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This product was prepared with support provided through a grant from the
Robert Wood Johnson Foundation’s State Health and Value Strategies program.
Is this Sanskrit? No!
It’s health insurance: Tips to understand
your health insurance plan
Webinar 1 for Oklahoma employees October 5, 2016
Diane Webb, MPH, CHES Health Literacy Program Manager
Some common questions:
o How do I choose the best plan for me and my family?
o What types of care are covered by my plan?
o What health care costs do I have to pay for myself?
Health insurance is hard to understand
A
B
C
D
E
Where does an insurance plan list the health services it covers?
How can I find out which plans are accepted by my doctor?
What’s the difference between a copay, deductible, and co-insurance?
If I owe money for a doctor visit, will my bill come from the insurance company or my doctor’s office?
Other (type a question in your chat box)
Poll: What questions do you have about health insurance?
What you will learn
What is health insurance?
What are your rights as a consumer?
How do you keep health insurance?
Do you understand your plan?
How do you use health insurance?
What you will learn
What is health insurance?
What are your rights as a consumer?
How do you keep health insurance?
Do you understand your plan?
How do you use health insurance?
Helps pay for big health events, and for smaller ones as well
What does health insurance do for you?
Illness Hospital
Counseling Care for kids
Emergency care
Check-up
Health insurance pays some of your medical bills, and you’ll pay some, too
You share the cost
The more money you pay for your insurance, the less you will pay for health care services:
The less money you pay for your insurance, the more you will pay for health care services:
To save money on health care, learn the difference between in-network and out-of-network health providers
Lower health care costs
In-network
$
Out-of-network
You will pay more
$
$
$
$
$
Every plan helps pay for these health services:
o Outpatient care, such as doctor visits
o Emergency room care
o Hospital stays
o Care before and after you have a baby
o Help with mental health issues
o Prescription medicines
o Services and devices to help you recover from injury or sickness
o Lab tests
o Pediatric care for kids
o Preventive and wellness services to help prevent sickness, disease, or other health problems
Essential health benefits
What you will learn
What is health insurance?
What are your rights as a consumer?
How do you keep health insurance?
Do you understand your plan?
How do you use health insurance?
Health insurance words to know
Premium
Out-of-pocket maximum
Copay
Deductible
Co-insurance
Premium
The cost you and your employer pay each paycheck for your health insurance.
Premium
Out-of-pocket maximum
Copay
Deductible
Co-insurance
David will pay $150 each month x 12 months = $1,800 a year
Copay
A fixed amount you may pay at the time you receive a health care service.
Premium
Out-of-pocket maximum
Copay
Deductible
Co-insurance
Primary: $25
Specialist: $50
Hospital: $500
Prescription: $15 generic
$20 brand
David will pay $150 each month x 12 months = $1,800 a year
Deductible
Premium
Out-of-pocket maximum
Copay
Deductible
Co-insurance
Primary: $25
Specialist: $50
Hospital: $500
Prescription: $15 generic
$20 brand
$3,000 per year
David will pay $150 each month x 12 months = $1,800 a year
An amount you must pay out of your own pocket for your covered health care services each year.
Co-insurance
Premium
Out-of-pocket maximum
Copay
Deductible
Co-insurance
David will pay $150 each month x 12 months = $1,800 a year
Primary: $25
Specialist: $50
Hospital: $500
Prescription: $15 generic
$20 brand
$3,000 per year
Health insurance plan will pay 80% which equals
$40,000
David will pay 20% which equals
$10,000
Your share of the cost for health care after you’ve paid your deductible amount each year. Once you reach your deductible, your plan will start sharing the cost of health care with you.
Out-of-pocket maximum
Premium
Out-of-pocket maximum
Copay
Deductible
Co-insurance
David will pay $150 each month x 12 months = $1,800 a year
Primary: $25
Specialist: $50
Hospital: $500
Prescription: $15 generic
$20 brand
$3,000 per year
Health insurance plan will pay 80% which equals
$40,000
David will pay 20% which equals
$10,000
$6,000
A limit on your out-of-pocket costs. After you’ve reached your out-of-pocket maximum for the year, your insurance plan will pay 100% of your covered essential health benefits.
David’s total costs with insurance = $7,800
Premium
Out-of-pocket maximum
Copay
Deductible
Co-insurance
David will pay $150 each month x 12 months = $1,800 a year
Primary: $25
Specialist: $50
Hospital: $500
Prescription: $15 generic
$20 brand
$3,000 per year
Health insurance plan will pay 80% which equals
$40,000
David will pay 20% which equals
$10,000
$6,000
Accident costs $50,000
David pays $7,800
A
B
C
D
E
Premiums
Copays
Deductibles
Co-insurance
Out-of-pocket maximums
Poll: What’s the hardest cost to understand?
What types of plans are available?
HMO All care is in-network
You
Primary care physician
Referral
In-network specialist
PPO Care can be in-network
or out-of-network
You
Primary care In-network physician specialist
What types of plans are available?
PPO Care can be in-network
or out-of-network
You
Primary care In-network physician specialist
2 accounts that allow you to spend pre-tax money:
Health Savings Account (HSA) o Must choose the Health Choice HDHP, a high-deductible health plan
o Put up to $3,400 from your paycheck into an account to spend on your qualified medical costs
o The money in your account rolls over each year
Flexible Spending Account (FSA) o Put money from your paycheck into an account to spend on
your qualified medical costs, deductibles, and copays
o You must enroll each Option Period or you lose the account
o Usually, you must use the money in your FSA within the plan year or lose it
o To estimate your possible savings, use the FSA Savings Calculator at: www. ebd.ok.gov/flexible-spending/Pages/FSA-Calculator.aspx
Ways to save your tax dollars
What you will learn
What is health insurance?
What are your rights as a consumer?
How do you keep health insurance?
Do you understand your plan?
How do you use health insurance?
Carry your card with you at all times
Insurance card
Shows a summary of your plan costs and benefits
Summary of Benefits and Coverage (SBC)
Choose a primary care provider to give you most of your care.
To find a list of in-network doctors and other health care providers:
o Visit your plan website
o Call your insurance company
o Ask family members or friends
Find providers in your plan’s network
o To get prescription medicines:
• Find an in-network pharmacy
• See if your plan offers a mail-order service
o To find out costs for medicines, find your plan’s drug formulary online
Medicine
Drug formulary tiers
Tier Drug Copay
Tier 1 Generic $15
Tier 2 Preferred brand $40
Tier 3 Non-preferred brand Pay 100% until deductible is met
Your plan covers preventive care such as routine checkups to help you stay healthy
Schedule a checkup
Well-woman checkups for women
Care for kids, such as checking hearing and
vision
Vaccines for adults and children
Screenings, such as for blood pressure
Counseling for obesity
A
B
C
D
E
Yearly checkup
Yearly well-woman visit
Flu shot
Cancer screenings, such as a mammogram or colonoscopy
Other (type in your chat box)
Poll: Which type of preventive care did you get most recently?
After you get a health care service, your insurance company will send you an EOB to show the costs.
An EOB is not a bill.
Explanation of Benefits (EOB)
Date: 06/12/2015 Date of service: 05/20/2015 Amount you owe: $ 100.00
What you will learn
What is health insurance?
What are your rights as a consumer?
How do you keep health insurance?
Do you understand your plan?
How do you use health insurance?
Speak up if you need more information about your:
o Health care
o Health insurance
o Medical bills
You have the right to call your doctors and insurance company for answers to your questions.
Benefit coordinators can also help.
What are your rights as a consumer
of health care and health insurance?
Speak up and ask questions of your providers:
o When you don’t understand a recommended treatment or procedure
o If you don’t understand the cost for a health care service
o If you can’t pay the total amount of a bill all at once
Speak up and ask questions of your insurance company:
o When you need to know if recommended treatments or procedures will be covered in-network
o When you see a mistake on your EOB or your plan doesn’t pay for a health care service you think should be covered
Speak up if you have questions for your
providers and insurance company
1. Call the insurance company
2. Call your benefit coordinator
3. If needed, file an appeal with the insurance company
An appeal is a request you make to your health insurance company to change its decision about your plan coverage.
If the company still won’t pay and you don’t understand why, contact a patient advocate for help at: www.patientadvocate.org
What if your plan doesn’t pay for
health care you think is covered?
What you will learn
What is health insurance?
What are your rights as a consumer?
How do you keep health insurance?
Do you understand your plan?
How do you use health insurance?
Place important papers about health insurance and health care in one file so you can get to them easily, such as your:
o Summary of Benefits and Coverage (SBC)
o EOBs
o Doctor bills
Keep your insurance papers together
When you call your insurance company:
o Write down your questions ahead of time
o Have your insurance card and any supporting papers or bills with you
o Take notes about the phone call, including the date and name of the person you talk to
o Afterwards, file the notes with your other insurance papers
Get prepared before calling your
insurance company
Best time to call is before 11:00 am and after 3:00 pm
If you have changes in your family that could affect your coverage, contact your benefit coordinator within 30 days.
Changes such as:
o Birth or adoption
o Divorce or separation
o Death
o A child on your plan turning 26
o You or your covered spouse turning 65
Keep your coverage up to date
Visit the Employee Benefits Department website at:
www.ebd.ok.gov/Benefits/Pages/default.aspx
o Shop for benefits
o Use the Flexible Spending Account (FSA) cost estimator tool
o Enroll for health plans and an FSA
Last day to enroll is
Monday, October 31st
Enroll during the Option Period
o Health insurance is hard to understand
o Learn about costs, plan types, and ways to save tax dollars to get the most value
o Use insurance tools such as your insurance card to get good health care
o Know your rights as a consumer
o Keep your papers together
o Re-enroll every year
Review and wrap-up
What questions do you have for me?
Take this short survey about today’s webinar. Your feedback will help us make our webinars better.
https://www.surveymonkey.com/r/JXX6MYJ
Please take our survey!
This product was prepared with support provided through a grant from the
Robert Wood Johnson Foundation’s State Health and Value Strategies program.
To learn more and shop for plans during the October Option Period, visit the Employee Benefits Department website:
www.ebd.ok.gov/Benefits/Pages/default.aspx
