This document provides an overview of health insurance and wellness topics. It discusses how lifestyle factors contribute to many preventable causes of death and influence health care costs. Several health insurance markets and plan types are described, including terms like premiums, deductibles, and networks. Cost examples for individual and family plans are given. Details are provided on Medicaid eligibility and the Medicare program, including Part C Advantage plans. Important dates for Medicare enrollment are listed. Contact information is given for further questions.

1. HEALTH CARE UPDATE
ERIN HART
EHART@AMERICAN-HEALTHCARE.NET
(412)563-7807

2. INTRODUCTION
 Health Insurance is insurance against loss by
illness or bodily injury.
 Health Care is the treatment of illness or
injuries.
 Wellness is good physical & mental health
obtained by healthy diet, physical activity
and healthy lifestyle.

3. WELLNESS AS COST CONTAINMENT
• Don’t have a good diet83%
• Are over weight or obese65%
• Don’t get enough exercise to get the health benefits67%
• Of all causes of death are lifestyle related and
preventable
~70%

4. HEALTH INSURANCE MARKET
 Individual Plans
 Group Plans
 Medicare
 Medicaid
 Workers Comp
 Auto
 Personal Liability

5. HEALTH INSURANCE TERMS
 Premium – monthly cost of policy
 Copay – flat amount charged for health care service
 Coinsurance – percentage charged for health care service
 Deductible – initial payment due to health care provider before
insurance pays
 Out of pocket max – the most the member pays out of pocket –
does not include premium

6. HEALTH INSURANCE TERMS
 Network – the providers that have contracted with the
insurance company
 PPO – Preferred Provider Organization – a product that
has an out-of-network benefit
 HMO – Health Maintenance Organization – a product
that does not have an out-of-network benefit
 Emergency Coverage – most plans allow for emergency
coverage notwithstanding network

7. INDIVIDUAL COVERAGE
 Insurance Companies
 No premium subsidy available
 Healthcare.gov in PA
 Coverage through Insurance Companies
 Premium Subsidies
 Other Cost Sharing covered – copays,
deductibles, coinsurance, out-of-pocket max

8. 12/1/2015 8
INDIVIDUAL ENROLLMENT
 February 15 – deadline for Federal
Marketplace
 Special Enrollment Periods – new baby,
change in marital status, loss of employer
coverage

9. INDIVIDUALS: UNDER 65 PENALTY
For 2015 you'll pay the higher of these amounts:
 2% of your income; (2.5% in 2016)
 $325/adult -$162.50/child; family max $975 (2016 - $695/adult,
$347.50/child; family max $2,085)
 Your health insurance status is recorded on your tax return.
 Exemptions to penalty: https://www.healthcare.gov/health-coverage-
exemptions/exemptions-from-the-fee/

10. HEALTHCARE.GOV – 2015 FEDERAL POVERTY
GUIDELINES
Household
Size
100% 133% 150% 200%
250%
300% 400%
1 $11,770 $15,654 $17,655 $23,540 $29,425 $35,310 $47,080
2 15,930 21,187 23,895 31,860 39,825 47,790 63,720
3 20,090 26,720 30,135 40,180 50,225 60,270 80,360
4 24,250 32,253 36,375 48,500 60,625 72,750 97,000
5 28,410 37,785 42,615 56,820 71,025 85,230 113,640
6 32,570 43,318 48,855 65,140 81,425 97,710 130,280
7 36,730 48,851 55,095 73,460 91,825 110,190 146,920
8 40,890 54,384 61,335 81,780 102,225 122,670 163,560

11. COST EXAMPLES
Married couple (43 & 48 years old) w/3 kids in
Allegheny County
 Bronze plans $640/month w/$12,000 family
deductible
 Silver plans $800/month w/$6000 family
deductible
 Gold plans $950/month w/$1,500 family
deductible
 Platinum $1700/month w/$500 family
deductible

12. COST EXAMPLES
Age Tobacco? Deductible Premium
18 N 1400 206.23
18 N 2700 167.94
18 N 4500 130.88
18 N 6000 137.79
30 N 1400 368.61
30 N 2700 300.18
30 N 4500 233.93
30 N 6000 246.28
50 N 1400 580.04
50 N 2700 472.36
50 N 4500 368.11
50 N 6000 387.54
64 N 1400 974.31
64 N 2700 793.44
64 N 4500 618.33
64 N 6000 650.97

13. MEDICAL ASSISTANCE: MEDICAID
 Find out if you’re eligible: http://www.phlp.org/quickscreen-
questionnaire
 Single Monthly Income Limit: $1,354
 Household size of 4 Income Limit: $2,789
 Pregnant Women: $2,922
 Household size of 4 (Pregnant woman counts as 2): $4,447
 (Will post PA Health Law info now)

14. HOW TO CHOOSE?
 Check network providers
 Annualize monthly premium
 Project services needed in the year (based on known
problems & family history)
 Calculate copays, coinsurance & deductibles for these
service
 Choose most affordable plan

15. GROUP PLANS:
STRATEGIC PLANNING CONSIDERATIONS
• Senior management should make final
decisions
• Determine total annual budget for health plan
• CFO – involved in analysis & plan selection
• 3 Brokers/agents competing for your business
• Assess employee’s health care needs
• Review claims data annually
• Wellness – assessment & incentives

16. GROUP PLANS:
STRATEGIC PLANNING CONSIDERATIONS
 Benefit Structure
 Determine if existing benefit plan is aligned with prevention and wellness goals &
objectives
 Identify screens & tests not covered
 Evaluate the potential costs and benefits of preventive services
 Analyze employee attitudes
 Interest in participating in specific programs
 Barriers to participation in prevention programs
 Perform a Health Risk Assessment
 Health risks and habits of employees and other beneficiaries
 Readiness to change unhealthy lifestyle habits

17. GROUP:
STRATEGIC PLANNING CONSIDERATIONS
 Medical claims analysis
 Identify “top ten” costliest conditions
 Are conditions preventable or related to lifestyle choices?
 Understand services being under- and over-used by workforce population
 Health plan
 Understand existing health plans’ current and potential capabilities
 Ability to incorporate coverage changes
 Ability to track preventive service utilization by employer or by plan
 Efforts to educate primary care physicians about appropriate preventive care benefit
administration
 Ability to support efforts to educate employees about preventive services
 Identify possible gaps between prevention program goals and the capabilities of
health plans
 HIPAA Wellness Incentives

18. MEDICARE COVERAGE DETAILS
Cost Sharing for 2015
 Part A: Generally Free
 $1,260 for a hospital stay 1 – 60 days
 $315/day for a hospital stay for days 61 – 90
 $630/day for a hospital stay for days 91 – 150
 All costs for 150+ days
 SNF - $157.50/day for days 21 – 100 for each benefit period – covered after 3 day
hospital stay
 Part B: $104.90/month
 Hold Harmless Clause – 2016 rates
 $147 deductible, then 20%

19. PART C: MEDICARE ADVANTAGE
 From private insurers
 Medicare Advantage and Medicare Advantage Prescription Drug
plans
 Live in plan’s service area
 Entitled to Part A & enrolled in Part B
 Premiums range from $0 – over $300.
 Copays for services
 Becomes only insurance
 Most include RX benefit

20. PART C CONTINUED
 Services covered that original Medicare doesn’t cover
 Lower cost sharing
 Vision, Hearing, Dental
 Podiatrist & Chiropractic
 Gym Membership
 Combine benefit coverage for hospitals and doctors
 Types: HMO, PPO, SNP, POS
 Considerations: Formulary, Network

21. PACE PACENET
RX Benefit $6.00 & $9.00,
potentially lower based
on income level
$8.00 & $15.00
Premium Benefit Covers the
premium if RX plan
is a partner plan
No premium
benefit
Income Individual Married
Percentage of FPL 133% 120%
Yearly $14,500 $17,700
Monthly $1,208 $1,470
Income Individual Married
Yearly $23,500 $31,500
Monthly $1,958 $2,625
PACE/PACENET Information

22. IMPORTANT DATES
 Timing
 Initial enrollment – 3 months before & after 65
 October 15 – December 7 in 2015 for January 1, 2016 effective date
 January 1 – February 14 – disenrollment
 Anytime throughout the year
 Dual eligible
 Move out of service area
 Institutionalized
 Lose employer coverage
 Low Income Subsidy

23. CONTACT ERIN HART
DIRECTOR, HEALTH BENEFIT SERVICES
EMAIL: EHART@AMERICAN-HEALTHCARE.NET
CALL: (412)563-7807