need to send a letter to your plan, provider or both.

You can ask your provider not to send you to collections while you appeal or correct the bill.

Keep copies of everything!

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Sample

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Appealing plan decisions:Appealing plan decisions: Most decisions from insurance

companies can be appealed! Act quickly – there may be time

limits. You may have to appeal in writing.

Your plan can not cancel your coverage because you appeal!

For guidance, see How to Appeal a Health Care Decision….

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Health care coverage Health care coverage options:options:

Vary based on whether you:

Have Medicare (due to age 65 or disability) – we’ll talk about this 1st

Are under age 65 and not Medicare-eligible – we’ll talk about this next

Your options and needs may change as time passes!

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Folks who qualify for Folks who qualify for Medicare:Medicare:

Folks at any income level who are:

Age 65 or over

Any age with End-Stage Renal Disease or Lou Gehrig’s Disease

Under age 65 with a disability and have had Social Security Disability Insurance (SSDI) for 24 months

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Especially for folks with Especially for folks with TBI or other disabilities:TBI or other disabilities:

Have you applied for SSDI?

Did you receive benefits and a Medicare start date?

Did you appeal denials or re-apply?

Did you apply for Supplemental Security Income (SSI) while waiting?

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Important things to know Important things to know about Medicare:about Medicare:

It’s not free – but there are programs to help pay the costs

It does not cover everything

Many folks get other coverage to fill gaps in Medicare

In some cases you and your family may not have to have the same coverage

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Some ways to fill Some ways to fill Medicare’s gaps:Medicare’s gaps:

Programs that help folks with limited income: Medicaid/State DSHS/Provider One

(all folks in our state with SSI qualify!)

Medicare Savings Programs – Help with Medicare premiums and sometimes medical costs

Extra Help – Help with Rx drug costs

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Some ways to fill Some ways to fill Medicare’s gaps:Medicare’s gaps:

Coverage or benefits you may already have: Employer/retiree insurance – Yours

or a spouse’s

TRICARE for Life – Military retirees

Tribal/Indian Health Services –Benefits for some tribal members

VA – Benefits for some veterans

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Some ways to fill Some ways to fill Medicare’s gaps:Medicare’s gaps:

Private insurance: Medicare Supplements/Medigaps –

Fill gaps in Medicare Part A (hospital) and Part B (medical)

Part D – Drug coverage

Medicare Advantage (Part C) – Private plans that substitute for Medicare Parts A+B and may include Part D

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Want help with your Want help with your Medicare options?Medicare options?

Talk to SHIBA to learn: More information about Medicare What options you have to fill

Medicare’s gaps How to compare options What points you may want to think

about with each option Whether you may use more than one

option together

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Folks under age 65 and Folks under age 65 and notnot on Medicare:on Medicare:

May include: Working-age adults Families and children Folks with SSDI who are waiting

(24 months) for Medicare to start In some cases you and your family

may not have to have the same coverage

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Especially for folks with Especially for folks with TBI or other disabilities:TBI or other disabilities:

Have you applied for SSDI, SSI, or both?

Did you receive benefits and a Medicare start date?

Did you appeal denials or re-apply?

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Coverage options: Folks Coverage options: Folks notnot on Medicare on Medicare

Programs that help folks with limited income: Apple Health for Kids – For kids

under age 19 with family income up to 300% FPL ($3678/mo for 2 people; $5,589/mo for a family of 4)

Medicaid/State DSHS (a.k.a. “Provider One”) – Folks must meet a “category.” All folks with SSI qualify!

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Medicaid/State DSHS Medicaid/State DSHS categories: Person who:categories: Person who:

Is Age 65 or over

Is Blind

Is a Child under 19 (Apple Health)

Has a Disability (folks on SSI qualify!)

Is Expecting

Is a Family with kids under age 19

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Coverage options: Folks Coverage options: Folks notnot on Medicare on Medicare

Programs that help folks with limited income: Basic Health Folks up to 133% FPL

($1208/mo for single people; $4831/mo for family of four)

Not on Medicare or Medicare-eligible

Currently a wait list to join – with some exceptions

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Coverage options: Folks Coverage options: Folks notnot on Medicare on Medicare

Coverage or benefits you may already have: TRICARE or CHAMPVA – For some

folks in the military and their families

Tribal/Indian Health Services –Benefits for some tribal members and their children

VA – Benefits for some veterans

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Coverage options: Folks Coverage options: Folks notnot on Medicare on Medicare

Coverage or benefits you may already have: Job-based plan: Through your work or your spouse,

domestic partner, or family member

If WA state law regulates plan: If plan covers workers’ kids, plan must share information with custodial parents, even if workers don’t live with kids or parents were never married.

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Coverage options: Folks Coverage options: Folks notnot on Medicare on Medicare

Coverage or benefits you may already have: Job-based plan: Plans that cover workers’ kids must

accept them up to age 26 (plans in effect before 03/23/2010 may deny adult kids with ins. through their jobs)

COBRA or other continuation coverage – right to continue job-based plans (may be costly!)

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Coverage options: Folks Coverage options: Folks notnot on Medicare on Medicare

Buying individual (private) insurance: Things to know: You may have to pass the Standard

Health Questionnaire (SHQ)

The plan may turn you down if you fail

Some folks are exempt (may buy insurance without taking the SHQ)

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Who’s exempt from the SHQ?Who’s exempt from the SHQ? Kids under age 19:

No wait period for pre-existing conds. Open enrollment for individual plans:

Mar. 15-Apr. 30 & Sep. 15-Oct. 31 Other times: WSHIP or PCIP

Some folks who: Moved out of old plan’s service area Had or lost other coverage Qualified for or lost COBRA

Time limits may apply!

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Coverage options: Folks Coverage options: Folks notnot on Medicare on Medicare

Buying individual (private) insurance: Things to know: Catastrophic plans: May cover fewer

benefits with a smaller premium and very high deductible (such as $5,000)

Comprehensive plans: May cover more services with a higher premium

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Coverage options: Folks Coverage options: Folks notnot on Medicare on Medicare

Buying individual (private) insurance: Another option: Washington Health Program Limited benefit insurance

Up to only $75,000 or $100,000 in coverage per calendar year

May cost less than individual insurance due to limited benefits

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Coverage options: Folks Coverage options: Folks notnot on Medicare on Medicare

Folks with pre-existing conditions, or who fail or likely will fail SHQ: Pre-existing Condition Insurance

Plan (PCIP): For folks who failed SHQ or have pre-existing conditions, and no health insurance for 6 months

Washington State Health Insurance Pool (WSHIP): High-risk pool for folks who failed SHQ.

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Resources for everyone:Resources for everyone: Charity care

Dental, vision, hearing programs

Disease-based or disability-based programs

Free clinics

Health clinics (community, free, rural, or sliding scale)

Pharmaceutical programs

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Resources for everyone:Resources for everyone:

Programs that help with costs of insurance: Premiums

Deductibles

Copays/Coinsurance

Legal resources – for appealing SSA or insurance decisions

Refer to “Resources” (blue sheet)

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Resources for everyone:Resources for everyone:

See if you may qualify for programs that help with a variety of costs, based on your situation:

BenefitsCheckUp.org

ParentHelp123.org

Help finding options and comparing individual insurance:

Healthcare.gov

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Want help with your health Want help with your health care coverage options?care coverage options?

Talk to SHIBA to learn: More information about your options

How to compare options

What points to think about with each option, and whether you may use more than one together

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Today’s agenda:Today’s agenda:

Explain what SHIBA is/what we do

Presentation: How insurance works and preventing problems; health care coverage options available

Time for individual counseling