Basic Training Getting Started A free, unbiased service, sponsored by the Washington State Office of the Insurance Commissioner
Welcome to Basic • In the next two days you will be presented with an overview of the topics that you need to advise clients. • You are not expected to remember everything you learn here! • The main goal is to help you learn where to go to find the answers you need in any counseling situation.
Welcome to Basic • At the end of the overview, you will take an open book exam. • Once you have passed this exam, you will be certified as a SHIBA Volunteer. • This is not the end of your training, it’s the beginning of a rewarding journey!!!
Basic Training Topics • Welcome to SHIBA • Insurance 101 • Medicare Introduction: • Part A • Part B • Part D • Medigaps • Part C
Basic Training • Once you leave this training, you and your volunteer coordinator can decide what your next steps will be. • In-depth training on specific topics • Counseling with a mentor • Go right to work! As a volunteer, you will never be asked to do more than what you are willing and able to do.
Welcome to SHIBA A free unbiased program within the Office of Insurance Commissioner
SHIBA: Statewide Health Insurance Benefits Advisors • First State Health Insurance Program (SHIP) began in our state in 1979 • All states have a SHIP program • Funded by the federal government • In Washington, we are also funded by the state legislature
What we Do SHIBA Mission Statement SHIBA provides free, unbiased information about health care coverage and access to help improve the lives of all Washington residents. We cultivate community commitment through partnerships, services, and volunteering.
Who we Serve People of all ages and backgrounds
How it Works • Funding comes from SHIBA through Federal and State resources • SHIBA uses these funds to award grants to Sponsors in our state to provide SHIBA services statewide • SHIBA provides volunteer training and education • Each sponsor site has a volunteer coordinator that manages the SHIBA program in their area • These programs are staffed by volunteers
Ways we Help Consumers • Assess health coverage needs • Determine general eligibility for programs • Evaluate and compare health insurance plans • Make referrals within our agency and to other agencies • Collect and report possible fraud complaints • Help consumers understand their health care coverage options
Ways We Educate Consumers Community Outreach: • Educational classes • Community events • Individual and group counseling
SHIBA Facts During 2013, our volunteers: • Numbered 570 statewide • Helped 54,252 consumers • Logged 81,863 hours
Volunteer Roles These are the roles volunteers fill: • Outreach • Data Entry • Speakers • Counselors • Event Staff
Common Terms • Premium - what you pay monthly for health coverage • Deductible - annual amount YOU pay before your plan begins paying • Copays – amount YOU pay upfront when receiving services • Coinsurance – the balance YOU pay after your insurance has paid • Maximum out-of-pocket (MOOP) – maximum YOU will pay in a year • Supplement – an additional policy to help YOU pay for services • Coordination of Benefits (COB) – who pays first when you have more than one plan • Explanation of Benefits (EOB) – form sent to clients after services
What is Insurance? • Healthcare services can take a big bite out of a person ‘s or family’s budget so insurance was created to allow another entity (payer) to share the financial risk • The earliest example of this program was a plan sold by hospitals to clients to use if hospitalized • This program soon expanded to include services offered by physicians and other providers • Employers began offering healthcare coverage to employees during WWII in lieu of wage or salary increases • By 1975, 75% of Americans had health insurance through their jobs
What Insurance Isn’t • Insurance is not designed to pay for all of a client’s cost of health care services • Insurance does not cover elective services but does cover those listed in the policy which are deemed medically-necessary • Insurance is not always affordable so many go without • Insurance is not always provided by an employer
Types of Health Coverage Today, there are two categories of health insurance: • Private Plans • Sold and administered by a private company • Plans don’t pay for everything • Public Plans • Offered by government • Examples are Medicare and Medicaid
Cost of Health Insurance • The average cost of private health insurance for an individual is about $8,000 annually • The average cost of private insurance for a family is about $16,000 annually • Workers generally pay about one-third of the annual cost of their employer-sponsored health insurance Source: Kaiser Family Foundation
What Are Other Costs? • Health plans don’t cover all costs • There are some exceptions, but even Medicare only pays 80% of covered benefits • Clients may pay for: • Annual deductible • Copay • Coinsurance • Excluded services
ACA’s Impact on Costs The Affordable Care Act (ACA) appears to be slowing down the rising cost of health insurance. • Focus of care is shifting from quantity to quality • Morepeople will have coverage so less cost-shifting • Care for those with chronic conditions is better managed, thus reducing costs
Where Can You Buy a Health Insurance Plan? • Private plans are available on the Washington Healthplanfinder website www.wahealthplanfinder.org • Licensed brokers and agents • Private insurance websites • Public plans are also available for qualified clients at the Washington Healthplanfinder
Main Plan Types Catastrophic (High Deductible) • These are plans that have a lower monthly premium but a higher deductible Comprehensive • These plans have a higher monthly premium with a lower deductible
Medicare Introduction A free, unbiased service, sponsored by the Washington State Office of the Insurance Commissioner
Getting Started… What is Medicare? • One of the nation’s largest health insurance program, serving over 52 million Americans • Medicare was created in 1965 by congress
The Four Parts of Medicare Medicare and You: Page 15
Medicare Card • Follow instructions on back of card • Client keeps card to accept Part A and B • Client signs card to refuse Part B Jane Doe Front Back Medicare and You: Page 19
Who is Eligible for Medicare? • Age 65 and older • Under age 65 and deemed disabled by SSA • 24 month waiting period • No waiting period if diagnosed with ESRD or ALS • Any US citizen or legal permanent resident (5 year residency required) Medicare and You: Page 15
Automatic Enrollment • Social Security benefits • Railroad Retirement Board benefits Automatic Enrollment for those receiving: Those above receive an enrollment packet: • Mailed 3 months before: • Age 65 • Eligibility date of Medicare Medicare and You: Page 19
When Enrollment is NOT Automatic If client is not receiving SSA retirement income: He/she will need to enroll with Social Security by: • Online at www.ssa.gov • Call 1-800-772-1213 • Visit local SSA office Medicare and You: Pages 20 and 21
When to Enroll in Medicare Initial Enrollment Period (lasts 7 months) • Starts 3 months before client’s 65th birthday • Includes client’s birthday month • Ends 3 months after client turns 65 Special Enrollment Period (other times a client can enroll) • But there may be a penalty if delayed Medicare clients do not have to be retired to enroll Medicare and You: Page 21
When Can Clients Enroll in Medicare? • The later a client enrolls, the later coverage starts: • Could be up to a 3-month wait Medicare and You: Page 21
Example George will turn 65 in May. He enrolled in Medicare in February and it will begin on May 1st. Sally turned 65 in May as well, but she did not enroll in Medicare until August. Sally faces no penalty, but her Medicare will not start until December 1st.
Original Medicare Part A – Hospital Insurance • Inpatient hospital • Skilled nursing facility (limited) • Home health care • Hospice care • Blood Medicare and You: Pages 29-54
Medicare Part A (Hospital Insurance) What does Part A cost? • Most people get Part A premium-free • They or their spouse must have paid FICA taxes for at least 10 years • If they paid into Medicare less than 10 years, they: • Can pay a premium to get Part A Medicare and You: Page 26
Original Medicare Part B– Medical Insurance • Doctor visits • Outpatient hospital services • Tests, lab, x-ray, etc. • Durable medical equipment and supplies • Preventive services Medicare and You: Pages 29-54
Medicare Part B(Medical Insurance) What does Part B cost? • In 2014 most people will pay the standard premium amount of $104.90 per month • Social Security will notify clients if they have to pay more or less than the standard premium • The amount may change depending on the client’s yearly income Medicare and You: Pages 27
Example • Evelyn is a widow and has contributed to Medicare for the last 20 years through her job. She has earned 40 working credits throughout her active work. This means when she enrolls in Part A, it will be premium-free.
Example • Vivian is single and has acquired only 35 credits for Medicare, so she does not qualify for premium-free Part A. Vivian will have to pay a monthly premium of $243 to receive Part A. Vivian can also continue working to earn more credits.
Paying for Parts A&B In addition to Part B premiums (sometimes Part A) • Client pays: • Part A Hospital deductible • Part B yearly deductible • 20% coinsurance for most services • MAY BE OTHER COSTS! Medicare Parts A and B are called OriginalMedicare (OM) Medicare and You: Pages 30-34 Part A; 35-55 Part B
WARNING! Medicare only covers 80% of the cost for services that are “medically necessary” Medicare and You: Page 56
Example • Sarah is diagnosed with glaucoma. Regularly scheduled eye exams for her are considered “Medically Necessary”.
What Does “Allowed Amount” Mean? Example: For a provider who accepts Medicare • Bill is $100,000 • Medicare may allow $60,000 • Provider writes off $40,000 • Medicare will pay 80% = $48,000 • You will owe 20% = $12,000