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Individual health insurance options in the age of health care reform
- 1. Individual Health Insurance Options in the Age of Health Care Reform Presented by Patrice S. Goldfarb Principal Employee Benefits Advisors Group
- 2. TYPES OF INDIVIDUAL POLICIES Health Insurance outside of the Exchange Health Insurance outside inside Exchange Medicare >65 Medicaid Income under 138% of Federal Poverty Limit Child Health Plus
- 3. INSURANCE OUTSIDE OF THE EXCHANGE This includes the same policies that are in the Exchange plus others that may include more benefits or different networks (usually larger ones) than plans in the Exchange. These policies can be purchased with the help of an insurance broker or directly through the carrier via their online website or over the phone.
- 4. INSURANCE IN THE EXCHANGE Steps to purchasing insurance in the Exchange: 1. Establish and account 1. Validate financial information so you can determine the amount of subsidy you qualify for a. Because of the high volume, this can take weeks 2. Review selection of plans you qualify for a. Determine if your physicians participate in the network b. Do the benefits fulfill your needs 3. Complete an application and submit
- 5. INFORMATION NEEDED TO OPEN AN ACCOUNT ON THE EXCHANGE • Address • Telephone Number • Date of birth for each family member • Social Security Number for each person in the household • Citizenship Information • Immigration Status Information • Employment Information • Household Income Information • Medicaid Benefit Information • Unemployment Information (benefits) • Tax information (which may be found o returns, W-2 Forms, etc.)
- 6. EXCHANGE DATA INPUT Steps: 1. Identity proofing 1. Build Household/Non-Income factors for help in determining eligibility 1. Build Household Income 1. Additional Information a. Does your employer offer a health plan b. Income tax deductions 2. Eligibility Determination This process can take weeks
- 7. PLANS IN THE EXCHANGE There are 3 carriers in the New Jersey Exchange: 1. AmeriHealth of New Jersey 2. Horizon Blue Cross/Blue Shield 3. Health Republic of New Jersey
- 8. PLANS IN THE EXCHANGE Plan designs are based on metallic levels Platinum – highest level of benefits Gold – next highest Silver – subsidies are applied to this level Bronze – highest deductibles Catastrophic – only available to those under age 30
- 9. PLANS IN THE EXCHANGE All plans must contain 10 essential health benefits: 1. Ambulatory Patient Services 6. Emergency services 2. Hospitalization 7. Prescription drugs 3. Maternity & Newborn Care 8. Laboratory services 4. Mental health & Substance 9.Rehabilitative & Habilitative Abuse Services Services & Devises 5. Preventive, Wellness Svcs. 10. Pediatric Dental & Vision Care including Chronic Disease Management Plans outside the Exchange also include these benefits
- 10. MEDICARE Eligibility has not changed Part A covers hospital expenses Part B covers medical expenses such as doctor’s fees Part D covers prescriptions Gaps in coverage can be filled in with either a Medicare Supplement or Medicare Advantage plan
- 11. MEDICARE COVERAGE CHOICES Medicare Coverage Choices What It Covers Coverage Directly From: Medicare Part A Hospital & Skilled Nursing costs Federal Government Medicare Part B Doctor’s Office Visits & Outpatient Services Federal Government Medicare Part C Combines into 1 plan, help with hospital costs, doctor ‘s office visits & prescription drug coverage if you want it Private Insurance Companies Medicare Part D Prescription drugs not covered under Parts A & B Private Insurance Companies Medicare Supplement Helps with costs not covered by Medicare Parts A & B Private Insurance Companies
- 12. Two Ways to Get Medicare Coverage Option 1 Part A + Part B + Part D + Medicare Supplement (optional) Option 2 Medicare Advantage Which includes: Part A Part B Part D Additional Benefits (hearing aids, silver sneakers, vision, dental)
- 13. NEW JERSEY MEDICAID PROGRAMS PRESENTED BY ANTONIETTE KOSHYKAR MEDICAID CONSULTANT MEDICAID PROS, LLC
- 14. NJ FAMILY CARE Children 18 and under with higher incomes up 82,425 for a family of four. Parents/Caretaker Relatives with income up to $31,322 for a family of four; must have tax dependent children in their household Adults without dependent children with ages 19-64 and incomes up to 15,282 single/ $20,629 couple) Pregnant Women up to 200% FEDERAL POVERTY LEVEL
- 15. GLOBAL OPTIONS (GO) MEDICAID • Must meet qualifications financially and medically • Must be 65 years of age or blind/disabled • Income limit $2,130 • Asset limit < $2,000 • Provisions for in-home care (maximum 20 hours weekly) or assisted living • IN HOME CARE COST APPROX $18-22/HR. • ASSISTED LIVING COST APPROX $ 4,000-8,000 MONTHLY
- 16. INSTITUTIONAL MEDICAID MUST QUALIFY FINANCIALLY AND MEDICALLY If over straight medicaid limit of $2,130, qualify as medically needy Must be 65 years of age or blind/disabled PROVISIONS FOR SKILLED NURSING CARE Applicants <$2,130 re-certify annually Applicants >$2,130 re-certify every 6 months
- 17. INSTITUTIONAL MEDICAID (CONTINUED) Applicants still need supplemental insurance as medicaid does not carry to hospitalization once applicant leaves nursing facility Medicare is primary insurance always Supplemental plan necessary for total coverage picks up the 20% that medicare does not cover Skilled nursing cost = approx. $10,000=$12,000 monthly in northern NJ
- 18. MEDICAID RESOURCES FOR INFORMATION ABOUT nj Family Care: http://www.njfamilycare.org For information about medicaid programs in bergen county: http://www.bcbss.com/ Bergen County Board of Social Services 216 Route 17 N. Rochelle Park, New Jersey 07662-3300 Tel 201-368-4200 Hours: Weekdays 8:00 am thru 4:30 pm (Tuesday's until 8:00 pm)