Washington Health Benefit Exchange
Insurance 101
Summer 2013
Purpose and Objectives
Purpose
This presentation is to provide an overview on health
insurance and what the Affordable Care Act (ACA) is
changing within the structure of insurance plans
Objectives
Upon completion of this presentation you will:
▪ Have a general understanding of health insurance
▪ Understand common health insurance terms
▪ Understand most common health insurance plans
▪ Understand the benefits of health insurance
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Today’s Agenda
▪ Health Insurance Basics
▪ The ACA Individual Mandate
▪ Health Insurance Terms
▪ Types of Commercial Health Insurance
▪ Things to consider about health insurance
▪ Understanding health insurance cost-sharing
▪ Benefits of health insurance
▪ Let’s review
Explore Your Options
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Customer Support
Field Level Help
Key Point
Estimated Premium
This is the amount of money that you
will pay monthly for your health
insurance coverage. This does not
include any out-of-pocket health
care expenses.
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Cycle without Health Insurance
Uninsured consumer
can't afford doctor
Consumer drops policy
due to high price and is
now uninsured
Consumer delays care,
goes to ER
Insurers shift cost to
consumer
Consumer can't pay
Providers shift cost to
Insurers
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Health Insurance Basics
Key Point
▪ What is Health Insurance
▪ The Value of Health Insurance
▪ The 10 Essential Health Benefits
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Ten Essential Health
Benefit Categories
1. Ambulatory services
6. Prescription drugs
2. Emergency services
7. Rehabilitative and habilitative services and
devices
3. Hospitalization
8. Laboratory services
4. Maternity and newborn care
9. Preventive and wellness services and chronic
disease management
5. Mental health and substance use
disorder services, including behavioral
health treatment
10. Pediatric services, including oral and vision
care
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The ACA Individual Mandate
Key Point
▪ What is the Individual mandate?
▪ How does the mandate work?
▪ What is Qualifying Health Coverage?
▪ What if someone cannot afford insurance?
▪ Are there Exemptions?
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Individual Mandate
▪ Require all citizens and legal residents (there are
some exceptions) to have health coverage in 2014.
▪ What happens if someone does not meet this
deadline?
▪ Will they go to jail?
NO!
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What is the penalty?
Key Point
2014: $95 per adult
and $47.50 per child
(up to $285 for a
family) or 1% of
income, whichever is
greater
2015: $325 per adult
and $162.50 per child
(up to $975 for a
family) or 2%,
whichever is greater
2016: $695 per adult
and $347.50 per child
(up to $2,085 for a
family) or 2.5% of
family income,
whichever is greater
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the Mandate IS SATISFIED WHEN
You were insured for the whole year through a
combination of any of the following sources:
▪ Medicare
▪ TRICARE
▪ The veteran’s health program
▪ A plan offered by an employer
No Penalty. The
requirement to
have health
insurance is
satisfied
▪ Medicaid or the Children’s Health Insurance
Program (CHIP)
▪ Insurance bought on your own that is at least at the
Bronze level
▪ A grandfathered health plan in existence before the
health reform law was enacted
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Types of Commercial Health Insurance
▪ Health Maintenance – HMO’s
▪ Preferred Provider Organizations – PPO’s
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Health Maintenance Organizations (HMO’s)
▪ Network providers and primary care physician
▪ Co-payment
Key Point
▪ Lower out of pocket expenses
“In-Network”
Individual must seek
care from
Health Care Professionals
Laboratory
Medical Facilities
Pharmacy
In-Network
Providers Only
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Preferred Provider Organization
(PPO)
▪ Contracted Preferred Provider List
▪ More choice of providers
Key Point
▪ Higher costs for using non-Preferred Providers
“Yes! My provider’s
on this list!”
Provider List
Choosing a provider from
the list = lower costs $$
Choosing a provider that is not on
the list = higher costs $$$$$
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Cost Sharing
Key Point
▪ Cost Considerations
▪ Maximum Out-of-Pocket
▪ Your choices determine your costs
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Understanding Health Insurance Cost Sharing
http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf
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Things to Consider
about Health Insurance
▪ Commercial private insurance
▪ Coinsurance or copayment
▪ Plan or calendar year deductible
HMO limited
to “InNetwork
Providers
PPO – Your
choice of
contracted
Providers.
To find out if a provider is contracted
with a specific health care plan either
contact the provider’s office or the
health care plan and ask.
▪ Contracting
▪ Protection
Cost Sharing
Coinsurance = a percentage
Key Point
Deductible
Copayment = a predetermined
amount
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Questions to ask Yourself
▪ What is the premium? Monthly? Annually?
▪ What is the deductible?
▪ What is the maximum amount of money my
customer might have to pay out of pocket during a
policy year?
▪ My customer has specific health care needs. Are
these needs covered by the Qualified Health Plans
we’re looking at?
▪ Are there any services that are limited in this
policy?
▪ What services are excluded in this policy?
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What are the Benefits of Health Insurance?
▪ Better Health
▪ Peace of mind
▪ Financial protection
▪ Control in health care options
▪ Ability to shop, compare and enroll online through
the Washington Healthplanfinder
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Let’s Review
▪ Health insurance terms
▪ Benefits of health insurance
▪ Health insurance plan types
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Knowledge Check
What is the definition of Estimated Premium?
A. The percentage owed for each visit to a provider
until the deductible is met.
B. The co-payment required until the maximum out
of pocket expenses are met.
C. A deductible.
D. The amount of money paid monthly for health
insurance coverage. This does not include any
out-of-pocket health care expenses.
E. All of the above.
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Knowledge Check
What is health insurance?
A. Health insurance is a contract between an
individual and an insurance company.
B. Health insurance is something bought to protect
against fire.
C. Health insurance can be “sold” by a Navigator or
In-person Assister.
D. Health insurance is required for all dogs and cats.
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Knowledge Check
Starting ____________, all individual and small
employer health plans must include 10 essential
health benefit categories.
January 1, 2014
October 1, 2013
March 31, 2013
December 15, 2014
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Knowledge Check
What is the Individual Mandate?
A. Every United State’s citizen and legal resident
(with no exceptions) must have qualifying health
care coverage or pay a penalty.
B. Every United State’s citizen and legal resident
(with some exceptions) must have qualifying
health care coverage or pay a penalty.
C. Individuals are mandated to have fire insurance.
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Knowledge Check
This is the amount you and/or your family pay each
policy period before your health plan starts to pay for
covered services.
A. Co-Insurance
B. Co-Payment
C. Premium
D. Deductible
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Knowledge Check
It’s the end of the year, 2014. I am an individual
adult that decided not to get qualifying health care
coverage. What is the minimum penalty I will be
assessed.
A. The cost of one year’s worth of premiums based
on a bronze level plan.
B. The cost of one year’s worth of premiums based
on a silver level plan.
C. $95
D. The cost of one year’s worth of premiums based
on a gold level plan.
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Knowledge Check
In a HMO an individual must seek care from…
A. Any provider they wish.
B. An In-Network provider.
C. A provider they’ve seen in the past.
D. The provider that is closest to the individual’s
home.
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Knowledge Check
Which of the following is not a characteristic of a
PPO?
A. They provide a Contracted Preferred Provider List
B. Out of pocket costs are lower when an insured
individual uses providers from the Contracted
Preferred Provider list.
C. Insured must use In-Network providers.
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Knowledge Check
An individual policy has a $200 yearly deductible and
a 30% coinsurance. This individual is not eligible for
any cost sharing reductions. The individual has not
been feeling well and decides to go to the Dr. for the
first time. Will the individual have any out of pocket
costs and if so, what will they be?
A. This individual is responsible for the first $200 of
the bill.
B. This individual is responsible for the first $200 of
the bill plus 30% of anything over $200.
C. Nothing. This is what they bought health care
coverage for.
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Knowledge Check
In the previous scenario the maximum out of pocket
expense the insured is responsible for is $2000. The
insured has been very ill and needs to go back to the
Dr. for further treatment. The insured has paid
$1900 out of pocket to date. They have already met
their $200 deductible. This Dr. visit is $200. How
much will this visit cost the insured?
A. $100
B. $60
C. $40
D. $200
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Knowledge Check
The insured has met their Maximum Out of Pocket
expense. They go to the Dr. and receive treatment
that is not a covered service. What amount of the
bill will they be responsible for?
A. $200
B. 30%
C. All of it. The service was not covered
D. None of it. This is why they purchased health
care coverage
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Knowledge Check
The insured has met their Maximum Out of Pocket
expense. They go to a Dr. and receive treatment for a
covered service. The bill is $173.50. How much of
this bill is the insured responsible for?
A. $17.35
B. $52.05
C. $173.50
D. Nothing
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Knowledge Check
Which of the following is not included in cost sharing
reductions?
A. Co-payments
B. Co-insurance
C. Premiums
D. Deductibles
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Questions
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Congratulations! You have completed
Insurance 101 course!
Thank you!
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