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Understanding Health Insurance

Understanding Health Insurance. Making Sense from Confusion. Would You Take This Deal?. “I’ll give you $6,000, if you agree to pay 70% of my medical bills for the next 12 months”. What If It Was. 20,000 people X $6,000 = $120,000,000 & you pay 70% of their medical bills?.

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Understanding Health Insurance

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  1. Understanding Health Insurance

  2. Making Sense from Confusion

  3. Would You Take This Deal? “I’ll give you $6,000, if you agree to pay 70% of my medical bills for the next 12 months”.

  4. What If It Was . . . 20,000 people X $6,000 = $120,000,000 & you pay 70% of their medical bills?

  5. What would you want to know before you agreed? 2. What conditions or requirements would want to protect all that money?

  6. What Is Insurance? “ A small known loss to protect you from a large unknown loss”

  7. Insurance Provides Protection Home Money Health “Bankruptcies resulting from unpaid medical bills will affect nearly 2 million people this year—making health care the No. 1 cause of such filings”. Source: NerdWalletHealth, a division of the price-comparison website

  8. Insurance Is A Contract I will give you $XXX and you promise to pay $YYY. And, we have agreed to the following conditions or details.

  9. Premium The amount you pay each month to have health insurance.

  10. Deductible

  11. A Relationship Small Deductible Big Premium

  12. Copay A fixed amount (for example, $25) you pay for a covered health care service, usually when you get the service.

  13. Co-Insurance The amount you pay after you have met the deductible amount for a covered service, calculated as a percent (for example, 20%) of the allowed amount for the service.

  14. Levels of Coverage Co-Insurance Premium $ $$ $$$ $$$$ When you get care $$$$ $$$ $$ $

  15. Out of Pocket Limit The most you pay during a policy period (usually a year) before your health insurance begins to pay 100% of the allowed amount. The maximum out-of-pocket costs for any Marketplace plan for 2016 are $6,850 for an individual plan and $13,700 for a family plan.

  16. Claim A request for payment that you or your health care provider submits to your insurance company when you get items or services you think are covered.

  17. Free Preventive Care All Marketplace plans and many other plans must cover preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible. Preventive care is care you receive when you're healthy and symptom-free, such as routine check-ups, screenings and immunizations.

  18. Mixed Family Status If Salma and Jimmy were married and had kids Brooklyn, New York Coatzacoalcos, Mexico

  19. Review https://www.youtube.com/watch?v=sBxLmKBqa60 https://www.youtube.com/watch?v=kT3H9pBP8fg https://www.youtube.com/watch?v=ai38NtMyJwk

  20. Progress Check Handout: Match the Definition to the Term by writing the letter of the correct definition in front of the correct term. Terms ____ Premium 2. 3. Definitions A. B. C.

  21. Provider Network • Insurance plans do not include all doctors and hospitals. • Providers that are contracted with your insurance plan are said to be in network. • If you use a provider outside of your network you will pay more. • If you use a provider outside of your network the insurance company will pay less of the bill.

  22. Know Your Network If you use a provider outside your “Provider Network” you will pay more.

  23. Using Your Insurance Primary Care Provider Urgent Care Emergency Room

  24. Where to Get Care • Urgent Care • Open more hours • No appointments • Don’t know you • $$$ • Emergency Room • Open 24/7 • No appointments • Don’t know you • $$$$$ • Primary Care Provider • Understand your history, conditions and prescriptions • They know your insurance • $$$

  25. Important Tools

  26. Three Affordability Programs 400% FPL $79,160 (3 people) 250% FPL $49,475 (3 people) 138% FPL$27,310 (3 people) 3. Premium Tax Credits MarketplaceFinancial Assistance AHCCCS 2. Cost Sharing Reduction 1. Medicaid AHCCCS

  27. Be Careful!

  28. Summary of Benefits and Coverage

  29. Do It Your Self AHCCCSwww.healthearizonaplus.gov Marketplacewww.healthcare.gov

  30. Key Ideas The amount I pay each month - premium The amount I pay before the insurance company starts to pay - deductible The amount I pay when I see a provider - copay The amount I pay before the insurance company pays 100% - out of pocket limit Providers who are contracted with my insurance plan – are in my provider network Where I find information - healthcare.gov, summary of benefits and coverage, provider directory and list of covered drugs Where can I find local help?

  31. Finding Help Talk with a Navigator 1-844-790-4946 or 602-218-3900 English or Spanish • www.coveraz.org

  32. Q & A Allen GjersvigDirector Healthcare Innovation alleng@aachc.org602.288.7554

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