UNDERSTANDING HEALTH INSURANCE AND YOUR OPTIONS

1. UNDERSTANDING HEALTH INSURANCE AND YOUR OPTIONS

2. HEALTH INSURANCE BASICS Presented by [insert organization’s name]

3. What do I need? What can I afford? What is included in the plan? How does the plan work? Does the network of providers meet my needs? When shopping for a plan, ask: 1

4. Where can you get insurance? • Your employer. • On your own. • Groups associated with employment. • Membership organizations. • State or federal government. 2

5. Health Plan Comparison 3

6. Important Parts of the Plan to Review • Doctor Participation – Does your doctor participate in the plan? • Coverage – Does the plan provide coverage for both routine care and major medical coverage (catastrophic illness) or only major medical? • Premium – How much will the insurance cost you? • Co-pays – How much will you have to pay when you go to the doctor? 4

7. Deductible – How much will you have to pay each year toward medical expenses before the insurance begins paying claims? Preauthorization – Does the health insurance company need to approve care or treatment before you receive it? Pre-existing conditions – Does the plan cover your pre-existing condition? Exclusions – Review what is not covered by the plan. Limits – Is there a maximum dollar limit on how much the plan will pay? Important Parts of the Plan to Review (continued) 5

8. 10 Questions to ask yourself before choosing a plan

9. Questions to Ask • Is the insurance company or agent selling the plan licensed by the Pennsylvania Insurance Department? • Is the company that offers the plan financially sound? • Will you be covered for care in an emergency situation or when you’re out of town? • Is it a discount health plan or an actual health insurance plan? • What degree of coverage will you receive? 6

10. Questions to Ask (continued) • What are the real costs of the plan? • Are the doctors, hospitals, laboratories and other medical providers you use included in the network? • Do you have to choose a primary care physician? • Do you need to get a referral before you see a specialist? • Are the prescription medicines that you use covered by the plan? 7

11. For more information on health insurance, please visit www.PAHealthOptions.com. 8

12. A Quick Guide to Medicare & Medigap 9

13. What is Medicare? Federal health insurance program • Ages 65 & older. • Younger than 65 with certain disabilities. • Any age with permanent kidney failure (End-State Renal Disease). Must be legal U.S. resident for five years Two types of Medicare Coverage: • Original Medicare. • Medicare Advantage Plans. 10

14. Original Medicare Medicare Part A • Hospital Insurance - Hospital, skilled nurse facility, hospice or home healthcare. • You may be automatically enrolled, but sign up as soon as you are eligible. Medicare Part B • Medical Insurance - Doctors, healthcare providers, outpatient care, durable medical equipment, home healthcare and preventative services. • Sign up as soon as eligible – avoid late enrollment fee. 11

15. Original Medicare (continued) You will need to sign up on your own if: • You are not receiving Social Security or Railroad Retirement Board (RRB) benefits. • You qualify for Medicare because you have End-Stage Renal Disease (ESRD) 12

16. Original Medicare (continued) You should apply for Medicare Part A and Part B three months before your 65th birthday. You can apply: • Online at www.socialsecurity.gov/medicareonly. • In person at your local Social Security office. • By phone at 1-800-772-1213. (If you worked for a railroad, call the RRB at 1-877-772-5772.) 13

17. Medicare Advantage Plans • Medicare plans that are run by private insurance companies. • Combine Medicare Part A and Part B in one plan. • Also called Medicare Part C. 14

18. Medicare Part D Medicare Part D is prescription drug coverage. • Some Medicare Advantage plans include Part D. • If covered by Original Medicare, you may purchase Part D coverage through a Medicare-approved prescription drug plan (PDP). 15

19. Medicare Quick Recap • Medicare Part A is hospital insurance. • Medicare Part B is medical insurance. • Medicare Part C is a Medicare Advantage Plan. • Medicare Part D is prescription drug coverage. 16

20. For more information on Medicare, please visit www.Medicare.gov. 17

21. Medigap (Medicare Supplemental Insurance) • Private health insurance option that helps fill gaps in Medicare coverage • You must have Original Medicare to purchase Medigap • Medicare Advantage Plans (Part C) are ineligible 18

22. Medigap Plans How to read the chart: If a check mark appears in a column of this chart, the Medigap policy covers 100 percent of the described benefit. If a row lists a percentage, the policy covers that percentage of the described benefit. If a row is blank, the policy doesn’t cover that benefit. Note: The Medigappolicy covers coinsurance only after you have paid the deductible (unless the Medigap policy also covers the deductible). • Source: Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare, Developed jointly by the Centers for Medicare & Medicaid Services (CMS) and the National Association of Insurance Commissioners (NAIC), 2012. • *Plan F also offers a high-deductible plan. If you choose this option, this means you must pay for Medicare-covered costs up to the deductible amount before your Medigap plan pays anything. • **Plans K and L have out-of-pocket annual limits. After you meet your out-of-pocket yearly limit and your yearly Part B deductible, the Medigap plan pays 100 percent of covered services for the rest of the calendar year. • ***Coinsurance is covered except copayments are required for certain office or emergency room visits. Review the plan carefully to understand the details. 19

23. Medigap. How much does it cost? • Each insurance company’s rates are different, but you’ll pay a monthly premium. • Policy pricing: • Community-rated • Not based on age • Same premium charged to everyone • Issue-age-related • Based on age when you buy policy • Attained-aged-related • Premium based on current age and rises with age 20

24. Medigap: Open enrollment (continued) • Starts the first day of the month in which you began Medicare Part B benefits & lasts for six months • Different than Medicare Advantage Plan open enrollment • The insurance company can’t consider your health status (use medical underwriting) to: • Refuse to sell or charge you more • Make you wait for coverage to start • Likely to receive the best rates at this time 21

25. Medigap (continued) For more information on Medigap, visit www.PAHealthOptions.com to download Your Guide to Choosing a Medigap Policy. 22

26. If you’d like to learn more about health insurance, visit www.PAHealthOptions.com