Health Insurance Literacy - Massachusetts Health Care Training

Health Insurance Literacy
Understanding Basic Health
Insurance Terms
Massachusetts Health Care
Training Forum
April 2015
Presented by:
Debi Lang
Debbie Raymond
Objectives:
After this presentation you will be able to:
• Define health insurance literacy
• Discuss the importance of health insurance literacy
• Explain the meaning of some basic health insurance terms to your clients • Recognize appropriate resources and tools to assist with health literacy challenges
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What is Health Insurance Literacy?
“The Health Insurance Literacy Expert Roundtable defines health insurance literacy as the “degree to which individuals have the knowledge, ability, and confidence to find and evaluate information about health plans, select the best plan for their own (or their family’s) financial and health circumstances, and use the plan once enrolled.”
“Health Insurance Literacy”, CMS National Training Program, 3
Why is Health Insurance Literacy
Important?
Individuals that understand health insurance terms:
• Are able to compare and choose an insurance plan that fits their healthcare needs
• Are able to compare and choose insurance plans that better fit their budget and avoid unnecessary high‐cost medical bills • Use their benefits wisely resulting in improved health and disease prevention
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How Do I Decide?
http://healthpopuli.com/2010/09/27/blondie-and-dagwood-on-thehealth-economy/
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Knowing how to explain basic health insurance
terms to your clients is important! Shopping
for health insurance can be:
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Premium:
The cost to purchase a health insurance plan.
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Network:
Doctors, Nurses, Specialists, Physical and Occupational Therapists, Mental Health providers
Hospitals, Nursing Homes
Labs
Pharmacies
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In Network:
Out of Network:
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Deductible:
The amount you must pay for most covered services before the plan begins to pay. Jane’s health insurance coverage just began. She has not met her annual $1500 deductible yet. She visits her doctor for a sick visit (e.g. sore throat and cough). The cost of the covered service is $125.
Jane pays = $125
Her plan pays = $0
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Certain in-network expenses may not be subject to the
deductible, which means your insurance may cover all or
part of the cost. Prescription medication, immunizations,
screenings, office visits…..always check with your plan if
you are not sure.
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A family may meet their annual “family” deductible without
each person having to meet their “individual” deductible.
$1500
$1500
$1500
$500
= Family Deductible $5000
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Out-of-Pocket Limit
The most you pay during a 12‐month policy period. This limit doesn’t include the premium, or payments for services your plan doesn’t cover.
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Summary of Benefits
CMS: Summary of Benefits & Coverage & Uniform Glossary
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Using Benefits
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Covered Service:
“A healthcare provider’s service or medical supplies covered by your health plan. Benefits will be given for these services based on your plan.” (Medical Mutual 2014)
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Co-Pay:
The fixed amount your plan requires you to pay when you
receive a covered service (a co-pay is usually paid at the time
you receive the service).
YOUR
CO-PAYMENT
Is due at the time
of your visit.
Thank You
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Co-insurance:
The amount you pay for your share of a covered service, calculated as a percent. Co‐
insurance starts once you’ve met your deductible. You also may have a co‐pay. 19
Summary of Benefits
CMS: Summary of Benefits & Coverage & Uniform Glossary
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CMS: Summary of Benefits & Coverage & Uniform Glossary
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The Insurance Card:
Center for Health Guidance ACA-Consumer-Guide-2014
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The Insurance Card:
Center for Health Guidance ACA-Consumer-Guide-2014
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Suppose that under your health insurance policy, hospital
expenses are subject to a $1,000 deductible and $250 per day
copay. You get sick and are hospitalized for 4 days, and the bill
(after insurance discounts are applied) comes to $6,000. How
much of that hospital bill will you have to pay yourself?
 $0
 $1,000
 $2,000
 $4,000
 Don’t know
From: The Henry J. Kaiser Family Foundation
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True or false: If you receive inpatient care at a hospital that
participates in your health plan’s provider network, all the
doctors who care for you while you’re in the hospital will also
be in network?
 True
 False
 Don’t know
From: The Henry J. Kaiser Family Foundation
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Suppose your health plan covers lab tests in full if you go to an
in-network lab, but only pays 60% of allowed charges if you go
out of network. You forget to check and go get your blood test at
a lab that turns out to be out of network. The lab bills you $100
for the blood test. Your health insurance allows only a $20
charge for that test. How much would you have to pay out of
pocket for that lab test?
 $0
 $40
 $80
 $88
 Don’t know
From: The Henry J. Kaiser Family Foundation
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Stay Tuned!
• The Health Connector, based on feedback from this
year’s Open Enrollment events, is working on a Health
Plan Shopping Guide for consumers and a Health
Plan Shopping Training for assisters
• The assister training is focused on shopping for an
unsubsidized QHP on the Health Connector website
• Training will be held at the end of May and an invite for
the training will go out through the MTF listserv
• The Health Plan Shopping Guide for consumers will
be available for download from MAhealthconnector.org
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Resources for Assisters
• Massachusetts Health Care Training Forum (MTF) www.masshealthmtf.org
• MassHealth
http://www.mass.gov/eohhs/consumer/insurance/masshealth‐member‐info/
• Massachusetts Health Connector https://www.mahealthconnector.org
• US Department of Health and Human Services www.Healthfinder.gov
• Center for Medicare and Medicaid Services (CMS) http://marketplace.cms.gov
• Glossary of Health Coverage and Medical Terms http://marketplace.cms.gov/help‐us/2partner‐with‐us.html
• From Coverage to Care
http://marketplace.cms.gov/help‐us/c2c.html
• Institute of Medicine Roundtable on Health Literacy
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http://iom.edu/Global/Perspectives/2013/LetsAsk4.aspx
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