Educating Consumers and Peers about Health Insurance and Assister Roles

Learning Objectives

I. Identify and examine the health insurance literacy problem in the U.S.

II. Define common health insurance terms and procedures

III. Identify effective strategies for educating peers about the Navigator’s role, building workplace and community support, and advocating for health insurance literacy

The Washington Post

Survey: Americans Have Low Health Insurance Literacy

• Only 12 percent of adults have proficient health literacy, according to the National Assessment of Adult Literacy.

• More than HALF of Americans cannot correctly define at least one of these common financial terms related to health insurance:– Premium– Deductible– Copay

Source: HHS; Kaiser Health News

Health Literacy Matters

– Older adults

– Recent immigrants

– People with low incomes

– Those enrolled in Medicare or Medicaid

People of all ages, races, incomes and education levels struggle with limited health literacy, but the groups who struggle the most are:

Health Literacy Matters

• Poor health literacy is a huge barrier standing between uninsured American and enrollment in health coverage– More than HALF of the American public find it difficult to understand

and use information written above an eighth-grade level. Most health-related materials are written at a tenth-grade reading level or higher.

Source: Enroll America

Health Literacy Matters

• Jargon and technical language make it harder for consumers to enroll and retain health coverage

• Many people also face linguistic and cultural barriers • These factors are a recipe for missed deadlines and

appointments, misunderstood instructions, and poor understanding and management of chronic diseases

• Low health literacy is associated with reduced use of preventive services and management of chronic conditions, unnecessary ER visits, and higher mortality. – This costs the US Economy between $106 billion and $236 billion

annually!

Source: Center for Health Care Strategies, Inc.

TERMS TO KNOW

Minimum Essential Coverage (MEC)

• The type of coverage an individual needs to have to meet the individual responsibility requirement (individual mandate) under the Affordable Care Act (ACA).– The individual mandate requires that ALL eligible Americans have at

least basic health coverage– If they don’t have coverage, then they are subject to the individual

shared responsibility fee for each month they are without health insurance or do not have an exemption

Minimum Essential Coverage (MEC)

• If you have coverage from any of the following, you’re covered and don’t have to do anything. – Employer-sponsored coverage, including COBRA and retiree– Individual coverage/Marketplace Coverage – Medicare (Part A) and Medicare Advantage plans– Most Medicaid coverage, including CHIP– Certain Veterans health coverage (from the VA)– Most types of TRICARE coverage – Coverage provided to Peace Corp volunteers – Refugee Medical Assistance (ACF)– Self-funded health coverage offered to students through schools– State high risk pools – Coverage under the Nonappropriated Fund Health Benefit

Program

Essential Health Benefits (EHBs)

• Marketplace plans MUST include essential health benefits in at least these 10 categories:

1. Ambulatory patient services

2. Emergency services

3. Hospitalization4. Maternity and

newborn care5. Mental health and

substance use disorder services

6. Prescription drugs

7. Rehabilitative and habilitative services and devices

8. Laboratory services 9. Preventive and wellness

services and chronic disease management

10. Pediatric services including oral and vision

Premium

• The amount that must be paid for health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

• You must pay the first month’s premium by the insurer’s deadline to avoid plan termination– Consumers receiving APTC who timely pay their first premium are

eligible for the three-month grace period

• Insurers must accept payments by:– Paper check, cashier’s check, money order, EFT, Pre-paid debit card – Some issuers may also accept online, credit card, or debit card

payments (check with plan)

Premium

• Monthly premiums are based on several factors including: Age Smoking status Location How many people are enrolling on the same plan The insurance company

• Consumers between 100 and 400% of the federal poverty level qualify for the Premium Tax Credit Available only through the Marketplace

Premium Tax Credit

Choose to Get It Now: Advanced Payments of the Premium Tax Credit

• All or some of the premium tax credit is paid directly to the plan on a monthly basis

• Consumer pays the difference between the monthly premium and advance payment

• Consumer reconciles when they file their tax return for the coverage year*

Choose to Get it Later

• Don’t request any advance payments • Consumer pays the entire monthly plan premium• Consumer claims the full amount on the tax return they file for the coverage

year

Cost-Sharing Reduction (CSR)

• A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and copayments

• CSR subsidies are automatically applied on the federal Marketplace for individuals/families with income between 100 and 250% of the federal poverty level ($11,670-$29,175 for an individual)– A silver plan must be selected to take advantage of CSR

Copayment

• A fixed amount you pay for a covered health care service, usually when you receive the service.

• The amount can vary by the type of covered health care service. – For example, Jane pays $15 to see her primary care physician, $25

for her cardiologist and $20 for her brand-name prescriptions

Deductible

• The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay.

• For example, Jane’s deductible is $1000, her plan won’t pay for anything until she’s met her $1000 deductible for covered health care services subject to the deductible. – This deductible may not apply to all services.

Coinsurance

• Percentage of allowed charges for covered services that you are required to pay after you have fulfilled the deductible.

• For example, Jane’s health insurance or plan’s allowed amount for an office visit is $115, and she’s met her deductible–her coinsurance payment of 20% would be $23.– The health insurance or plan pays the rest of the allowed amount—

$92.

Out-of-Pocket Maximum

• The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount.

• This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover.

• Some health insurance or plans don’t count all of your copayments, deductibles, coinsurance payments, out-of-network payments of other expenses toward this limit.

Explanation of Benefits (EOB)

• Summary of health care charges that your health plan sends you after you see a provider or get a service.

• It is not a bill—it is a record of the health care you or individuals covered on your policy got and how much your provider is charging your health plan. If you have to pay more for your care, your provider will send a separate bill

Health Maintenance Organization (HMO)

• A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage

Preferred Provider Organization (PPO)

• A type of plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers.

• You pay less if you use providers that belong to the plan’s network, and you can use doctors, hospitals and providers outside of the network for an additional cost

Explaining Appeals: Insurance Company

• Insurers must tell consumers why they’ve denied any claim or ended coverage, and they must inform about the appeals process

• There are two ways to appeal a health plan decision:1. Internal Appeal: a consumer may ask their insurance company to

conduct a full and fair review of its decision. If the case is urgent, the insurance company must speed up this process.

2. External Review: a consumer has the right to take their appeal to an independent third party for review. The insurance company no longer gets the final say over whether to pay a claim

Explaining Appeals: Marketplace

• A consumer may file an appeal for the following types of Marketplace decisions:– Eligibility to buy a Marketplace plan– Eligibility for a special enrollment period – Eligibility for lower costs based on income– The amount of savings the consumer is eligible for – Eligibility for Medicaid or CHIP– Eligibility for an exemption from the individual responsibility

requirement

• He or she can write a letter to the Marketplace or use an appeal request form for Indiana

• Appeal decisions are made within 90 days

Explaining How to Report Life Changes

• It is extremely important to remind consumers that they must report changes such as:– Marriage, divorce or death of a spouse– Birth, adoption or placement of a child – A permanent move outside the current insurer’s

coverage area– Involuntarily losing health coverage from events

such as end of job-based coverage, losing eligibility for Medicaid or CHIP, aging off a parent’s policy, COBRA expiration, decertification of a health plan

– A change in income or household status that opens up eligibility for premium tax credits or CSRs

– Change in citizenship status

Explaining How Health Insurance Works

• Health insurance is a contract – You compare plans – You choose a plan and enroll– You pay a monthly premium and other

costs – The insurance company pays a

predetermined part of your healthcare expenses and you pay part

– You get access to health care

Explaining How to Choose a Health Plan

• Compare plans based on the coverage you need – What is covered and your needs – Your preferences (doctors, hospital, etc.)– The costs– Marketplace plan categories—actuarial value

PLATINUM

GOLDSILVERBRONZE

Higher Premiums

Lower Premiums

60% 70% 80% 90% Percent of Total Cost of Care Covered

Lower Consumer Cost-Sharing Higher Consumer Cost-Sharing

Explaining How to Choose a Health Plan

• Deciding which plan can be a challenge, so it is important to help the consumer consider health and financial situations when comparing plans on the Marketplace– Someone expecting to have a lot of health care visits or regular

prescriptions may be better off with a Gold or Platinum plan that pays a higher percentage of the costs

– On the other hand, a healthy individual who does not expect to have many health care bills may be comfortable choosing a Bronze or Silver plan

Comparing Health Plans—Important Checklist

• Review plan information– See if their doctor is in the plan (in-network)– See what prescription drugs are covered (plan

formulary or list of covered drugs)• What is the cost?

• Does the plan have a convenient pharmacy?• Check plan rules

– Does a consumer need a referral (primary care doctor refers you or pre-authorization (plan’s permission) before they see a specialist, or can they go to one directly)

Explaining How to Use Health Insurance

• Use familiar language, and limit the amount of information you provide to a manageable amount

• Check for understanding– Make sure the consumer walks away knowing what their next steps

are – Continue working with consumer if you sense hesitation or confusion

• Utilize visuals and keep the conversation interactive – KFF’s YouToons or Healthcare.gov’s YouTube channel for helpful

explanation videos—many individuals learn better visually or through interactive activities or tutorials

• Facilitate healthy decision-making by asking questions and explaining in detail

Improving Health Insurance Literacy

• Know the terms and how to explain them in clear, concise ways

• Use materials that are accessible, user-friendly and easy to navigate– Organize your information so that the most important points come first – Use translations that are adapted for readers with limited literacy skills

• Hold educational events open to the public at your local library, public space or health center in nontraditional hours

• Remember that Remember that everyone’s health care needs and health everyone’s health care needs and health literacy levels are differentliteracy levels are different, and it is your job to help them find , and it is your job to help them find a plan that meets their needsa plan that meets their needs!

EDUCATING OUR PEERS ON ASSISTER ROLES

Explaining What a Navigator Is

Tell your consumers and peers that you are:•A trained and certified professional through the Indiana Department of Insurance and Centers for Medicare and Medicaid Services •Prepared and capable to determine coverage eligibility, assist with coverage applications, answer questions about health insurance, and plan or participate in outreach events•Willing to connect individuals to different resources and information in the healthcare system and your community

Educating Your Health Center Staff

• Both clinical and non-clinical staff in your health center can benefit from knowing more about your position and responsibilities as a Navigator and CAC

• Identify the stakeholders in your organization—anyone who touches consumers via the written word, spoken word, or the web– It is important to let your colleagues know how low health literacy

impacts your community and how you can work together to improve access to affordable health care

– Capitalize on individual staff expertise by building an internal referral system for consumer questions and concerns—know who to ask!

Advocating for Health Literacy in Your Health Center

• You can advocate for health literacy in your organization– Use this information to make the case for health literacy improvement

—most staff members are in a position to educate and encourage patients to enroll

– Incorporate health literacy into mission and planning • Convene a work group or committee to develop a health literacy agenda

for your organization

• Include health literacy in grants, contracts, and memorandums of understanding

– Establish accountability for health literacy activities – Include health literacy in staff training and orientation

• Make a presentation on health literacy at your next staff meeting

• Circulate relevant research and reports on health literacy to colleagues

• Post and share health literacy resources

Advocating for Health Literacy in Your Health Center

• Host a workshop or panel discussion about health insurance literacy• Create informative, flashy bulletin boards or posters in an area with

a lot of foot traffic• Promote a contest for developing a catchy phrase for encouraging

consumers to enroll in coverage • Involve the entire health center in planning a health literacy outreach

event with agenda like: – ACA and health coverage outreach

– Free blood pressure checks and other health screenings

– “Ask a nurse/physician” booth

– Flu shots

– Games and activities for children

Advocating for Health Literacy in Your Community

• October is Health Literacy Month• Use this month to build awareness

about the open enrollment period, educate about health coverage options, and encourage consumers to commit to enrolling There are many community festivals and events during

October as well as other health-related holidays to partner with such as National Breast Cancer Awareness month, National Disability Employment Awareness Month, National School Lunch Week (11-15th), Mental Illness Awareness Week (4-10th), and National Child Health Day (4th)

Advocating for Health Literacy in Your Community

• Consumers who understand health care information may:– Follow more fully instructions on medications– Call back less often– Visit less often– Have fewer hospitalizations– Have better health outcomes– Have increased patient satisfaction

Start being a health literacy hero now!Start being a health literacy hero now!