S H I B A HelpLine Statewide Health Insurance Benefits Advisors Health Insurance 101:

1. S H I B AHelpLine Statewide Health Insurance Benefits Advisors Health Insurance 101: Taking the “Huh?” out of health care coverage Especially for those with Traumatic Brain Injury, their families, friends, caregivers, and supporters Sponsored by the 03/31/2011

2. Hello and welcome! Who are we? • Audrey Pitchford, Curriculum Writer AudreyP@oic.wa.gov360-725-7107 • JoAnn Ehlers, Regional TrainerJoAnnE@oic.wa.gov509-633-3788 • We welcome your questions!  03/31/2011

3. What is the SHIBA HelpLine? • Statewide Health Insurance Benefits Advisors (SHIBA) • Free service of the Consumer Protection Division at the Washington State Office of the Insurance Commissioner (OIC) 03/31/2011

4. What is the SHIBA HelpLine? • Network of folks around the state: • 15 staff • 20 sponsors • About 450 volunteers • Multiple partner agencies • Unbiased – not part of an insurance company, not selling any product 03/31/2011

5. What does the SHIBA HelpLine do? • Helps folks of all ages, from all walks of life: • Understand health care coverage options, benefits and bills • Access coverage and apply for some programs that may help with costs 03/31/2011

6. What does the SHIBA HelpLine do? • Helps folks know what steps to take if a bill is denied • Reports complaints and possible fraud for review and investigation • Provides information so folks can make the best decisions for themselves 03/31/2011

7. Why do folks contact SHIBA? • Uninsured or underinsured • Problem with insurance or want to change coverage – such as during Medicare Part D open enrollment • Questions about how insurance works • And so on! 03/31/2011

8. Real SHIBA case: • Divorced dad called SHIBA – his minor-age son fell while visiting from out-of-state • Concussion + broken leg • Surgery on leg + overnight in hospital for head injury observation • Dad thought son’s mother had coverage for kids but she did not • Bill: Over $17,400 03/31/2011

9. Real SHIBA case (cont’d): • Dad’s on Medicare due to disability and has a fixed income, can’t pay • SHIBA helped identify options: • DSHS/state Medicaid (denied) • Charity care (granted) • Provider reduced bill to $3,300 • Dad was able to set up an affordable payment plan for balance 03/31/2011

10. How do folks contact SHIBA? • Toll-free: 1-800-562-6900 (ask for SHIBA!) • Web: www.insurance.wa.gov 03/31/2011

11. How do folks contact SHIBA? 03/31/2011

12. Our sponsors, volunteers and partners here today: • Many folks make SHIBA happen! • We couldn’t do it without our sponsors and volunteers!  • We also have partners in the community who help us out. • Let’s take a moment and meet everyone! 03/31/2011

13. How you can help us! • Please complete the pink Optional Comments Page! • We are not experts on Traumatic Brain Injury (TBI)! We will learn from you today as well! • We always need more partners and volunteers, especially folks with a specialty or area of focus. • Want to join us? 03/31/2011

14. Today’s agenda: • Explain what SHIBA is/what we do • Presentation: How insurance works and preventing problems; health care coverage options available • Time for individual counseling 03/31/2011

15. How is health insurance supposed to work? • Folks pay a monthly amount (premium) to have health insurance. • If folks with health insurance have a medical need or problem, they usually do not have to pay all costs for their medical care. 03/31/2011

16. Insurance and serious conditions such as TBI • Some diagnoses (medical conditions) cause insurers to look for other sources of payment (such as homeowners, drivers, job, liability, etc.). • Insurers may investigate whether other sources will pay first. 03/31/2011

17. Case studies: We want to hear from you! • What insurance, if any, was there for the injury? • Were there problems with getting care or getting bills paid? • What was the financial impact? • What were or are the impacts on or issues for family or caregivers? 03/31/2011

18. How is health insurance supposed to work? • Often, understanding how health insurance works can help you avoid unnecessary bills. • Let’s talk about this next. 03/31/2011

19. How is health insurance supposed to work? • Many times health insurance doesn’t pay the full amount the doctor’s office bills. • Most folks want to know: Who pays the leftover amount? It depends! • Let’s learn about: Allowable Charges 03/31/2011

20. Allowable Charges • Goal: Save insurance plans and patients $$$! • Insurance plans enter contracts with providers. All contracts vary! • Contracts set Allowable charge for every medical service – the maximum dollar amount/percent: • Plan pays provider, and • Provider may collect from patient 03/31/2011

21. Allowable Charges • Providers in contracts with the plan are Participating Providers • Plans often pay most of the Allowable Charge • Patients often must pay a smaller share of the Allowable Charge • Copay = Fixed amount (Example: $25) • Coinsurance = Percent (Example 20%) 03/31/2011

22. Allowable Charge Example • Doctor bills plan = $100 • Plan contract says Allowable Charge = $60 • Who pays what on that bill? • Doctor writes off (can’t collect) = $40 • Plan pays 80% of AC = $48 • Patient’s coinsurance 20% = $12 • Bill is considered “paid in full” 03/31/2011

23. Participating Providers • Providers who sign a contract with the insurance plan • Going to them saves you money! • Before you get care, Rx’s, etc., ask providers if they take your plan: • Including Medicare and Medicaid • Not all providers take all plans! • If not, you could be stuck with the bill! 03/31/2011

24. Who has ultimate responsibility for the bill? • The Guarantor, who is usually: • The patient (if age 18+) • The parent or guardian (for minors) • Sometimes, other sources (see next slide) 03/31/2011

25. Who has ultimate responsibility for the bill? • The Guarantor may be: • L&I: on-the-job injuries • L&I: Crime Victims Comp. Program • Auto policy: motor vehicle accidents • Homeowners, business, etc: other injuries (such as slips/falls, etc.) • Employer: job-required exams (such as hearing tests, CDL, etc.) 03/31/2011

26. Who has ultimate responsibility for the bill? • If it is not you, be sure your doctors have information about Guarantor: • Full legal name and address • Birth date and Social Security No. • Claim number and policy number • Name of employer and billing info If info is missing or the other source doesn’t pay, bills may go to you! 03/31/2011

27. Who has ultimate responsibility for the bill? • If you have more than one plan or type of coverage: • Tell your plans about each other! • Complete and turn in to your plan the plan’s Coordination of Benefits forms (which coverage pays 1st or 2nd) If info is missing, you may get bills or delays in coverage! 03/31/2011

28. We suggest you know for each plan you have: • Plan billing address and phone • For each person your plan covers: • Full name and date of birth • Policy number and group number • Social Security Number • Current address and phone number • Employer’s name, address and phone 03/31/2011

29. We suggest you know for each plan you have: • Who is the: • Guarantor: responsible for the bill • Subscriber: person who carries the insurance (example: person with insurance through their job) • Patient: receiving the health care This may be one person, or several people! 03/31/2011

30. We suggest you know for each plan you have: • If you have more than one plan: • Primary:which pays first? • Secondary: which pays second? • Rules vary! There are exceptions! • Let’s see some examples…. 03/31/2011

31. Primary or secondary? • Medicare: May be primary or secondary to other insurance • Medicaid: Always secondary to private or employer plans • Crime Victims Compensation Program: Always secondary 03/31/2011

32. Primary or secondary? • Children covered by both parents: Parent with first birthday in the year has the primary insurance • Couples: If both partners cover each other, their own insurance is primary and their spouse’s is secondary 03/31/2011

33. We suggest you know for each plan you have: • Premium: Your plan’s monthly cost • Deductible: What you must pay out-of-pocket before the plan pays • May be for one person or the family • Usually per calendar year • Medicare hospital: per benefit period (restarts after 60 days out of hospital) These may change every year! 03/31/2011

34. We suggest you know for each plan you have: • Copayment (copay) or coinsurance: • Usually one or the other • Copay: usually a flat fee per service or appointment (such as $25) – you pay when you check in • Coinsurance: Usually a percentage (such as 20%) of the Allowable Charge These may change every year! 03/31/2011

35. Short exercise • If you wish, and you have your plan card or cards with you, you may take them out now. • You don’t have to show them to anyone! • In fact, please keep them private to protect your personal information! 03/31/2011

36. Short exercise • Does your card have the information we’ve talked about? • Full name and date of birth? • Subscriber name (if not you)? • Policy number and group number? • Name of plan? Billing address? Customer service phone number? • Premium, deductible, copays, or coinsurance? 03/31/2011

37. Short exercise • Your card likely does not have all this information on it! • We suggest you know information from the last slide, in case there are issues or problems. • Also, do you get a new card every year? When you do, destroy last year’s card! 03/31/2011

38. We suggest you know for each plan you have: • Plan-covered services (what the plan will pay for) • Non-covered or excluded services (what the plan won’t pay for) • Your plan benefits booklet or Certificate of Coverage lists these These may change every year! 03/31/2011

39. Sample • Placeholder – benefits booklet page on covered services 03/31/2011

40. Sample • Placeholder – benefits booklet page on excluded services 03/31/2011

41. We suggest you know for each plan you have: • Which providers you may go to, such as participating providers • Whether the plan covers care with non-participating providers (not contracted with the plan) • How do you get these bills paid? These may change every year! 03/31/2011

42. We suggest you know for each plan you have: • Timelines that affect you: • When can you access your benefits? • When can you make changes to your benefits? These may change every year! 03/31/2011

43. Places to find answers: • Your plan benefits booklet or Certificate of Coverage • Your plan benefits card, customer service phone or plan website • Your plan administrator or for job-based plans, the HR office • Coming up next: Billing cycle 03/31/2011

44. Billing cycle of a doctor visit: • Make your appointment. Tell scheduler what you need – don’t assume doctor sees this! Put the date and time in your calendar. • Get ready. Write down questions or invite a support person. If you need a specific service, bring your benefits book or other information. 03/31/2011

45. Billing cycle of a doctor visit: • Check in. Ensure front counter staff have your current insurance (they may copy your plan card and ID). If needed, pay copayment (copay). • Nurse calls you in. Tell the nurse why you’re there – don’t assume the doctor sees this! Nurse takes your vital signs. 03/31/2011

46. Billing cycle of a doctor visit: • See the doctor. Make sure the doctor knows what you need. Ask your questions. Take notes if needed. • Doctor decides diagnosis, treatment and level of care provided in today’s visit. 03/31/2011

47. Billing cycle of a doctor visit: • Medical records staff and billing staff convert diagnoses and treatment into billing codes. • Office staff bill insurance using the codes. “Errors” in some steps may cause your plan to deny the bill! 03/31/2011

48. Things to know about billing codes: • Some diagnoses (for certain injuries and accidents) trigger insurance plans to send you a form. • The form may ask questions to verify who is the guarantor, which insurance is the primary payer, etc. 03/31/2011

49. If everything goes right in the billing process: • Your plan will determine the Allowable Charges. • The plan pays their part of the bill. • The plan sends you an Explanation of Benefits (EOB). • Not a bill – don’t pay yet!! • Shows what plan paid • States your share of costs 03/31/2011

50. Sample 03/31/2011