3 rd ) Examples from the Onsite /Hospital Navigator Resource Library

1. 3rd) Examples from the Onsite/Hospital Navigator Resource Library Thru employer specific meetings, build data base of insurance plans, how to read the EOB, deductibles, etc. 1 on 1 intervention with the patient/family – complete work paper Create glossary of terms Create reference guide for additional community resources Create networking ‘handoffs’ with existing hospital team - payment options, social work, estimates, patient experience, physician offices, others Innovation Lab: After Hours Q&A – Weds 5:00 -6:00 p.m.; using patient portal; tracking and trending improvements/feedback; integration with medical community; face to face and automation. Volunteer staffing plus a full time Manager and an unpaid Director/Foundation PFNF Education

2. Think like the family who is scared with a new ER visit w/insurance, employer specific • Daughter has just been admitted thru the ER. (Inpt vs obs means what to the pt?) • Parents are scared and distraught about the health of their daughter with the unplanned ‘admit.’ • As comforting as the care givers are, the financial questions loom large. What happens now? • Who has insurance? What was done with the insurance? What is my coverage? “I have never had to use it before, so I don’t know anything! “ • Think Pt Financial Navigator Program referral PFNF Education

3. TODAY: Affordable Care Act 2010/ACA aka Obamacare.Previously = nothing similar. Mandates major medical insurance for all Americans. Exchange/Marketplace – Myidaho for any employer, self employments under 50 employees-usually ‘small.’. Allows for subsidies with premiums so lower income individuals can get insurance. Insurance companies are ‘made whole/or close to whole ‘ thru federal money/taxes. Rates are determined by the Insurance companies. Examples of under 50 employees who are not mandated to offer medical insurance. CPAs, builders, electricians, individual business owners, small businesses/2-50 employees, farmers, early retirees/prior to turning 65 PFNF Education

4. Affordable Care Act 2010created “ESSENTIAL BENEFITS” – Commercial Ins.*Only required for over 50 employees*coverage until 26, even if married*No pre-existing limitation*No limitation on coverage /capping out Only employers with 50 employees must offer insurance +Pre-existing protection *Go to Idaho Exchange/less 50 +Children covered until 26 PFNF Education

5. Short Term Health Insurance – 4 things to know (Becker Hospital Review 8-18) • Administration released FINAL rule for short term health insurance plans/STP. Open ended with coverage. • Previously could only offer 3 months, now can last up to 3 yrs. • 1) STP do not have to abide by the rules by the ACA requiring coverage of essential health benefits and pre-existing protection. Nor do they have to abide by insurance plans imposing limits on how much care is covered or the requirement that at least 80% of premium money go toward care. • 2) Not abide by ACA, STP do not cover as much as more comprehensive plans. They tend to not cover: maternity, prenatal care, mental health, drug treatment and prescription drugs. May not cover sports injuries and other specific services like cataract treatment, immunizations, and chronic fatigue or pain treatment. • 3) Some do not cover $250,000 - $2M. Others only covered inpt on weekdays, others with waiting periods. • 4) Generally they are cheaper than the ACA plans. Kaiser study found ex) 40 yr old single man in Atlanta was $371/ACA compared with $47 for STP. • BUYER BEWARE! Less coverage = more out of pocket if healthcare is used. PFNF Education

6. Medicaid –Coverage for low income 2016- 76M low income; 32 states expanded State specific programs –tax based with matching federal funds Covers 1 in 5 Americans including many with complex and costly needs for care. It is the principle source/payer of long term care. 6 in 10 are pd by Medicaid- after all resources are ‘spent down.’ Covers: 76% of poor children; 48% of children with special healthcare needs; 50% of births: 45% of nonelderly adults with disabilities-such as autism, traumatic brain injury, serious mental illness, & Alzheimer’s disease. 1 in 5 low income seniors receive help with their Medicare premiums and cost-sharing. Most eligibility is based on Federal Poverty Level. US Census Bureau poverty threshold/2016: two adults & 1 child= $19,318 yr income Kaiser Family Foundation 2018 PFNF Education

7. How many Srs are still working past retirement age? • Only about ½/50% of all employees are covered by a retirement plan. • Recent study by Bankrate.com: • 70 % of non-retired Americans plan to work as long as possible during retirement. • 2% say they have NO plans to work during retirement. • Of those who plan to work as long as possible, 38% say its because they like to work, 35% need the money, and 27% say it’s a mix. • Largest # of working after retirement since 1965. • Medicare as Secondary payer – after age 65 – but still working and covered by major commercial insurance. PFNF Education

8. CMS advocating Comparisons of charges. 11-18 JAMA Internal Medicine Study/9-18 = Only 21% of hospitals had the ability to provide a complete hospital price estimate for a common procedure. CMS has created an online pricing comparison tool for outpt procedures. Part of Exec Order to Increase Choice and Reduce Cost. Medicare.gov. It compares average prices for a procedure in BOTH ambulatory surgery centers and outpt hospital departments. EX) Input name= Release and/or relocation of median nerve of hand. Pt pays: $157 ASC or $322 in hospital Medicare pays: $628 ASC vs $1289 in outpt hospital. Disclaimers: no physician fees are included, treatment may include additional procedures, ask your doctor. PFNF Education

9. The Healthcare Nation at a Glance • CMS/Medicare will cancel major bundle payment initiatives – Cardiac • LA hospital to close, laying off 638 employees • At least 26 non-profit hospitals at risk of bankruptcy. • Tenet/for profit to close 232-bed Phoenix hospital • 450 Hospitals at risk of closure. 15% have weak financials. Morgan Stanley 8-18 • CHI’s operating loss swells to $585M in FY 2017 • Hospital operating margins dropped 39% in 3 yrs. Expenses grew by 3% more than income. • 20 bed critical access hospitals in NC to close Dec 31, 2017 • Healthcare bankruptcies more than TRIPLE in 2017 • 89 RURAL hospitals close in 2018 –so far. • CA hospital files for bankruptcy after missing payroll PFNF Education

10. Idaho’s Rural Community Hospitals8 of 27 hospitals are financially viable, per IHA, 2018 PFNF Education

11. Welcome to the Patient Financial Navigator Foundation, Inc. “MEDICARE 101” PFNF Education

12. Clarifying:Medicare = Assistance with Medical costs after 65 Social Security Benefits = Monthly payments- 62/early or 65/66/67+ PFNF Education

13. Social Security History The Great Depression Oct 29, 1929-1939 Social Security Act signed by FDR on Aug 14, 1935 Taxes were collected starting Jan 1937 First payments made 1940. PFNF Education

14. Who is paying …. Today’s workers help pay for current retirees; not their own future benefits. • Money collected per paycheck under “Medicare’ does not go into your personal savings account with your name on it for when you need it. • Same for Social Security taxes • Current recipients of SS and Medicare are using current money being withheld. • BABY BOOMERS ARE HERE! PFNF Education

15. Social Security Check will get a 2.8% boost in 2019 • The Social Security Administration announced that the cost-of-living adjustment for 2019 will be 2.8 %. *$35 approx. • In 12 years/2030 – 1 in 5 Americans will be of retirement age/65. • By 2035, those over 65 and older will outnumber those under 18 by about 2 mil. • Only about ½/50% of all employees are covered by a retirement plan. • Recent study by Bankrate.com: • 70 % of non-retired Americans plan to work as long as possible during retirement. PFNF Education

16. Introduction What Is Medicare?Created 1965- tax funded • A health insurance program for • People 65 years of age and older • People under age 65 with certain disabilities • People with End-Stage Renal Disease (ESRD) • Administered by Centers for Medicare & Medicaid Services (CMS) (July 1965) • Enrollment by Social Security Administration (SSA) or Railroad Retirement Board (RRB)

17. Introduction Applying for Medicare • Apply 3 months before age 65 • Don’t have to be retired • Contact the Social Security Administration &/or.. • Enrollment automatic if receiving Social Security or Railroad Retirement benefits • Visit “MyMedicare.gov” to access your personalized Medicare information.

18. Introduction Traditional Medicare Medicare Basics Part A Hospital Insurance Part B Medical Insurance Outpt Hospital Services Part D Prescription Drug

19. Patient – New Medicare Cards- no longer SS# Between 4-18 and 4-19, New Medicare Beneficiary Identifier. MBI # will be a combination of numbers and uppercase letters. EX) 1EG4-TE5-MK72 Ensure address is current. SSA.gov/my account Transition period thru Dec 2019. BIG: Plan F & C Supplemental gone 1-20 for new pt . Change so pt pays more 1st $ - like Part B Deductible PFNF Education

20. Introduction Medicare Coverage Basics (See handout)

21. Introduction Medicare Part A • Most people receive Part A premium free- must have 40 worked quarters. 99% pay nothing • People with less than 10 years of Medicare (30-39 quarters)- covered employment $232 /2018 • Can still get Part A if worked less 30 quarter • Will pay a premium of $248/$441/$407/$411 per month/2012/13/15/16 $422 for 2018, $437 2019 • For information about Part A entitlement • Call SSA 1-800-772-1213/get signed up • Contact Medicare 1-800-663-4227; Medicare.gov

22. Introduction Enrolling in Medicare Part B • Pay monthly Part B premium • Base with higher amt based on income /beginning in 2007. $99.90 2012, down from $115 2011, $104.90/15&16. • Average monthly premium for Part B $134 per month 2017& 18, $135.50 2019. • Initial Enrollment Period (IEP) • 7 months starting 3 months before month of eligibility • General Enrollment Period (GEP) • January 1 through March 31 each year • Coverage effective July 1 • Premium penalty!! • 10% for each 12-month period eligible but not enrolled • Paid for as long as the person has Part B

23. Introduction Enrolling in Medicare Part B • Some people can delay enrolling in Part B with no penalty • If covered under employer or union group health plan. “Credible Coverage” • Based on current employment • Person or spouse (Called: Working Aged) • Will get a Special Enrollment Period (SEP) • Sign up within 8 months after coverage ends or retire or penalties

24. Introduction Paying the Part B Premium • Taken out of monthly payments • Social Security /SSA • Railroad retirement/RRB • Federal government retirement (Plan: Federal BX) • Income adjustments can impact the monthly premium. • For information about premiums –call who enrolled them • Call SSA, RRB, or Office of Personnel Management NOTE: There is help with premiums for low income seniors. Medicaid – Aid for Aged, Blind and Disabled.

25. Original Medicare Original/Traditional Medicare Plan – Medicare Costs • Go to any health care provider that accepts Medicare - nationwide • Patients are responsible for out of pocket amounts • Part A – Inpt deductible • $1156 deductible/2012 /$1184 in 2013/$1260 in 2015 , $1288 in 2016. $1316 for 2017; $1340 for 2018; $1364 2019 • Deductible is due every 60 days that the pt is out of the hospital. If out of the hospital/Part A for 60 days = another $1364 inpt deductible is due. If 2 admits within the same 60 day period = 1 -$1364 deductible for the 1st admit only. • Additional costs after 60 days if no break in services. Coinsurance days 61-90 $289 per day./$296 2013/$315 2015, $322 2016. • 91-150 Lifetime Reserve days $578 per day/$592 2013./$630 2015 ; $644 2016 • Pt pays 100% after 150 days without a 60 day break • $ amt increases each year for the additional days

26. Let’s make this real- Traditional Inpatient • Hospital billed for 4 day medical inpt stay. Billed Medicare $16,900. • Medicare pays a flat fee for the entire stay based on the diagnoses that were treated during the stay. *DRG • Hospitals are required to ‘accept assignment’ with inpt services and must absorb/write off all charges beyond the DRG payment with consideration of the $1364 inpt deductible. • The total payment from Medicare to the hospital: DRG payment *no consideration for charges* less the inpt deductible due every 60 days = Total payment from Medicare. All remaining charges are absorbed. EX) $16,900 DRG payment $10,000 --- from which the inpt deductible of $1,340 is withheld and collected from the pt TOTAL Medicare $ 8,660 ($10,000 - $1,364 = $8,636) 51% of billed charges Amount written off: $ 6,900 (difference between DRG payment and billed charges. Required)