The Industry_MFA Thesis_AAU

1960

1950

1970

1980

1990

the

INDUSTRY health insurance

01

02

03

04

THE INDUSTRY

by CareAware

05

UPPORT NCOURAGE DUCATE

000 INTRO careaware the mission

001 HEALTH INSURANCE the difference timeline how it works the dollar

002 THE CONSUMER your engagement before buying basic rights

003 THE PROVIDERS provider network out-of-network be prepared

004 THE SUBSIDIZED who are the subsidizers medicaid chip aptc

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What if I had looked into getting better health insurance?

�

SAMI LUKENS BFA Student 24 years old Wisconsin Student Insurance

THE INCIDENT While in college I was attending my friend’s graduation party during a gorgeous summer afternoon. It was one of those perfect afternoons. I was sitting at a picnic table drinking a beer near the edge of the lake I planned to take full advantage of later on.

While in mid-conversation with my friends I heard panicked screams from the crowd, and a split second later my body went numb.

What Happened?

That July afternoon I learned that I was not invincible.

A young man had carelessly jumped his jet ski onto land, losing control while sliding on slippery grass and stone.

Though he killed the engine the jet ski struck me in the back, an inch from my spine at roughly 25 mph.

Doctors proclaimed it a miracle that I was even able to walk away from the freak accident with only sciatic nerve damage, something I will deal with the rest of my life. Well that and of course the $14,000 medical bill that caused me financial frustrations.

Medical Bills $14,000

Court Case won, 2009

Coverage $7,000

Collected $0.00

Debt Owed $7,000

09

001

WHO WE ARE 002

WHY WE DO IT 003

WHAT WE DO

14 %

THE PROBLEM Dr. Loewenstein’s research showed that only 14 percent of individuals who held health insurance actually understood it.

Yet we are now asking 34 million people in the United States who are currently uninsured—as of 2014—to be able to not only understand it, but to successfully obtain health insurance.

OUR MISSION CareAware’s mission is to simplify health insurance information so individuals can now make an educated decision when purchasing their health insurance plan.

001

Educate

002

Support

003

Encourage

CAREAWARE.US Here individuals are able to access important health insurance information that is now broken down and simplified. They will be able to easily digest and internalize the massive amount of important content.

Our main focus is to empower them to make an educated decision when buying health insurance.

Through strong visuals, plain language, real world scenarios, and gamification it is our goal to simplify the complexity of health insurance.

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CareAware was created with the intention of helping to close the knowledge gap that currently exists between individuals and health insurance.

Sami Lukens an MFA Design graduate from

While concluding her research including

the Academy of Art University in San Francisco

the study by Dr. Loewenstein, Sami was able

developed CareAware in 2015.

to identify a major problem.

The idea sparked while working on her initial

With the new health insurance mandate that

thesis research when she came across a study

recently came into effect in 2014, millions of

by Dr. George Loewenstein of Carnegie Mellon

uninsured individuals are now expected to not

University. His focus was to see if people really

only understand it, but to also successfully

understood health insurance. He gathered

obtain affordable health insurance.

his research from quizzing individuals who held health insurance.

Her idea was to apply design thinking to the

It was there he discovered that only 14 percent

to internalize and digest its massive amount

of the individuals he tested actually understood

of information.

education of health insurance, to make it easier

their health insurance.

WHAT IF YOU UNDERSTOOD YOUR HEALTH INSURANCE? 013

014

001 health

INSURANCE

015

Is a plan that covers medical expenses for illnesses, injuries, and conditions. health

INSURANCE

Is the care you receive for your physical and mental well-being from health professionals. health

CARE

*SUBSIDIZE: to support financially.

HEALTH CARE REFORM

ACA

It increases the quality, accessibility, and affordability of health insurance.

Obamacare

In Exchange

Also known as

The Patient Protection and

People who can afford to need to get health insurance, or pay a per month fee.

Affordable Care Act

While Insurance Companies ››› Can no longer deny coverage of individuals for their pre-existing conditions. ››› Are not allowed to drop individuals when they become sick. ››› Can no longer gender discriminate. ››› Must expand free preventative services and benefits.

The Benefits ››› Lessens your chance to become sick. ››› Creates a marketplace to find free or low-cost plans that are *subsidized by the government. ››› Requires larger employers to offer health insurance to their employees. ››› Expands Medicaid, Children's Health Insurance Program, and Medicare. ››› Decreases healthcare spending.

017

018

019

020

The Bureau of Indian Affairs Health Division was created, forerunner to the Indian Health Service.

1921

1910

Individual hospitals began offering services to individuals on a pre-paid basis.

1900 1700_01

1920

1798-2014

The first employer sponsored group disability policy.

1700

National Insurance Act was passed by British, and the term “health insurance” was coined.

Conversion of the Marine Hospital Service into the Public Health and Marine Hospital Service.

1902

Health Insurance

1911

Passage of an act for the relief of sick and disabled seamen, forerunner of today’s U.S. Public Health Service.

1798

TIMELINE 1900_01

1920

1976

Health Maintenance Organization Act required employers with twenty five or more employees to oer federally certified HMO options.

1973

1960

Some states began providing guaranteed issuance risk pools.

Community Health Center and Migrant Health Center programs were launched.

1966

Migrant Health Act was passed, providing support for clinics serving agricultural workers.

1960_04

1977

1965

President Lyndon B. Johnson signed the Medicare and Medicaid programs into law, making health care available to millions.

1962

1950_02

Health Care Financing Administration was created to manage Medicare and Medicaid separately from Social Security .

1960

The Cabinet-level Department of Health, Education and Welfare was created under President Eisenhower.

1953

1950

Kerr-Mills Act provided matching funds to states assisting patients with their medical bills.

The Federal Security Agency was created, bringing together related federal activities in the fields of health, education, and social insurance.

1939 1940

1930_02

Seventy Five percent of Americans had some form of health coverage.

Blue Cross was developed.

1930

First employer-sponsored hospitalization plan was created by a group of Dallas teachers.

1930 1920_03

1958

1929

1910_01 1970_03

1970

021

*

PREMIUM: amount paid for health coverage.

PROVIDER NETWORK: doctors/hospitals that are connected to your plan.

HOW IT WORKS Health Insurance acts just like any other service bill, such as your cable and your telephone. You must pay your bill—the insurance *premium—or the service—your insurance coverage—will be canceled. It basically works like one shared healthcare piggy bank. Consumers all chip in each month even when they are healthy so the money is there when they need it.

_Once you receive your card it’s a good idea to put it in your wallet so it is with you at all times. _Take advantage of the free preventative care provided by your plan so you can stay healthier and have a good chance for early detection of a serious illness. _Always remember your cost will be affected by your insurance plan's *provider network.

001 Take the initiative.

002 Read your materials.

003 Take time to educate yourself.

022

Important to Remember It is important to understand that having health insurance helps a lot, but it doesn’t mean all your health care will be free. There are many details about your plan that affect how much you pay when you get sick or injured. Not taking the time to understand could lead to owing thousands of dollars.

PATH TO COVERAGE direct to carrier

INDIVIDUAL & FAMILY

SUBSIDIZED

& 001

002

+

TAKE INTO ACCOUNT

TAKE INTO ACCOUNT

››› Zip

››› Household Income

››› Household Size

››› Zip

››› Age

››› Age

PICK A PLAN

PICK A PLAN

››› Plan A

››› Plan C

››› Plan A

››› Plan D

››› Plan B

››› Plan D

››› Plan B

››› Plan E

››› Plan C

››› Plan F

››› 100% you

››› X% you

››› X% subsidizer

RISK POOL

RISK POOL

CLAIMS

CLAIMS

››› A request for payment that you or your provider submits to your insurer when you get items or services you think are covered.

››› A request for payment that you or your provider submits to your insurer when you get items or services you think are covered.

003 A premium is what you pay for your coverage.

004 Place where your premium is held.

005 The payments come out of the risk pool.

PATH TO COVERAGE through your employer

SMALL GROUP

LARGE GROUP

2-50 employees

50+ employees

TAKE INTO ACCOUNT

TAKE INTO ACCOUNT

››› Zip

››› Age

››› Age

››› Health

››› Zip

PICK A PLAN

PICK A PLAN

››› Plan A

››› Plan C

››› Plan A

››› Plan C

››› Plan B

››› Plan D

››› Plan B

››› Plan D

001 Employers create a census of employees and dependents.

002

003 Employers pay some to most of your premium.

››› X% you

››› X% employer

RISK POOL

››› X% you

››› X% employer

RISK POOL

004 Place where your premium is held.

CLAIMS

CLAIMS

››› A request for payment that you or your provider submits to your insurer when you get items or services you think are covered.

››› A request for payment that you or your provider submits to your insurer when you get items or services you think are covered.

005 The payments come out of the risk pool.

There are many different ways you can obtain health insurance.

Depending on how you obtain it, paying for your premium will be different.

Risk Pool This is where everyones premium gets paid into, and only those who need medical care can take the money out in the form of a claim.

In general, the way risk pools work is that people get placed into different pools based on very limited data such as age. Companies are no longer allowed to use gender or other issues like a pre-existing condition to exclude or charge higher rates for high-risk individuals.

››› If you are self insured you are responsible to pay your entire premium. ››› If you are insured through an employer, they pay at least some to most of your premium while the rest comes out of your paycheck. ››› If you are insured through Medicaid you most likely will not have to pay a premium, because the federal government and your state of residence take care of it. ››› If you are insured through a new Health Insurance Marketplace you may be eligible for

However, it is important to understand that risk pools will be different for each state and company.

a tax credit that pays a portion of your premium, depending on your income.

025

026

027

14¢

Drugs

15¢

Outpatient costs

20¢

Inpatient costs

33¢

Physician services

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FEDERAL RESERVE NOTE

Other medical services

3

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3

Government payments & administrative costs

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06¢ FED E

Insurers profits

Consumer services: support & marketing

03¢ 04¢

THE DOLLAR Other Drivers An increased use of medical services.

Cost is above and beyond the rate of inflation.

Our premiums are increasing because of medical costs—charges from hospitals, doctors, pharmaceutical companies, and etc.—are increasing. These are the costs that your premium is ultimately supposed to cover.

The Affordable Care Act prevents insurance companies from spending excessively. It requires them to use eighty cents from every premium dollar for claims and support activities that improve the quality of care.

Fee for Service This is one of the biggest drivers behind rising U.S. medical costs, driving it thirty percent higher. Fee for Service basically means the more services that are performed by your providers the more they get paid, no matter the outcome.

Right now, our healthcare system is rewarded by doing more rather than doing better, which doesn’t give much incentive for those who are providing the care to work more efficiently.

30 %

Increase to U.S. medical costs due to fee for service.

029

*MLR: a basic financial measurement.

You Can Make a Difference Avoid spending more at the doctor and help eliminate wasted insurance money, which is another factor that is increasing premiums.

Avoid repeated tests.

Be aware of the care you have already received. Keep track of your records, and bring them with you to your appointments.

Treat medical conditions early.

The longer you wait the more expensive the treatment will most likely be.

Reduce being overly tested.

Before you receive any medical test make sure you know exactly why they are being conducted.

Compare procedure prices.

Start comparing prices for procedures you need. Increasing the competition starts driving down the costs.

Stop inappropriate use of the ER. Stop using the emergency rooms inappropriately. The common cold can end up costing you hundreds of dollars. Unless it is an absolute emergency check for urgent care centers that are within your provider network.

Medical Loss Ratio The *MLR requirement means that health insurers are not allowed to just increase rates as a way to increase profits. If insurance companies spending on medical care falls below the minimum percentages—eighty to eighty five percent—they are required to refund the extra money to their customers.

030

031

AMY BRUSS 23 years old Wisconsin STD Insurance The Plan: No Kids

THE INCIDENT My husband and I work for a small business and we decided to go with a standard health insurance plan.

We were not planning on having children so we opted out on including pregnancy and delivery coverage.

For contraceptive, I decided to go with the kind that gets inserted inside of you that lasts for several months.

It's intended to protect from pregnancy, and I would not get my period.

What Happened?

Several months later I went to the doctor only to find out that I was five months pregnant.

When we found out, we tried to get extra insurance, but they said we made too much money. So we ended up having to pay for all of the doctor's appointments, and the delivery out-of-pocket. We paid monthly for 5 years and then refinanced our house for the rest.

Though it was crazy we got a great boy, and that is all that matters. It was just a very costly lesson to learn that anything can happen, even when it's not planned.

Medical Bills $20,000 Coverage 0%

032

Paid Off 5 years & one refinanced house

Debt Owed $20,000

“

You never know when life will throw you a curve ball.

”

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002 the

CONSUMER

035

*SUBSIDY: financial help.

YOUR ENGAGEMENT It is time to realize that you the consumer play a vital role in the health insurance industry! Currently you are expected to choose among a variety of health plans, wade through cost and quality information on insurance companies, and make sense of complicated medical information on services and treatment.

So What Do You Do? ››› Accept that you are not invincible to illness or injury. ››› Understand what you are being charged for on your medical bills, and ask questions for charges that you don’t understand. ››› Understand how the insurance is being applied to your bills. ››› Learn how to talk to your care providers and your insurance companies. ››› Educate yourself before making any major health insurance decisions.

Self Questions

Before Buying

001 Who is getting covered?

Before deciding on a health insurance plan you need to take your current situation into consideration. The self questions provided are five questions that can help get you started.

002 Are you healthy or do you go to the doctor a lot?

003 Must you keep your primary doctor?

004 What’s your budget?

005 Do you qualify for a *subsidy?

036

Also remember the more freedom of choice you have in a health plan generally means the more expensive a plan will be. This is how health insurers keep their cost down by limiting your freedom of choice.

It’s time to be proactive and educate yourself.

IMAGE

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TIPS TO BUYING 001

002

Employers Vs. Individual

Narrow the Search

Look into your employers plan as well as options on the individual market.

If you’re paying for the insurance and are in good health, it might be better to get a policy on your own.

Narrow your search by limiting your choices to the ones that include your doctor, your medications, and the services you want.

››› Group plans base premiums on the group’s average health. ››› Group plans are better for people in ill health or who have pre-existing conditions.

››› Look out for dollar caps, other limitations, and exclusions. ››› Look into the *drug formularies. This could literally mean the difference between paying $15 per month to fill a prescription versus paying $1,500 per month.

003

004

Shop for Care

Your Budget

We often price compare the cost of everything from food to cars, but why not for health care procedures?

This does not apply to emergencies or *catastrophic situations.

How much can you afford? It may be worth it to pay a little more for a plan that has less cost-sharing. It could be a difference of thousands of dollars.

››› Care is needed for routine services and

››› Decide which has the mix of premiums and

things you can plan in advance. ››› Register on your plan’s website and look for cost estimators. ››› You’re likely to find startling variations in prices for the same service depending where you get it from.

potential out of pocket expenses that you’re most comfortable with. ››› Ask about the premiums, out of pocket limit, co-payments, deductibles, and coinsurance. ››› Find out about the dollar limits on how much you’ll be responsible for the health care services you receive. ››› Understand how your providers get paid and what portion you have to pay.

040

*

DRUG FORMULARIES: a list of both generic and brand name prescription drugs in your health plan.

CATASTROPHIC: a medical emergency that may cause a financial disaster

005

006

Get Help

Master the Rules

Consider consulting a broker. You won’t be paying more for getting their help.

Become a master of your plan's rules. After getting a plan, try to spend a few minutes with its Summary of Benefits and Coverage.

››› Brokers get paid out of the money you pay for your premiums which are the same whether you use a broker or not.

››› Plans are not designed alike. ››› Example of understanding. Lets say you have a sore throat and fever. A: a trip to the doctor could cost you a $40 copay, B: a trip to urgent care could cost you a $60 copay, C: a trip to the emergency room could cost you a $1,500 copay.

007

Do not auto renew. Plans change from year to year and so do your circumstances.

041

BASIC RIGHTS Just like with any other service we as consumers have basic rights when it comes to having health insurance. It is not only important to understand them, but to also take full advantage of them. The rights listed here only give you a brief overview. These rights may apply to employer coverage, the health insurance marketplace, or individual insurances.

If you would like to learn about all of your rights, you can visit healthcare.gov, or you can ask your current insurance company.

Not applied to *grandfathered plans. ››› Insurance companies must justify any rate increases of 10%. ››› Seek emergency care at a hospital outside a plan’s network without being charged higher co-payments, higher coinsurance, or require approval first. ››› To provide preventative care without having to share the cost. ››› Insurance companies can’t set a yearly dollar limit on what they spend for your coverage.

However they can still put a limit for services that are not *essential health benefits.

042

Everyone ››› Gets coverage with a pre-existing health condition. ››› Will not be discriminated because of gender. ››› Receives a short, plain language summary of Benefits and Coverage from your insurance company. ››› Receives a Uniform Glossary of terms used in health coverage and medical care. ››› May renew their policy if they pay their premium in full. ››› Has coverage for mental health and substance abuse services as essential health benefits if you have marketplace insurance plans. ››› Is protected on dollar limits. Insurance companies can not set a dollar limit on what they spend on essential health benefits for your care during the entire time you are enrolled in that plan. However they still have the right to put a limit for services that are not essential health benefits.

*

GRANDFATHERED PLANS: plans created or bought before March 23,2010 ESSENTIAL HEALTH BENEFITS: benefits that must be covered by your insurance. However they vary by state, and vary by health insurance companies within that state.

Women ››› Only plans in the health insurance marketplace must cover contraceptive methods and counseling prescribed by the health care provider.

001 As long as the services are provided in-network they must cover the service without charging you a co-payment or coinsurance even if you haven’t met your deductible.

002 Does not apply to health plans sponsored by certain exempt religious employers, and non-profit religious organizations.

003 They are not required to cover drugs to induce abortion, or services

Not applied to grandfathered plans. ››› Do not need a referral for OB-GYN services. ››› Eligible for women preventive services without being charged a co-payment, or coinsurance even if they haven’t met their yearly deductible. Services must be provided by an in-network provider. ››› Plans must provide breastfeeding support, counseling, and equipment for the duration of breastfeeding before and after you have the baby.

related to a man’s reproductive capacity.

Under 26 Years Old ››› You can join, remain, or return to a parent's plan even if you are married, not living with your parents, attending school, financially independent, or eligible to enroll in your employer's plan.

Medicare ››› Seniors who reach the point of having to start paying for prescription drug expenses by themselves will now receive a 52.5% discount when buying name brand drugs, and 21% discount on generic.

043

044

You have the right to appeal a decision if your health insurer refuses to pay a claim or ends your coverage.

Appeals Insurance companies have to tell you why you were denied or canceled, and they have to let you know how to dispute their decisions. Remember that it is now illegal for your health insurance to cancel your plan when you get sick.

The first way to appeal is through an internal appeal.

You have the right to ask your insurance company to conduct a full and fair review of its decision.

The second way to appeal is through an external review.

An external review is the right to take your appeal to an independent third party for review, therefore, your insurance company no longer gets the final say over if they pay the claim or not.

045

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047

“ 048

I felt I didn't have a choice in picking any other plan.

�

LYN HEWITT 27 years of age Illinois Student Insurance

THE INCIDENT When I was 27 I started taking an antibiotic for a sinus infection that was prescribed from my physician at the student health center. She warned me that it might upset my stomach. Two days later the terrible stomach pains started, but I continued to take the medications because I thought this is what she meant by upset.

However the next day I discontinued the medication because of the pain, but since it was a Saturday I was unable to be seen for a follow-up.

What Happened?

After the pain continued to persist, I went to the local emergency room on a Sunday where I was admitted for colitis and c.diff. The antibiotics had killed all of the good bacteria in my intestines, allowing bad bacteria to take over. I was admitted due to severe dehydration, a high fever, and stayed in the hospital for two nights.

C. diff is a problem that typically affects older adults, and my providers in the hospital kept bringing in all the medical students to talk about my case. It was quite rare for someone of my age and good health status.

Medical Bills $7,500

Started As sinus infection

Coverage 80%

Ended With c.diff & colitis

Debt Owed $1,500

049

050

003 the

PROVIDERS

051

*

CONTRACTED RATE: amounts insurance companies pay their provider network for services.

YOUR SHARE: amounts that you are responsible for in the form of co-pay, deductible, or co-insurance.

WHO ARE THE PROVIDERS An individual who helps in identifying, preventing, treating illness or disability, and provides health care services to people, families, or communities giving direct patient care and support.

Provider Network A provider's network is when an insurance company contracts with a range of doctors, specialists, hospitals, labs, radiology facilities, and pharmacies. This means these health care providers have all agreed to accept your plan’s *contracted rate as a full payment for services. This list of providers is then connected to your plan and is referred to as your in-network providers.

The contracted rate includes both your insurer’s share of the cost and *your share. To avoid costly mistakes it is important to be aware of your in-network providers.

_Let's say you have a cold and decide to go to your primary care doctor that is in your provider network.

If your insurer's contracted rate for a primary care visit is $110, and your co-pay for a primary care visit is $20 your insurer will pick up the remaining $90.

Work Within ››› Medicine the diagnosis and treatment of disease and the maintenance of health by nonsurgical means. ››› Surgery treats diseases, injuries, or deformities by manual, or operative methods. ››› Psychology dealing with the mind and mental processes.

››› Dentistry concerned with the teeth, and the oral cavity. ››› Nursing to provide services to or helpful in the promotion, maintenance, and restoration of health. ››› Pharmacy dealing with the preparation, dispensing, and proper utilization of drugs.

Health care professionals & health care facilities that are a part of your insurance company’s network. in-NETWORK

Health care professionals & health care facilities that are not apart of your insurance company’s network. out-of-NETWORK

››› Obstetrics deals with the care of women during pregnancy, childbirth, and recovery. ››› Diagnostics practice of diagnosis of disease. ››› Technical a procedure or its results that require special techniques, skill, expertise, or knowledge.

053

IN-NETWORK & OUT-OF-NETWORK

in action

An Example

$1000

PROVIDER’S CHARGE

INNETWORK

HMO $

POS $

$500

CONTRACTED RATE

EPO $

PPO $

Service charge

$1000

$1000

$1000

$1000

Your insurer’s contracted rate

$500

$500

$500

$500

Your cost sharing Your plan pays

You pay

$10 co-pay $490

$500-$10

$10 one percent

$1000

PROVIDER’S CHARGE

$10 co-pay $490

$500-$10

$10 one percent

OUT-OFNETWORK

HMO $

POS $

20% co-insurance $400

$500x80%

20% co-insurance $400

$100

$100

ten percent

ten percent

$800

ALLOWED AMOUNT

EPO $

PPO $

Service charge

$1000

$1000

$1000

$1000

Your insurer’s allowed amount

$0

$800

$0

$800

Your cost sharing

100%

30% ÷ $800 + $800 - $1000

You pay

$1000

$440

Your plan pays

$0

70%

Your total cost

$1000 one hundred percent

$240+$200 $560

$440 forty four percent

$500x80%

100%

30% ÷ $800 + $800 - $1000

$1000

$440

$0

70%

$1000 one hundred percent

$240+$200 $560

$440 forty four percent

Out-of-Network It is important to remember that all insurance plans differ on how they handle out-of-network provider costs.

Receiving care from them will likely have you paying more for your care. For example, if you have a serious illness you could end up paying tens to thousands of dollars more. For some this might be unavoidable, but for others it's very important to stay informed about how your insurance plans handle out-of-network.

_Unless there is a specific reason why you need to go out-of-network, always ask your provider to refer you to an in-network specialist. _When scheduling an appointment with a new provider, always confirm that they are in your network. _Before you schedule a surgery, ask your doctor if all the providers who will be a part of your treatment are in-network. _When you must go out-of-network, compare prices for all out-of-network providers in your area to find the best deal.

Self Questions

Why it Costs More

001 Must you keep your primary doctor?

››› Providers outside of your network have not agreed to any set rate with your insurer.

002 What’s your budget?

››› Your plan may cover part of the out of network care but could require you to pay a higher co-pay, deductible, and coinsurance. ››› You may also be responsible to pay the difference between the allowed amount for out-of-network and what the provider charges. ››› Your plan may not cover out-of-network care at all, and you'd have to pay the full cost.

055

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Be Prepared Use these helpful questions to start a conversation with your insurer to help avoid financial surprises.

001

Are my providers in-network for this plan? Is there a way to look up in-network providers?

002

003

››› How can I find out in advance what I will have

››› What are the rules for accessing care out of

to pay for out-of-network care? Where in my

your plan's network? Is there a number I can

policy does it talk about out-of-network care?

call to check if a service or a test needs to be pre-approved?

004

005

››› What services and tests are covered by my

››› What is your definition of screening tests? If

plan? Will they be covered if performed by an

my doctor recommends it, will I have to pay

out-of-network provider? What services or

a co-pay or meet a deductible to have a

tests are excluded?

screening test recommended by my doctor?

006

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››› Is there a deductible? Do both in-network

››› How can I confirm that all providers who

and out-of-network services count towards

will provide care during a procedure, surgery,

the same deductible?

or hospitalization are in-network?

008

009

››› Would I be responsible for additional costs if

››› How does the plan cover emergency services

my in-network provider sends lab tests to an

from out-of-network providers? How does the

out-of-network laboratory? If so, how can

plan define an emergency? If I am brought

I guard against this additional expense?

by ambulance to an out-of-network provider Emergency Room, am I responsible for a decision that was not in my control?

058

During an Emergency Even if you go out-of-network many insurance plans cover some part of emergency care, because during an emergency waiting to receive care can be considered life threatening. However once you are considered to be in stable condition, you will often be transported to an in-network provider.

Often insurers won’t pay the same amount if it’s not a true emergency, and the costs compared to a primary care doctor or urgent care can differ by the thousands.

Make sure you ask your insurer what is and what is not considered an emergency when you get your plan.

Common Mistakes ››› Your doctor refers you to a specialist that isn't in your network. Remember it is not their job to know the details of your insurance plan. ››› You have a surgery at an in-network hospital but not all of the providers that were part of your procedure are in-network. A surgeon, anesthesia, medication, operating room, hospital room, and more all will have their own charges, and all contract separately with the insurers.

Make a Difference The more we make educated decisions about our care, the more we can help shape a health care market that offers better quality at lower prices. This will help the insurance dollar go down when new collaborations with hospitals and doctors exist with the goal of providing top quality health care as efficiently as possible.

059

“ 060

With the insurance that is provided by my work, I felt like I had no choice.

�

SHAWN BOWERS Truck Driver 42 years old Wisconsin United Healthcare through employer

THE INCIDENT It started as just another regular workday of driving my truck. I am in charge of loading and unloading my deliveries. A few hours in, I started to get discomfort in my stomach. I have experienced this before so I began trying to do things to alleviate it. None of those things worked to lessen the discomfort. As the day progressed the discomfort turned into pain mixed with waves of nausea. That is when I said to myself that something was not right.

What Happened?

Five hours after I started I was dropped off at the hospital by an employee that works for the company I deliver to. Later that afternoon I ended up having emergency surgery to get my gallbladder removed.

When all was said and done, I got my bill but I didn’t understand why I needed a sonogram and a CAT scan.

If I had not been doped up on painkillers I probably would have asked about the necessity of some of the labs that were performed.

I have an extremely high deductible that is why I only got the discounted price as coverage.

Medical Bills $29,715

Started As discomfort

Coverage $26,213

Ended With emergency surgery

Debt Owed $3,502

061

062

004 the

SUBSIDIZERS

063

Premium tax credits & savings on deductibles, co-payments, and out-ofpocket costs based on *household size & income. marketplace PROGRAM

Coverage to millions with limited incomes or disabilities. medicaid

PROGRAM

Coverage for children & for some states pregnant women in families with incomes too high for Medicaid & too low to afford private insurance. chip

PROGRAM

064

*

SUBSIDIZER: the individual who financially assists.

HOUSEHOLD: includes tax filers & tax dependents.

WHO ARE THE SUBSIDIZERS Individuals Included In Your Household ››› Yourself. ››› Your spouse—legally married couple, opposite or same-sex. ››› Your children who live with you, even if they make enough money to file a tax return. ››› Anyone else under 21 who lives with you and you take care of. ››› Anyone included on your tax return as a dependent, even if they don't live with you.

Not Included ››› Individuals that are not your spouse. ››› Individuals that earn their own income. ››› Individuals that file their own taxes. ››› Individuals covered by their own insurance.

There are many organizations and individuals that can be considered *subsidizers when it comes to health insurance. Parents, the military, employers, and the government are known as subsidizers.

Subsidized Coverage Health coverage that is obtained through financial assistance from programs to help people with low and middle incomes. It is important to remember there are different programs for each state, and that even similar programs such as Medicaid may be named differently and may have a different sets of rules.

Are You Eligible First you will need to answer a few simple questions like your *household size, your yearly income, and your location. This will help determine if you are eligible for a no cost, or low cost insurance program. A few of these programs include Medicaid, Children's Health Insurance Program, and the Advance Premium Tax Credit.

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MEDICAID You can qualify for a medicaid program based on household size, yearly income, and other factors, like age and disability. With no limited enrollment period for Medicaid, you can apply for and enroll any time of year. If you qualify, coverage can begin immediately.

Some Medicaid programs pay for your care directly while others use private insurance companies to provide the coverage.

If you have a Medicaid coverage, you're considered covered under the health care law. Meaning that you don't have to buy a marketplace insurance plan, and that you won't have to pay the fine that people without health coverage need to pay.

How to Apply

Things to Remember

001 To your state Medicaid agency.

››› Income cutoff will depend on which state you live in.

002 A Marketplace application.

››› In states that have expanded Medicaid coverage, you may qualify for Medicaid based only on your income and family size.

››› Eligibility rules differ state to state.

››› In some states the program covers all adults below a certain income level. ››› They all must follow federal guidelines, but coverage and costs may be different from state to state. ››› In all states, they provide free or low-cost care for some low-income individuals, families, children, pregnant women, the elderly, and individuals with disabilities.

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How to Estimate Your Income Employed

001

002

003

AGI

Modified AGI

Expected Income

First start with your adjusted gross income. This can be found on your recent federal income tax return.

Next you will want to make adjustments to estimate your modified adjusted gross income.

Now adjust your expected income for the following year.

››› Form 1040: Line 37

››› Add in tax-exempt foreign income, tax-exempt social security benefits,

››› Form 1040 EZ: Line 4

tax-exempt interest.

››› Form 1040 A: Line 21

››› Do not include any Supplemental Security Income—SSI.

››› Consider raises, new jobs, employment changes, higher or lower tax deductions, and changes in income from self-employment. ››› Make sure you include income changes for anyone who will be a dependent on your federal income tax return. ››› Account for any expected changes to your household, including gain or loss.

How to Estimate Your Income Unemployed It's hard to predict an annual income if you are unemployed but it's still important to make your best estimate based on all current or expected sources.

001

003

Unemployment Compensation.

All household members' income.

002

004

Most withdrawals from traditional IRAs & 401ks. To help clarify, research IRS form 8606 instructions & IRS Publication 590-B.

Additional types of income, including cash support, interest income, capital gains, and any alimony.

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068

069

CHIP If your children need health coverage, they may be eligible for the Children's Health Insurance Program.

You qualify for CHIP based on your household size, income, and other factors, like age and disability. With no limited enrollment period for CHIP, you can apply and enroll any time of the year. If you qualify, coverage can begin immediately.

Key Points ››› In some states it covers parents and at times pregnant women. ››› Each state offers it and works closely with its state Medicaid program. ››› In many cases if you qualify for Medicaid your children will qualify for CHIP. ››› The benefits are different in each state.

What it Costs Routine "well child" doctor and dental visits are free of charge, but there may be co-payments for other services. In some states there is a monthly premium charge, which is different in each state. However you won't have to pay more then 5% of your family's yearly income.

070

If you have CHIP coverage you are considered covered under the health care law. This means you will not have to pay the fee that people without coverage have need to pay.

Do you Qualify ››› You can go to www.insurekidsnow.gov, and remember to select your state. ››› You can also call 1.877.543.7669. ››› Fill out a marketplace application. If you qualify, they will let your state CHIP agency know so the coverage will start right away.

HOW TO CALCULATE THE SUBSIDY

an example

Meet Tom

SINGLE

$23,000 TOM’S INCOME

$11,670 FEDERAL POVERTY LEVEL

197%

001 Figure out how Tom’s income compares to the Federal Poverty Level.

002 Find Tom’s expected contribution rate in the graph below.*

OF FEDERAL POVERTY LEVEL

$23,000

4–6.34%

÷ $11,670 × 100 =

INCOME

USES 6.34% BECAUSE HE IS NEAR THE TOP OF HIS CATEGORY.

FPL

003

*EXPECTED CONTRIBUTION RATE

Calculate how much Tom is expected to contribute.

÷ 100 × $23,000 = 6.34%

10

ECR

9.56% 8.10%–9.56%

8

6.34%–8.10%

TOTAL

$1,458.20 PER MONTH

$121.52

6

4.02%–6.34% 4

2

3.02%–4.02% 2.01%

0 100–132

133–149

150–199

200–249

Find subsidy amount by subtracting his expected contribution from the benchmark plan’s cost.

$3,900 - $1,458.20 = TOM’S EXPECTED CONTRIBUTION

250–299

poverty level %

TOTAL

004

BENCHMARK HEALTH PLAN

income %

INCOME

$2,441.80 PER MONTH

$203.48

300–400

APTC Sometimes known as advance payments of the premium credit, or premium tax credit. When you buy health insurance coverage in the Marketplace, you may be able to get a premium tax credit that lowers what you pay in monthly premiums. You'll get the credit each month instead of having to wait until you file your federal tax returns the next year.

Qualifying Depends On ››› Household Size. ››› Annual Income.

How it Works Part of your monthly payment is made by the federal government directly to the health plan that you were enrolled into. Individuals making 100 – 400 percent of federal poverty level can qualify.

_The federal poverty level changes every year. _You can't use the subsidy to buy a catastrophic plan. _If not used correctly, you could end up owing.

Apply It 3 Ways

What Can Effect It

001 Equal monthly installments.

Changes in life such as having a baby, getting married, or changing jobs can affect the amount of your APTC or even your eligibility.

002 As smaller monthly payments—good if unsure about income.

003 All towards next year's tax return.

Of course you never know what's going to happen during the coming year which is why it's so important to update your Marketplace application all year with changes that could affect your coverage.

How You Could End Up Owing If you make more income than you expected, your APTC will be lower and you might owe some money at the end of the year. However if you make less than you expected, you may be eligible for a tax refund instead.

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careaware.us 074

001

COST 002

PLAN 003

TERMS

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CAREAWARE.US A tool to help internalize and digest health insurance.

CareAware.us will help you to find the most important information on health insurance broken down and simplified. Focuses are Cost, Plan, and Terms.

Cost ››› Breaking down the health care dollar. ››› Explaining fee for service. ››› Making a difference.

Plan ››› Before you buy. ››› Finding your plan. ››› Deeper understanding of your subsidizes.

Terms ››› Tops words. ››› When you buy. ››› As you use.

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“

Tell me and I forget, teach me and I remember, involve me and I learn.

”

BENJAMIN FRANKLIN 077

THE RESOURCES CONTENT RESEARCH hhs.gov/about/hhshist.html ehow.com/facts_5509445_did-health-insurance-begin.html Price Water House Coopers academyhealth.org/files/issues/ConsumerEngagement.pdf forbes.com/sites/financialfinesse/2012/08/08/5-things-you-needto-know-before-buying-health-insurance/ ctmirror.org/2013/11/27/6-things-consider-when-picking-yourhealth-insurance/ insurance.wa.gov/your-insurance/health-insurance/understanding-health-insurance/what-to-consider/ healthinsurance.about.com/od/healthinsurancebasics/a/Before-YouBuy-Health-Insurance.htm consumerreports.org/cro/news/2014/09/8-things-to-know-beforeyou-buy-health-insurance/index.htm anthem.com/ca/health-insurance/health-plans/health-insurancebasics healthcare.gov/health-care-law-protections/ consumerreports.org/cro/2012/06/update-on-health-care-reform/ index.htm healthcare.gov/preventive-care-benefits/women/ en.wikipedia.org/wiki/Health_professional fairhealthconsumer.org/reimbursementseries.php?id=15 uspirg.org/resources/usp/so-you-need-health-insurance-now-what fairhealthconsumer.org/reimbursementseries.php?id=15 bcbsm.com/index/health-insurance-help/faqs/topics/how-healthinsurance-works/difference-between-in-network-out-of-networkbenefits.html thefreedictionary.com/subsidizer thefreedictionary.com/subsidizer healthcare.gov/glossary/subsidized-coverage/ healthcare.gov/lower-costs/save-on-monthly-premiums/ healthcare.gov/income-and-household-information/how-to-report/ healthcare.gov/medicaid-chip/childrens-health-insurance-program/ healthinsurance.about.com/od/reform/a/How-Does-The-PremiumTax-Credit-Health-Insurance-Subsidy-Work.htm healthinsurance.about.com/od/reform/a/How-Does-The-PremiumTax-Credit-Health-Insurance-Subsidy-Work.htm PHOTOGRAPHY MAIN Sami Lukens X-RAYS shutterstock.com/

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