Health Insurance 101
I pulled this template from Google Slides for free.
Also I’m not an expert, I’ve just sat through a lot of benefits trainings.
Not Confidential
Made for TMAC by Dee <3
Version 1.0
TOC (these are links)
Not Confidential
Made for TMAC by Dee <3
Version 1.0
What I can cover And what I can’t
Open market plans Medicare
Employer plans Medicaid
What they do What they do (sorry)
Also because teeth and eyes aren’t important to the human body /s, we’re not talking about vision and dental insurance.
Basic Types
HMO
PPO, POS
EPO
Health Maintenance Organization Nearly all care from one network so you need to be near it, and they encourage preventative care.
Preferred Provider Org, Point of Service In-network care is cheaper, PPO doesn’t need referrals, POS does.
Exclusive Provider Organization All non-emergency care from one network so make sure there are doctors you can see.
Open Market Insurance
Have your financial information with you in order to see what plans and prices you qualify for.�Plans can have very low monthly rates.
Not all plans are the same.�Since you get to pick, balance monthly cost with the services you expect to need covered and doctors you want to have in network.
In Illinois, if you qualify for benefit programs, they will try to help get you into these programs.�You may be unable to select a plan and they will follow up with you.*
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*might be out of date, but this was the case in 2018
Open Market Insurance
05 | Catastrophic - Under 30 yrs old with some exemptions,� very basic coverage. Not good if you need more than� regular checkups. No tax credit.
04 | Bronze - Low monthly cost, higher out of pocket. Tax � credit eligible.
03 | Silver - Tax credit eligible AND if you qualify for “Extra � Savings” out of pocket maximums are reduced.
02 | Gold - Tax credit eligible.
01 | Platinum - Tax credit eligible (based on income and� household). Highest monthly cost for lowest out of pocket� (check that expected care costs covered are greater than� total monthly costs)
0% 20% 40% 60% 80% 100%
You
Them
Open Market�Insurance
10 Essential Health Benefits
Plus: Birth control & chestfeeding, but what methods or benefits are covered vary
Open Market Insurance
^ that’s a link (Illinois)
Resources:
Pre-enrollment Checklist (Illinois)��Health Insurance Glossary
FAQs (Illinois)��Quick Start Guide (Federal)��FREE Enrollment Assistance (Illinois) >>>>>>
Employer Benefits
Find out before you accept the job:�▸ Does this job come with health insurance?�▸ What is the plan type and costs?�▸ What doctors and care are covered?
Use the provided information to check if your preferred doctors are in network and any necessary care is covered.�Check the costs of the plans and how much you expect they’ll end up paying.
Sign up for coverage within the special enrollment period (tbc).�If you are covering anyone else, you need to provide proof they’re your dependent, domestic partner, spouse, etc.
Investigate other health related benefits like discounts on premiums for having a gym membership, or smoking cessation incentives.
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Open Enrollment & Qualifying Life Events
Open Market Employer Benefits�
Open Enrollment Nov 1st-Jan 15th ??? (Generally 2-4 weeks in Nov-Dec)�
Qualifying Life The same (mostly)�Events
Qualifying Life Events - Usually ~30 Day Period
Loss of coverage: � Loss of employment, � End of COBRA coverage (tbc),� Turning 26 & losing parent’s coverage,� Retirement, � Loss of Medicaid��Other events: Moving, Naturalization (becoming a US citizen), Leaving incarceration,� Becoming a recognized tribe member (access to different insurance plans & premiums)
Change in Household: � Marriage & divorce, � Birth & adoption, � Death,� (Employer dependent) New domestic � partner qualification
COBRA
Useless acronym. Consolidated Omnibus Budget Reconciliation Act, should be Continuation of Health Coverage
Benefits:
Maintain same plan (doctors, copays, dollars spent towards out of pocket)� Deal with other things during time of transition (not the gender kind)� Continuity for dealing with a specific, active health concern��Drawbacks:
Cost - you pay what employer used to pay plus a fee� Temporary - 18 to 36 months max, may not qualify for extended coverage� Not every job is covered by COBRA (small or religious employers)
Low vs High Deductible
Premium: what you pay monthly regardless of what care you get�
Deductible: what you pay when receiving care before insurance starts paying
Low Deductible: higher premium plan where you pay less before insurance covers your medical bills (relative to the high deductible version)
High Deductible: lower premium plan where you pay more before insurance covers your medical bills (relative to the low deductible version)
Low vs High Deductible
Example employer plans w/ made up round numbers:
Low Deductible Low Deductible High Deductible High Deductible� Individual Couple Individual Couple
Premium $200/month $400/month $100/month $200/month
Deductible $1500 $3000 $2000 $4000
Max Out of $2000 $4000 $3000 $7000�Pocket�
Here’s the catch, these are both technically high deductible plans. Anything over $1400 for an individual or $2800 for a family is considered high deductible (at least in 2022).
Same doctor network, same procedure and drug coverage. Different cost structures.
Copays, Coinsurance, Max Out of Pocket
Copay: Flat rate you pay for a doctor’s office/specialist/etc visit once you’ve met �your deductible
Coinsurance: % of the bill you pay for a doctor’s office/specialist/etc visit once you’ve �met your deductible
Maximum Out of Pocket: the maximum amount you can be �made to pay on covered in-network bills*
*If a medical bill includes costs above the negotiated �rate, your provider and insurance will fight and �you might still have to pay even if you’ve met this!�You can also join the fight to refuse payment (a charge for service you didn’t receive), negotiate a lower bill, or accept and work out a payment plan.
HCAs, FSAs, HSAs
Health Coverage Account: an annual amount of medical bills that will be covered by your employer, counts towards your deductible. Sometimes called HRA.
Flexible Spending Account: a pre-tax account where you give a little each paycheck to an account your employer owns and use it to pay medical �bills. $3050 annual max, limited rollover if you don’t use it!
Health Savings Account: a pre-tax account where you �deposit money to pay for medical expenses. It gains interest!�You keep the money if you change employers, and you can �pull the money out for non-medical expenses but you’ll owe�taxes and a penalty. Has annual contribution limits.
Not all employers or open market plans offer these.
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Choosing Plans
Some plans or HR teams give examples of potential annual medical costs and the resulting costs per plan.
You can check this yourself!
Math Ahead
Anecdotally, both my insurance and my parent’s insurance as couples there’s � no benefit to the low deductible plan. Why? Because that’s the rates our� employers and the insurance companies negotiated. ¯\_(ツ)_/¯
To pick what’s right for you, estimate your medical costs for the year. Include an unexpected ER visit.
Choosing Plans
You look at the low deductible plan from before, because you know you need�routine appointments and you’re trying to have surgery this year. You call the health advocate team (tbc) to check negotiated costs and coverage.
Regular checkup appointment is free.
Doctor visits & therapy sessions are $100/visit before deductible, 20% coinsurance after. You want biweekly therapy and visit the doctor 4 times a year.
Surgery cost is negotiated to $6000 & coinsurance is 20%.
Unexpected ER visit is $1000 including the follow up, coinsurance is 20%.
Let’s say you stay in network all year because it’s much simpler.
Total medical claims:
$0
$3000
$6000
$1000
$10,000
Choosing Plans
Annual Premium + Annual Deductible + OOP Remainder = Total�$200*12=�$2400 set cost $1500 variable cost $500 variable cost $4400
(Out of Pocket Max: $2000 - $1500 deductible = $500 ^ after deductible)
Total medical claims for the year: $10,000
You paid: $4,400
Insurance covered: $8,000
Remember your out of pocket maximum of $2000.
Choosing Plans
Annual Premium + Annual Deductible + OOP Remainder = Total�$100*12=�$1200 set cost $2000 variable cost $1000 variable cost $4200
(Out of Pocket Max: $3000 - $2000 deductible = $1000 ^ after deductible)
Total medical claims for the year: $10,000
You paid: $4,200
Insurance covered: $7,000
Check the High Deductible plan.
In & Out of Network
In Network: doctors/treatment locations with negotiated service rates
Out of Network: doctors without negotiated service rates� The actual cost of treatment may not be more expensive but the� insurance company has an incentive to drive you to doctors they are� networked with. Usually it has nothing to do with the quality of care.
Plans can count out of network claims in a totally separate deductible & maximum out of pocket bucket, making the cost to you much higher.�They can also decline to cover the portion of a bill they consider to be higher than “”Reasonable & Customary”” according to them.
Find a good trans competent doctor.
Health Advocates & Online Portals
Health advocates: a phone number to call a team or a chat system to ask what your insurance covers and what it will cost you� Sometimes called case managers, varying ease of use.� Can look up specific doctors and services for you.� Easier to use than trawling the Certificate of Coverage, but get everything� important in writing
Online Portals: your health insurance provider’s website with your plan details� Claims� Doctor network� Incentive programs
Preauth & Appeals
Have your medical provider submit preauthorization paperwork, also called �precertifcation by some insurance companies. Check:� Diagnosis codes (ICD10) & Procedure codes (CPT)� Documentation of medical necessity� Asking for “max allowed by plan”��Document calls, meetings, emails, etc. Contact both insurance and provider until approved��If you are denied, you can appeal!�Appeal processes vary, pay attention to deadlines and hoops.� Checking a box on paperwork, writing a letter, having your doctor call them
This is for major scheduled procedures, top surgery �is just a convenient example.
EAPs - Employee Assistance Programs
Chosen by your employer.��Benefits vary by service provider.
Ask HR for what services are covered.��Arrange an EAP explanation of benefits presentation for your team.
Typically cover:� Short term counseling� Referrals� Work and life assistance
May be adjacent to other programs like mindfulness, gym reimbursement, joint and muscle pain programs…��Get all the benefits you can!
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Sliding Scale & Free Community Clinics
Healthcare providers who take clients who cannot afford the full cost of treatment, whether up front or on a payment plan.
Usually local community clinics, sometimes pop-ups for vaccines, etc.��Often ask for less identifying information to serve at risk groups.
Sometimes they can work with you even if you have insurance.� ie if you have insurance but can’t afford treatment, ask for help.
Know your needs. These programs are funded with grants and community fundraising.��If you qualify, you are exactly who they want using it!
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Thank you.