03/31/2011 1 S H I B A HelpLine Statewide Health Insurance Benefits Advisors Health Insurance 101: Health Insurance 101: Taking the “Huh?” out of health care Taking the “Huh?” out of health care coverage coverage Especially for those with Traumatic Brain Injury, their families, friends, caregivers, and supporters Sponsored by the
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S H I B A HelpLine Statewide Health Insurance Benefits Advisors Health Insurance 101:
S H I B A HelpLine Statewide Health Insurance Benefits Advisors Health Insurance 101: Taking the “Huh?” out of health care coverage Especially for those with Traumatic Brain Injury, their families, friends, caregivers, and supporters Sponsored by the. - PowerPoint PPT Presentation
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03/31/2011 1
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
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
03/31/2011 33
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!
03/31/2011 34
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!
03/31/2011 35
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!
03/31/2011 36
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?
03/31/2011 37
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!
03/31/2011 38
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!
03/31/2011 39
Placeholder – benefits booklet page on covered services
Sample
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Placeholder – benefits booklet page on excluded services
Sample
03/31/2011 41
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!
03/31/2011 42
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!
03/31/2011 43
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
03/31/2011 44
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.
03/31/2011 45
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.
03/31/2011 46
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.
03/31/2011 47
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!
03/31/2011 48
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.
03/31/2011 49
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
03/31/2011 53
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!
03/31/2011 54
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?
03/31/2011 55
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
03/31/2011 56
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!
03/31/2011 57
Sample
03/31/2011 58
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….
03/31/2011 59
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!
03/31/2011 60
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
03/31/2011 61
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?
03/31/2011 62
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
03/31/2011 63
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
03/31/2011 64
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
03/31/2011 65
Some ways to fill Some ways to fill Medicare’s gaps:Medicare’s gaps:
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
03/31/2011 66
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
03/31/2011 67
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
03/31/2011 68
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?
03/31/2011 69
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!
03/31/2011 70
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
03/31/2011 71
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
03/31/2011 72
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
03/31/2011 73
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.
03/31/2011 74
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!)
03/31/2011 75
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)
03/31/2011 76
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!
03/31/2011 77
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
03/31/2011 78
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
03/31/2011 79
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.
03/31/2011 80
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
03/31/2011 81
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)
03/31/2011 82
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
03/31/2011 83
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
03/31/2011 84
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