Erin Hart from American Healthcare Group discusses Healthcare Basics and How to Choose Your Health Plan. Navigating through deductibles, out-of-pocket expenses and coverage benefits can be overwhelming; get guidance from experienced and independent healthcare professionals.

1. HEALTHCARE BASICS: HOW TO
CHOOSE YOUR HEALTH PLAN

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

4. 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

5. 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

6. 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

7. 9/19/2016 7
INDIVIDUAL ENROLLMENT
 Open Enrollment – November 1 – January 31,
2017
 Special Enrollment Periods – new baby,
change in marital status, loss of employer
coverage
 CHIP/Medicaid

8. COST EXAMPLE
Married couple (43 & 48 years old) w/3 kids in
Allegheny County
 Bronze plans $640/month w/$12,000 family
deductible = $7,680/year
 Silver plans $800/month w/$6000 family
deductible = $9,600/year
 Gold plans $950/month w/$1,500 family
deductible = $11,400/year
 Platinum $1,700/month w/$500 family
deductible = $20,400

9. 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

10. MEDICAL ASSISTANCE: MEDICAID
 Find out if you’re eligible: http://www.phlp.org/quickscreen-
questionnaire (Pennsylvania Health Law Project)
 Single Monthly Income Limit: $1,367 – 1 person; $1,843 – 2
people; $2,319 – 3 people

12. MEDICARE BASICS
 65 or older
 Social Security Disability for 24 months
 End Stage Renal Disease
 Retiree Coverage
 Medicare Advantage vs. Medigap plans

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