UNDERSTANDING HEALTH INSURANCE AND YOUR OPTIONS

HEALTH INSURANCE BASICS

Presented by[insert organization’s name]

When shopping for a plan, ask:

• What do I need?• What can I afford?• What is included in the plan?• How does the plan work?• Does the network of providers meet my needs?

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Where can you get insurance?

• Your employer.• On your own.• Groups associated with employment.• Membership organizations.• State or federal government.

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Health Plan Comparison

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• Doctor Participation – Does your doctor participate in the plan?

• Coverage – Does the plan provide coverage for both routine care and major medical coverage (catastrophic illness) or only major medical?

• Premium – How much will the insurance cost you?• Co-pays – How much will you have to pay when you go

to the doctor?

Important Parts of the Plan to Review

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• Deductible – How much will you have to pay each year toward medical expenses before the insurance begins paying claims?

• Preauthorization – Does the health insurance company need to approve care or treatment before you receive it?

• Pre-existing conditions – Does the plan cover your pre-existing condition?

• Exclusions – Review what is not covered by the plan.• Limits – Is there a maximum dollar limit on how much the plan

will pay?

Important Parts of the Plan to Review (continued)

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10 QUESTIONS TO ASK YOURSELF BEFORE CHOOSING A PLAN

1. Is the insurance company or agent selling the plan licensed by the Pennsylvania Insurance Department?

2. Is the company that offers the plan financially sound?

3. Will you be covered for care in an emergency situation or when you’re out of town?

4. Is it a discount health plan or an actual health insurance plan?

5. What degree of coverage will you receive?

Questions to Ask

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6. What are the real costs of the plan?

7. Are the doctors, hospitals, laboratories and other medical providers you use included in the network?

8. Do you have to choose a primary care physician?

9. Do you need to get a referral before you see a specialist?

10. Are the prescription medicines that you use covered by the plan?

Questions to Ask (continued)

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For more information on health insurance,

please visit www.PAHealthOptions.com.

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A Quick Guide to Medicare & Medigap

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Federal health insurance program• Ages 65 & older.• Younger than 65 with certain disabilities.• Any age with permanent kidney failure (End-State Renal Disease).

Must be legal U.S. resident for five years

Two types of Medicare Coverage:• Original Medicare.• Medicare Advantage Plans.

What is Medicare?

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Medicare Part A• Hospital Insurance

- Hospital, skilled nurse facility, hospice or home healthcare.• You may be automatically enrolled, but sign up as soon as you

are eligible.

Medicare Part B• Medical Insurance

- Doctors, healthcare providers, outpatient care, durable medical equipment, home healthcare and preventative services.

• Sign up as soon as eligible – avoid late enrollment fee.

Original Medicare

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You will need to sign up on your own if:

• You are not receiving Social Security or Railroad Retirement Board (RRB) benefits.

• You qualify for Medicare because you have End-Stage Renal Disease (ESRD)

Original Medicare (continued)

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You should apply for Medicare Part A and Part B three months before

your 65th birthday. You can apply:

• Online at www.socialsecurity.gov/medicareonly.• In person at your local Social Security office.• By phone at 1-800-772-1213. (If you worked for a railroad, call the

RRB at 1-877-772-5772.)

Original Medicare (continued)

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• Medicare plans that are run by private insurance companies.• Combine Medicare Part A and Part B in one plan.• Also called Medicare Part C.

Medicare Advantage Plans

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Medicare Part D is prescription drug coverage. • Some Medicare Advantage plans include Part D.• If covered by Original Medicare, you may purchase Part D coverage

through a Medicare-approved prescription drug plan (PDP).

Medicare Part D

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• Medicare Part A is hospital insurance.• Medicare Part B is medical insurance.• Medicare Part C is a Medicare Advantage Plan.• Medicare Part D is prescription drug coverage.

Medicare Quick Recap

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For more information on Medicare, please visit www.Medicare.gov.

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• Private health insurance option that helps fill gaps in Medicare coverage

• You must have Original Medicare to purchase Medigap• Medicare Advantage Plans (Part C) are ineligible

Medigap (Medicare Supplemental Insurance)

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Medigap Plans

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How to read the chart:If a check mark appears in a column of this chart, the Medigap policy covers 100 percent of the described benefit. If a row lists a percentage, the policy covers that percentage of the described benefit. If a row is blank, the policy doesn’t cover that benefit. Note: The Medigap policy covers coinsurance only after you have paid the deductible (unless the Medigap policy also covers the deductible).

Source: Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare, Developed jointly by the Centers for Medicare & Medicaid Services (CMS) and the National Association of Insurance Commissioners (NAIC), 2012.

*Plan F also offers a high-deductible plan. If you choose this option, this means you must pay for Medicare-covered costs up to the deductible amount before your Medigap plan pays anything.

**Plans K and L have out-of-pocket annual limits. After you meet your out-of-pocket yearly limit and your yearly Part B deductible, the Medigap plan pays 100 percent of covered services for the rest of the calendar year. ***Coinsurance is covered except copayments are required for certain office or emergency room visits. Review the plan carefully to understand the details.

• Each insurance company’s rates are different, but you’ll pay a monthly premium.

• Policy pricing:• Community-rated

• Not based on age• Same premium charged to everyone

• Issue-age-related• Based on age when you buy policy

• Attained-aged-related• Premium based on current age and rises with age

Medigap. How much does it cost?

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• Starts the first day of the month in which you began Medicare Part B benefits & lasts for six months• Different than Medicare Advantage Plan open enrollment

• The insurance company can’t consider your health status (use medical underwriting) to:• Refuse to sell or charge you more• Make you wait for coverage to start

• Likely to receive the best rates at this time

Medigap: Open enrollment (continued)

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For more information on Medigap, visit www.PAHealthOptions.com

to download Your Guide to Choosing a Medigap Policy.

Medigap (continued)

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If you’d like to learn more about health insurance, visit

www.PAHealthOptions.com