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What I need to know about health insurance.
Introduction to Health Insurance
Basics Terms Scenario
Mandated covered services
Plans Identify Explain
Pros and Cons Metal tiers How to choose
Other considerations
Basic Terms for Personal Cost
Premium Deductible Coinsurance Copayment Out-Of-Pocket Max
What is a premium?
Amount you pay to maintain insurance coverage. This is reflected in a monthly payment.
What is a deductible?
Amount you are responsible for paying for a covered medical expense before the plan begins to pay for covered medical expenses per year.
What is Coinsurance?
A shared cost between you and the plan.
Either pay coinsurance or copayment.
What is a Copayment?
AKA “Copay” A payment you will make each time
you visit the doctor or fill a prescription. Some policies or plans have additional copays for Emergency and Urgent Care services.
What is an Out-of-Pocket Maximum?
The most you will be required to pay for covered medical expenses during the plan year.
Includes costs to meet deductible and coinsurance/copayments.
Plan will pay at 100% once OOP has been reached.
How Does Health Insurance Work?
Scenario: You have inpatient surgery to remove your gallbladder on January 1st. Your accumulated expenses total $40,000.
Scenario Plan: Deductible: $3,000 Coinsurance: 10% Out-of-Pocket Max: $4,000
Scenario balance you are responsible for: $4,000. For the rest of the year, covered medical expenses will be covered at 100%.
What is health insurance mandated to cover in 2014?
Ambulatory patient services (outpatient 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 (those that
help patients acquire, maintain, or improve skills necessary for daily functioning) and devices
Laboratory services Preventive and wellness services and chronic disease
management Pediatric services, including oral and vision care
Types of insurance plans
Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Point-Of-Service (POS)
HMO-Health Maintenance Organization
PROS Plan pays for visits
with out having to file a claim.
Minimal OOP costs. All in-network
providers clearly listed in plan.
CONS Limited network of
providers. Plan will not pay for
specialty care with out pre-approval from “gatekeeper” (except in emergencies).
No coverage for use of out of network providers.
A type of health insurance plan that limits coverage to care from doctors who work for or contract with the
HMO.
PPO-Preferred Provider Organization
PROS Contracts with
individual physicians, hospitals and providers in community.
Contracts with providers for discounted fees.
Can use out of network providers.
Able to see specialists without a referral from “gatekeeper.”
CONS Have to pay more to
use out of network providers.
Patient is responsible for a percentage of the discounted service fee.
A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of
participating providers.
POS-Point of Service plan
PROS Functions like an
HMO if primary care provider is in network.
Option of using other physicians and self referrals.
CONS Deductible and co-
insurance apply if utilizing providers out of network/ non-participating plan providers.
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.
Metal Tiers
How do I choose a plan?
Review medical needs (self/family). Prescriptions, doctors, etc.
Estimate total cost for the year with new plan. Total premium, anticipated deductible
payments, coinsurance, copayments and other OOP expenses.
Help Paying for Insurance
Additional resources- VIDEO LINKS
Cost Sharing and Advanced Premium Tax Credit (APTC) https://www.healthcare.gov/will-i-qualify
-to-save-on-monthly-premiums/ https://www.healthcare.gov/will-i-qualify
-to-save-on-out-of-pocket-costs/
References
http://www.bcbsla.com/FINDAPLAN/GETTINGSTARTED/Pages/UnderstandInsurance.aspx#works
http://www.cbsnews.com/news/get-your-ppos-hmos-poss-straight/
http://www.standupforhealthcare.org/blog/10-essential-health-benefits-insurance-plans-must-cover-starting-in-2014
