Transcript The Affordable Care Act - Korean Medical Program

뉴저지 건강보험
Healthcare.gov
Plan Levels of Coverage
Plan Pays
On Average
Enrollees Pay
On Average*
(In addition to the monthly
plan premium)
Bronze
60%
40%
Silver
Gold
70%
80%
30%
20%
Platinum
90%
10%
Levels of
Coverage
*Based on average cost of an individual under the plan and may not be
the same for every enrolled person
July 1, 2013
DRAFT - Current Topics
4
Catastrophic Coverage
 Who is eligible?
• Young adults under 30 years of age
• Those who can not afford coverage and
waiver from the
Marketplace
obtain a hardship
 What is catastrophic coverage?
• Plans with high-deductibles and lower premiums
• Includes coverage of 3 primary care visits and preventive services with no
out-of-pocket costs
• Protects consumers from high out-of-pocket costs
July 1, 2013
DRAFT - Current Topics
5
NJ 건강보험 플랜
 3개 보험회사 에서 제공하는
35 가지 종류 보험
 Horizon Blue Cross Blue Shield of New
Jersey (5)
 AmeriHealth New Jersey (16)
 Health Republic Insurance of New Jersey
(14)
Essential Health Benefits
1. Ambulatory patient
services
2. Emergency services
3. Hospitalization
4. Maternity and newborn
care
6. Prescription drugs
7. Rehabilitative and
habilitative services and
devices
8. Laboratory services
9. Preventive and wellness
services and chronic
disease management
5. Mental health and
substance use disorder 10. Pediatric services,
services, including
including oral and vision
behavioral health
care
treatment
05/09/2013
A New Way to Get Health Insurance
7
보험 선정시 고려 사항
 Monthly 보험료
 Co-payment
 CoInsurance
 Deductible
 Out of Pocket Maximum
 Network – 의사와 병원, 기타 의료업체
How does health insurance work?
 예를 들어, 심장수술을 $100,000 heart surgery,
가정하여 어떻게 medical expense 가 pay되는지?
 가지고 있는 보험 혜택
•
•
•
•
$20 Co-payment
$1,000 annual deductible,
20% coinsurance after deductible,
$2,000 out-of-pocket limit per year.*
What is Co-payment?
 Specific flat fee you pay for each medical service,
 $30 for an office visit, after which the insurance company often
pays the remainder of the covered medical charges.
 Let’s say you are not feeling well and went to see your doctor
who charges $200 for the office visit. If your insurance plan has
an office visit co-payment of $30, then you will only be
responsible for the $30 and the insurance company will cover
the remaining $170.
What is a Deductible?
 Must pay first each year before insurance plan
starts to pay for covered medical expenses.
 So with a $100,000 heart surgery bill, you are
responsible for paying the first $1,000.
 After this $1,000 deductible is met, the insurance
company will pay a percentage of the bill in what
is called the coinsurance.
What is Coinsurance?
 Cost-sharing - Paying a certain percentage and the
insurance company will pay the remaining percentage of
the covered medical expenses after your deductible is
met.
 예로 20% coinsurance 인경우,
 먼저 Deductible is met, insurance company will pay 80%
of the covered expenses while you pay the remaining 20%
until your out-of-pocket limit is reached for the year.
What is Out-of-Pocket Limit?
 Maximum amount you will pay out of your own pocket for
covered medical expenses in a given year.
 예를 들어 $2,000 out-of-pocket limit, you will pay a $1,000
deductible and $1,000 coinsurance
 Insurance company covers the remaining $98,000 of the
heart surgery bill.
 If you are hospitalized again in the same year, the
insurance company will pay 100% of your covered
expenses.
How the Insurance Works?
Health Maintenance Organizations (HMOs) and Exclusive
Provider Organizations (EPOs)
 HMOs and EPOs may limit coverage to providers inside their
networks.
 A network is a list of doctors, hospitals, and other health care
providers that provide medical care to members of a specific
health plan.
 If you use a doctor or facility that isn't in the HMO’s network,
you may have to pay the full cost of the services provided.
 HMO members usually have a primary care doctor and must
get referrals to see specialists. This is generally not true for
EPOs.
Preferred Provider Organizations (PPOs) and Point-ofService plans (POS)
 In Network or Out of Network.
 With PPO or POS plans, you may use out-of-network
providers and facilities, but you’ll have to pay more than if
you use in-network ones.
 PPO plan, you can visit any doctor without a referral.
 POS plan same as HMO, you can visit any in-network
provider without a referral, but you’ll need one to visit a
provider out-of-network.
High Deductible Health Plan (HDHP)
 Lower premiums and higher deductibles than
traditional insurance plans
 HDHP, use a Health Savings Account or a health
reimbursement arrangement to pay for qualified
out-of-pocket medical costs. Federal tax saving.
 2014 HAS Limit

2014
2013
Maximum Annual
Contribution
Self-Only Coverage
Limit
Family Coverage
$3,300
$3,250
$6,550
$6,450
Catastrophic Health Insurance Plan
 A catastrophic health insurance plan covers
essential health benefits but has a very High
Deductible.
 “Safety Net" coverage in case you have an
accident or serious illness.
 No prescription drugs or shots.
 Premiums for catastrophic plans may be lower
 Under 30 years old.
Horizon Blue
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Advantage EPO Essentials EPO | Catastrophic
onthly premium for Only you $185.92
Advantage EPO Bronze EPO | Bronze
Estimated monthly premium for Only you $285.87
Advance EPO Silver EPO | Silver
Estimated monthly premium for Only you $292.00
Advantage EPO Silver EPO | Silver
Estimated monthly premium for Only you $322.69
Advance EPO Gold EPO | Gold
Estimated monthly premium for Only you $363.32
Advance EPO
 Must select a Primary Care Physician to
coordinate care and
 Provide referrals to specialists who participate
 For non-emergency care, choose to maximize
their benefits by using Preferred Tier 1 hospitals.
 Members can also access other hospital in the
Horizon Hospital Network but will have higher out
of pocket costs.
Advantage EPO
 Access to all doctors, specialists and hospitals that participate
in Horizon BCBSNJ's Managed Care Network.
 Key Features
• Medical and pharmacy benefits
• No Primary Care Physician (PCP) selection required
• Lower out-of-pocket costs when care is coordinated through a selected
PCP
 The Horizon Advantage EPO plans provide integrated medical
and pharmacy benefits, including wellness and emergency
care.
 Although members are not required to select a Primary Care
Physician (PCP), there are lower out-of-pocket costs when care
is coordinated through a PCP.
®
AmeriHealth
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New Jersey
NJ Select Local Value Silver HMO
Estimated monthly premium for Only you $264.13
NJ Standard Local Value Silver EPO H.S.A.
Estimated monthly premium for Only you $279.55
NJ Premium Regional Preferred Bronze HSA EPO Bronze
Estimated monthly premium for Only you $284.41
NJ Premium National Access Bronze HSA EPO | Bronze
Estimated monthly premium for Only you $298.63
®
AmeriHealth
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New Jersey
NJ Standard Local Value Gold HMO | Gold
Estimated monthly premium for Only you $303.32
NJ Standard Local Value Gold EPO H.S.A. EPO | Gold
Estimated monthly premium for Only you $340.39
NJ Premium Regional Preferred Silver EPO EPO | Silver
Estimated monthly premium for Only you $342.90
NJ Premium National Access Silver POS+ | Silver
Estimated monthly premium for Only you $360.11
NJ Standard Regional Preferred Gold EPO | Gold
Estimated monthly premium for Only you $376.19
Features of Amerihealth EPO
 Free to visit in-network providers and hospitals directly: No
referrals are required;
 No PCP to coordinate care;
 More than 12,500 doctors and 63 hospitals in the Value
Network.
 Option to add an HSA on the 50% coinsurance plan;
 wellness programs, including fitness reimbursement and
discounts on alternative health care services, are included at no
additional cost;
 enhanced programs to control and manage chronic conditions
are available;
 preventive care for children and adults included;
Amerihealth NJ
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NJ Premium National Access Gold POS+ | Gold
Estimated monthly premium for Only you $437.06
NJ Select National Access Platinum POS+| Platinum
Estimated monthly premium for Only you $478.01
Health Republic Insurance of
New Jersey
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Catastrophic Plan EPO | Catastrophic
Estimated monthly premium for Only you $223.03
PrimeBronze EPO | Bronze
Estimated monthly premium for Only you $297.37
SolidBronze EPO | Bronze
Estimated monthly premium for Only you $297.37
SolidSilver EPO | Silver
Estimated monthly premium for Only you $328.72
PrimeSilver EPO | Silver
Estimated monthly premium for Only you $330.17
CO-OP plan
 Consumer Operated and Oriented Plan Program
 The Affordable Care Act calls for the establishment of the
Consumer Operated and Oriented Plan (CO-OP) Program,
which will foster the creation of qualified nonprofit health
insurance issuers to offer competitive health plans in the
individual and small group markets.
 Cost-effective & comprehensive healthcare coverage from New
Jersey's only health insurance CO-OP. Shop our plans and find
one that's right for you.
Prime
 Include four visits with no out-of-pocket expenses to a primary
care doctor. Additional preventive and wellness benefits are
also covered.
 Referrals required for specialists
 Access to one of New Jersey's leading provider networks
 Integrated wellness and alternative care programs
 Out-of-area coverage for emergency services
Core
 Use co-pays to cover regular costs, such as prescription drugs
and visits to primary care doctors and specialists.
 Office visit co-pays that keep your ongoing healthcare costs low
 Referrals required for specialists
 Low cost generic and brand drugs
 Cost-effective premiums and low deductibles
 Access to one of New Jersey's leading provider networks
 Integrated wellness and alternative care programs
 Out-of-area coverage for emergency services
Solid
 Co-insurance plan
 Instead of paying a higher monthly premium, you will pay a
percentage of the cost for your health services.
 For added security, tax savings through a Health Savings
Account (HSA)
 Access to a health savings account (HSA) that rolls over
unused funds to the next year
 Access to one of New Jersey's leading provider networks
 Integrated wellness and alternative care programs
 Out of area coverage for emergency services
Health Republic Insurance of
New Jersey
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CoreSilver EPO | Silver
Estimated monthly premium for Only you $337.48
SolidGold EPO | Gold
Estimated monthly premium for Only you $372.60
CoreGold EPO | Gold
Estimated monthly premium for Only you $375.28
CorePlatinum EPO | Platinum
Estimated monthly premium for Only you $413.99
7 Gold health plans
뉴저지 Plan HorizonBlue
3인 가족(자녀 1명) Income $45,000
Qualified Health Plans Can Vary
 Some may cover additional benefits
 You may have to see certain providers
 The premiums, copays, coinsurance
 Quality of care
 Some special types of plans
• Like high-deductible plans
05/09/2013
A New Way to Get Health Insurance
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보험 가격 결정 조건
 Where you live.
거주 지역 Right state and County first.
 5 plan categories.
Bronze, Silver, Gold, Platinum, and Catastrophic.
 Age and family situations.
Single, Couple, Parent with Children, Family.
감사합니다. Thank You!
Jae Chun 전 재 현
718-306-4176
j
[email protected]
Certified Agent for Marketplace NY & NJ
www.healthcarekorean.com
05/09/2013
A New Way to Get Health Insurance
45