health care update jan-2016-american-health care-group

HEALTH CARE UPDATEERIN [email protected](412) 563-7807

ERIN HART - [email protected] - 412-563-7807

INTRODUCTION

Health Insurance is insurance against loss by illness or bodily injury.

Health Care is the treatment of illness or injuries.

Wellness is good physical & mental health obtained by healthy diet, physical activity and healthy lifestyle.


WELLNESS AS COST CONTAINMENT

• Don’t have a good diet83%• Are over weight or obese65%• Don’t get enough exercise

to get the health benefits67%• Of all causes of death are

lifestyle related and preventable~70%


HEALTH INSURANCE MARKET

Individual Plans Group Plans Medicare Medicaid

Workers Comp Auto Personal Liability


HEALTH INSURANCE TERMS

Premium – monthly cost of policy Copay – flat amount charged for health care service Coinsurance – percentage charged for health care

service Deductible – initial payment due to health care provider

before insurance pays Out of pocket max – the most the member pays out of

pocket – does not include premium


HEALTH INSURANCE TERMS

Network – the providers that have contracted with the insurance company

PPO – Preferred Provider Organization – a product that has an out-of-network benefit

HMO – Health Maintenance Organization – a product that does not have an out-of-network benefit

Emergency Coverage – most plans allow for emergency coverage notwithstanding network


INDIVIDUAL COVERAGE

Insurance Companies No premium subsidy available

Healthcare.gov in PA Coverage through Insurance Companies Premium Subsidies Other Cost Sharing covered – copays,

deductibles, coinsurance, out-of-pocket max


INDIVIDUAL ENROLLMENT

January 15 – deadline for Federal Marketplace

Special Enrollment Periods – new baby, change in marital status, loss of employer coverage


INDIVIDUALS: UNDER 65 PENALTY

For 2015 you'll pay the higher of these amounts: 2% of your income; (2.5% in 2016) $325/adult -$162.50/child; family max $975 (2016 - $695/adult,

$347.50/child; family max $2,085) Your health insurance status is recorded on your tax return. Exemptions to penalty: https://www.healthcare.gov/health-

coverage-exemptions/exemptions-from-the-fee/


HEALTHCARE.GOV – 2015 FEDERAL POVERTY GUIDELINES

Household Size 100% 133% 150% 200% 250% 300% 400%

1 $11,770 $15,654 $17,655 $23,540 $29,425 $35,310 $47,080

2 15,930 21,187 23,895 31,860 39,825 47,790 63,720

3 20,090 26,720 30,135 40,180 50,225 60,270 80,360

4 24,250 32,253 36,375 48,500 60,625 72,750 97,000

5 28,410 37,785 42,615 56,820 71,025 85,230 113,640

6 32,570 43,318 48,855 65,140 81,425 97,710 130,280

7 36,730 48,851 55,095 73,460 91,825 110,190 146,920

8 40,890 54,384 61,335 81,780 102,225 122,670 163,560


COST EXAMPLESMarried couple (43 & 48 years old) w/3 kids in Allegheny County

Bronze plans $640/month w/$12,000 family deductible

Silver plans $800/month w/$6000 family deductible

Gold plans $950/month w/$1,500 family deductible

Platinum $1700/month w/$500 family deductible


COST EXAMPLESAge Tobacco? Deductible Premium

18 N 1400 206.2318 N 2700 167.9418 N 4500 130.8818 N 6000 137.7930 N 1400 368.6130 N 2700 300.1830 N 4500 233.9330 N 6000 246.2850 N 1400 580.0450 N 2700 472.3650 N 4500 368.1150 N 6000 387.5464 N 1400 974.3164 N 2700 793.4464 N 4500 618.3364 N 6000 650.97


MEDICAL ASSISTANCE: MEDICAID

Find out if you’re eligible: http://www.phlp.org/quickscreen-questionnaire

Single Monthly Income Limit: $1,354 Household size of 4 Income Limit: $2,789 Pregnant Women: $2,922 Household size of 4 (Pregnant woman counts as 2):

$4,447

http://www.phlp.org/quickscreen-questionnaire


HOW TO CHOOSE?

Check network providers Annualize monthly premium Project services needed in the year (based on

known problems & family history) Calculate copays, coinsurance & deductibles for

these service Choose most affordable plan


GROUP PLANS: STRATEGIC PLANNING CONSIDERATIONS• Senior management should make final

decisions• Determine total annual budget for health

plan• CFO – involved in analysis & plan

selection• Assess employee’s health care needs• Review claims data annually• Wellness – assessment & incentives


GROUP PLANS: STRATEGIC PLANNING CONSIDERATIONS Benefit Structure

Determine if existing benefit plan is aligned with prevention and wellness goals & objectives

Identify screens & tests not covered Evaluate the potential costs and benefits of preventive services

Analyze employee attitudes Interest in participating in specific programs Barriers to participation in prevention programs

Perform a Health Risk Assessment Health risks and habits of employees and other beneficiaries Readiness to change unhealthy lifestyle habits


GROUP: STRATEGIC PLANNING CONSIDERATIONS Medical claims analysis

Identify “top ten” costliest conditions Are conditions preventable or related to lifestyle choices?

Understand services being under- and over-used by workforce population

Health plan Understand existing health plans’ current and potential capabilities

Ability to incorporate coverage changes Ability to track preventive service utilization by employer or by plan Efforts to educate primary care physicians about appropriate preventive care benefit administration Ability to support efforts to educate employees about preventive services

Identify possible gaps between prevention program goals and the capabilities of health plans

HIPAA Wellness Incentives


MEDICARE COVERAGE DETAILSCost Sharing for 2016 Part A: Generally Free (or up to $411/mo)

$1,288 for a hospital stay 1 – 60 days $322/day for a hospital stay for days 61 – 90 $644/day for a hospital stay for days 91 – 150 All costs for 150+ days SNF - $161/day for days 21 – 100 for each benefit period – covered after 3

day hospital stay

Part B: $104.90/month or $121.80/month Hold Harmless Clause – 2016 rates $166 deductible, then 20%


PART C: MEDICARE ADVANTAGE

From private insurers Medicare Advantage and Medicare Advantage Prescription Drug

plans Live in plan’s service area Entitled to Part A & enrolled in Part B Premiums range from $0 – over $300. Copays for services Becomes only insurance Most include RX benefit


PART C CONTINUED

Services covered that original Medicare doesn’t cover Lower cost sharing Vision, Hearing, Dental Podiatrist & Chiropractic Gym Membership

Combine benefit coverage for hospitals and doctors Types: HMO, PPO, SNP, POS Considerations: Formulary, Network


PACE PACENETRX Benefit $6.00 & $9.00,

potentially lower based on income level

$8.00 & $15.00

Premium Benefit Covers the premium if RX plan is a partner plan

No premium benefit

Income Individual MarriedPercentage of FPL 133% 120%Yearly $14,500 $17,700Monthly $1,208 $1,470

Income Individual MarriedYearly $23,500 $31,500Monthly $1,958 $2,625

PACE/PACENET Information


IMPORTANT DATES Timing

Initial enrollment – 3 months before & after 65 October 15 – December 7 in 2015 for January 1, 2016 effective date January 1 – February 14 – disenrollment Anytime throughout the year

Dual eligible Move out of service area Institutionalized Lose employer coverage Low Income Subsidy

CONTACT ERIN HARTDIRECTOR, HEALTH BENEFIT SERVICES

EMAIL: [email protected]

CALL: (412)563-7807