Healthcare 101

1. Healthcare 101 Understanding the healthcare system and your health insurance

2. What is health insurance? • It insures us against the risk of incurring medical costs. • Insurance companies look at the likelihood of a group of people getting sick and healthcare expenses to decide on a routine payment structure (monthly premium) • This premium ensures that money is available to pay for the healthcare expenses of someone in an insured group. 2014 CNMI Consumer Assistance Program with thanks to Families USA

3. Why do I need health insurance? “I never get sick. Why do I need to pay for something I don’t use?” • It entitles you to discounted rates • Insurance companies negotiate rates with hospitals and clinics. • Without coverage, the fee charged for a regular office visit can be twice as high. • It protects you from unexpected medical costs • Even if your health plan requires you to pay certain costs out of pocket, being covered can help save you from bankruptcy in case of injury or hospitalization. • It improves your access to quality care • As a member of a health insurance plan, you have access to a broad network of health care providers. • It provides you critical care • While uninsured patients will often get emergency-room care and be billed afterwards, they may not get important treatment for a life-threatening chronic condition without an upfront payment. • It encourages a healthier lifestyle • You may be more likely to take advantage of regular checkups and preventive care if you know it won’t cost you an arm and a leg. And thanks to the Affordable Care Act, most preventive care services must be freewith every health insurance policy. 2014 CNMI Consumer Assistance Program with thanks to Families USA

4. Health insurance options in the US • In the CNMI, there are both public and private options for health insurance coverage • Public: Medicaid, Medicare, CHIP, Veteran’s Affairs • Private: Employer-sponsored insurance, Individual market (Aetna, Staywell, Calvo’s etc.) 2014 CNMI Consumer Assistance Program with thanks to Families USA

5. Public Health Insurance • Medicaid A program designed for the low-income and disabled. • Financed jointly by the states (or territories) and the federal government through taxes. • Medicare A federal program that covers individuals aged 65+ and some disabled individuals. • Financed by federal income taxes, a payroll tax shared by employers and employees, and individual enrollee premiums (parts B and D only) • Other public systems CHIP (Children’s Health Insurance Plan) and Veteran’s Administration • CHIP was designed to cover children whose families make too much to qualify for Medicaid, but too little for private insurance. Shares similar structure with Medicaid. • VA is a federally administered program for veterans of the military. Healthcare is delivered in government-owned hospitals and clinics and offers very cheap, if not free, care to veterans. 2014 CNMI Consumer Assistance Program with thanks to Families USA

6. Private Health Insurance • Employer-sponsored Insurance • Employers provide health insurance as part of the benefits package to employees • Financed by both employers and employees. Employers usually pay the larger part of the premium and the employees pays the remainder. • These are plans in the small group and large group insurance market. • Individual (non-group) insurance • A health insurance policy purchased without your employer getting involved – for yourself or your family. • Usually for those who have no employer-sponsored options, are self-employed, or the employer-sponsored option is getting too expensive 2014 CNMI Consumer Assistance Program with thanks to Families USA

7. What costs do I need to pay? • If you are not eligible for public health insurance, it’s important to know that there are different costs associated with health insurance. • Premium- The money you pay the insurance company (usually every month or pay period) • Deductible- The amount of money you need to pay before your insurance starts paying for care. • Like car insurance, many plans require a certain “out of pocket” cost before coverage kicks in. • For example, if your deductible is $300, you have to pay the first $300 of medical costs before the insurance starts paying. 2014 CNMI Consumer Assistance Program with thanks to Families USA

8. What costs do I need to pay? • Copay/Co-insurance- The money that you may have to pay “out of pocket” for each service you receive. • These services may include doctor’s visits, x-rays or prescription. • If the money you may is a set amount (for example $15 for a doctor’s visit), it is called a copay. If the money you pay is a percentage (20%) it’s called co-insurance. • Maximum out-of-pocket limit- This is the most you will have to pay each year for care covered by your plan. • When you hit your limit, your insurance starts paying for all of your covered costs. 2014 CNMI Consumer Assistance Program with thanks to Families USA

9. What are some important things to look for when shopping for health insurance? 2014 CNMI Consumer Assistance Program with thanks to Families USA

10. Premium price is not always the most important factor • Different plans have different rules about how you can get the health care you need and still have your medical costs covered. • It’s important to know these rules to make sure you get the benefits of your health insurance and save money. • Because insurance companies negotiate rates with hospitals and clinics, “networks” are developed based on your insurance company’s rates with a given health provider (hospital, clinic, etc.) • Most insurance companies will charge higher rates if you go to a hospital or clinic outside of their network. 2014 CNMI Consumer Assistance Program with thanks to Families USA

11. Types of Provider Networks • Preferred Provider Organizations (PPOs) • Plans that usually cover some of the costs you get outside of their network, but you will probably have to pay more for service. • Health Maintenance Organizations (HMOs) • Plans that usually cover only care that is provided within their network. • They often require you to pick a “primary care doctor” to go to for regular visits (like a family physician) to get permission or a “referral” to see a specialist. 2014 CNMI Consumer Assistance Program with thanks to Families USA

12. What to consider when choosing your plan • Don’t just look at the “sticker price”. Consider all the costs and benefits related to the insurance you’re getting. • Usually, a lower premium means a higher deductible, and a higher premium means a lower deductible. • Some plans have separate deductibles for different services. • Remember that there may also be differences in copays and co-insurance • Don’t assume deductibles or copays are the only difference between plans 2014 CNMI Consumer Assistance Program with thanks to Families USA

13. What to consider when choosing your plan • Be sure to check that the plan covers the prescription drugs you take and at what price • Remember that most plans have provider networks you need to use to get the lowest-cost care. • Make sure these providers work for you • Most importantly….READ AND UNDERSTAND YOUR PLAN’S RULES AND BENEFITS 2014 CNMI Consumer Assistance Program with thanks to Families USA