- [Male Narrator] Living longer, living healthier, living better than ever before.
Welcome to Mountain-Pacific's Healthy Living For Life, a weekly series that gives you the
information, education and expert insight you need to become an active participant in
today's ever changing health care climate.
Here now is today's program host.
- Health insurance in today's world is a must, but understanding your health plan and what
it does and doesn't cover can be confusing, at best.
If you're one of the many whose eyes glaze over at the mere mention of health insurance,
wipe those eyes and stay tuned.
I'm your host, Janet Whitmoyer, and today, we're here to help you understand your health
plan because the best way to save money on your healthcare is to get the most out of
your insurance.
Welcome to Healthy Living for Life, the show dedicated to helping you do just that.
Stay tuned.
- Welcome back.
Joining us this morning is Meg Jacoby.
Meg has over 25 years of health insurance experience.
She's licensed in Montana and understands the nuances of the life and health insurance
markets.
Meg, thanks for being with us this morning.
- Thank you for inviting me.
- Absolutely.
I want to start off with a question about the people who are under the age of 65 who
might be thinking of retiring early and what they should really be thinking about as far
as health insurance plans go.
- When they're under age 65 and they're thinking of retiring, there's many different things
they should be looking at.
Do they have Cobra eligible to them?
What is the cost?
Have they already met their maximum out-of-pockets and deductibles?
Or is it better for them to maybe look at an individual policy?
They can either go direct to the company or they can look through the healthcare.gov and
the federal marketplace.
- [Janet ] Okay, so for the folks that are under 65 that might have a plan through the
marketplace or some other type of insurance, what happens when they turn 65?
Do they lose that plan or how would that work?
- They can actually keep that policy, however, most people find it financially better for
them to come off the individual policy when they're first eligible for Medicare and go
onto a Medicare Plan.
It could be original Medicare paired with a supplement and a drug plan or they could
do a combo plan, like a Medicare Advantage plan.
But, they can come off the month, at the end of the month prior to their Medicare effective
date.
- Okay, that's good information for them to know.
So, going back to the insurance marketplace, you brought that up.
How would people go about enrolling or getting a plan in the marketplace?
What would be the first thing that they should do?
- Well, the first thing I would recommend is that they find somebody to help them with
the process if they're not comfortable doing it on their own.
- [Janet] Okay.
When thy go onto healthcare.gov, they can look at all the plans that are out there and
eligible to them.
If they work with either an agent, a navigator or a certified assistor, they can also help
them with that process because there's many different nuances that go into it.
- Okay, so you brought up the agent and the assistor ideas, if somebody needs that help,
what can those people actually do for them to get a plan?
- They help them identify what is needed to do the application on healthcare.gov because
they need everybody who is in that household has to be on that application, which includes
the names, the date of birth, social security numbers, income also is a big factor in that
because you have to include everybody on that tax income for that household to go under
that application to determine if they're eligible for a subsidy with the healthcare.gov or if
they would be then paying full price.
Or in some cases, they might be eligible for Medicaid.
- So, even if somebody really has a plan and they like it, it might be a good idea to find
somebody to help them because it might change and they might have to provide more complicated
information.
- Yes, yes, correct.
- Okay, so how would somebody go about finding an assistor or an agent to help them?
- They can go into healthcare.gov and there is a place on there where they can actually
locate to find an agent or an assistor.
The assistors are in the healthcare facilities around, a lot of doctors' offices and the
hospitals provide that.
Navigators, they can find around, as well, and agents, they can go directly to the company
and ask who is out there who is also doing individual coverage because not all agents
do individual coverage anymore.
- Okay, so once a person has found somebody to help them with that, what would you recommend
that they do to prepare for the meeting with somebody like you or an assistor?
- Gather up all of the information that they are going to need for that meeting to include
how much they have spent out of pocket to date in their current plan because it may
be better for them to stay on Cobra if it's available to them, but they also want to compare
going onto healthcare.gov and they will need all that information about their household,
dates of birth, the names, the social security numbers, that all has to be input into healthcare.gov
to calculate if they'll get a subsidy or not or be eligible for Medicaid.
- Okay, so once they've got all that information and you're helping them to look for a plan,
can you tell us a little bit about the differences of what they should actually be looking for
in a health insurance plan?
- Well, there're actually four different levels of plans through the healthcare.gov and direct
on the marketplace.
There are your platinum, gold, silver and bronze, they all determine what is eligible
for them in the benefits.
Platinum is the richest, which means it has the lowest out-of-pocket cost to the person.
Bronze is the least expensive, or least expense out of the person's pocket.
- Oh, okay, that's good clarification.
So, when they've gone through all of this and they've decided on a plan, is there a
certain time that they can sign up or enroll in these plans or can they do that at any
time?
- They have to enroll during the open enrollment window unless they have a qualifying event
or a life trigger.
So, the open enrollment window goes from November 1st through December 15th every single year,
no matter what day of the week it falls on.
Now, if they have a life trigger or a qualifying event, which could be moving in or out of
state, married, divorced, had a baby, just lost coverage for some reason other than "I
didn't pay my premium", those would be a life trigger that they could then go onto the healthcare.gov
or apply for a plan.
- [Janet] And you could help them if they felt like they had one of these life triggering
events to work through
- Yes, yes.
- that whole problem.
Now, they have to provide proof of that triggering event within 30 days of applying and if they
don't provide that proof, their plans that they apply for will become null and void.
- Okay, great information.
I would like to take a pause here for a short break and we'll continue this conversation
after these messages.
Stay tuned with us as we learn about what health plans cover and explain all the confusing
insurance terms.
We'll be back.
- Welcome back.
We're talking to Meg Jacoby of Jacoby Insurance and Health Insurance.
So, Meg, I want to talk now about the companies that are actually in the marketplace.
Can you tell us, in Montana, which companies actually sell on the healthcare.gov?
- Absolutely.
We have Blue Cross Blue Shield, Montana Health Co-Op and Pacific Source.
- [Janet] Oh, okay, so it's not a long list.
- No.
- [Janet] Okay.
So, can you tell us what kinds of healthcare services are covered under these plans?
- Yes.
So, all of the plans are going to offer the same essential benefits, and that is a mandate
- Okay.
- by the healthcare.gov, and they cover your outpatient services, which is your doctor
and outpatient care,
- Okay.
- emergency services, hospitalization, which would include surgery and overnight stays,
maternity, including pregnancy and newborn care, mental health and behavioral health,
substance abuse, prescription drugs, rehabilitative services, lab services, preventive and wellness
care.
- [Janet] Wow, that's quite a list.
So, do any of the companies go beyond and offer services beyond what you just listed
there?
- Yeah, some of those do go above and beyond and offer some added benefits, but not all
of them do the same types of things.
- Okay.
- There are some of them out there that are offering wellness incentives.
- [Janet] Oh, okay.
Well, that's kind of a nice benefit then.
- Yeah, they--
- So, you can, you have those options to look at
- Yes.
- and choose from.
- Yes.
- Okay, so for the essential health benefits, do they have deductibles or co-pays that people
are going to be responsible for?
Can you talk about that a little bit.
- Yes, every one of them has a deductible, maximum out-of-pocket, some of them also have
co-pays available too.
So, what a deductible is is if they have a plan that is applying the service towards
a deductible first, that is the first dollar that is going to be paid and it will be paid
by the individual.
So, it could be a $3,000 deductible and then after they have the deductible, they may pay
a co-insurance, which is the percent, which could be an 80/20, you would pay the 20% and
the insurance company might pay the 80% up until the point you would hit a maximum out-of-pocket.
So, the maximum out-of-pocket is the most that that person would pay in that calendar
year for coverage services.
That would include everything that is paid by that person, to include prescription drugs,
doctor, hospital, outpatient, all that would apply to it.
- Okay, so if somebody needed to take a deeper dive into a particular plan, is that something
that you could help them understand what they would need to do?
- Yes, yes.
Most of the plans out there now have higher deductibles than what has been seen in the
past and it's very eye-opening for people when they come in and they say, "Oh my gosh,
the lowest cost plan I have "is $6,550 deductible," it's an eye-opening experience for them and
that's why it's important to talk to somebody who does understand these benefits.
- Okay, great advice.
I want to kind of switch gears a little bit here 'cause we always hear the term in-network
and out-of-network provider.
Can you tell us how that applies or whether it does apply for these types of plans?
- Absolutely.
So, an in-network provider has a contractual agreement with the insurance company to provide
those services at a better cost for the person.
So, if they go into the hospital and that hospital's a participating hospital with the
insurance company, they will not be balance billed for anything above and beyond what
the cost of care would be.
- [Janet] Okay.
Out-of-network means there is not a contractual relationship and they will be paying a higher
cost out of their pocket.
It could also mean they have a separate higher deductible and a separate higher maximum out-of-pocket.
- Okay, that's really good information to know.
Another piece of, or another service that people are usually really interested in are
coverage of drugs under the plans.
Are they covered or how would people go about finding about drug coverage under a certain
plan?
- Most of the plans offer prescription drug coverage, but not all of them offer a flat
dollar co-pay and that's something we didn't talk about earlier.
A co-pay is a flat dollar amount that would be paid for a service or prescription drug.
- [Janet] Okay.
- Now, with the prescription drugs, they're usually put into tiers.
Tier one would be a preferred generic, tier three would be a preferred brand, tier five
might be a high end specialty drug.
So, depending upon the tier, it could either trigger a certain co-pay or if it's a drug
that applies to a deductible, they need to be aware of those up front.
Now, some prescription drugs require pre-authorization.
We encourage people to pick a drug that is on the list, so they don't have to go through
that special authorization process, but some, even approved drugs, have to be pre-authorized
due to the cost of those medications.
- Okay.
Wow, you've given us a lot of information.
So, if somebody sits through all of that and they've chosen a plan, what tips would you
give people?
What is the first thing they should do after they have chosen the plan?
- Well, after they choose the plan, first, the first thing, we want to make sure their
coverage gets activated, so they have to pay their premium.
If paperwork is required to be submitted, they have to do that within 30 days to prove
they are eligible for that coverage, which would mean loss of other group coverage.
And then, enjoy the benefits of the plan, read the documents.
Most people get that information in the mail and they put it in the round file or they
just put it away, but it's important to actually understand what those benefits are.
Take advantage of the preventive medicine benefits that are out there because those
are good things for people to have and most of those are no cost to that person.
- [Janet] Thanks so much, Meg.
You've given us a tremendous amount of really informative information that will be helpful,
I'm sure.
- You're welcome, thank you for having me.
- Absolutely.
Coming up, our next guest will talk to us about how to make the most of our insurance
once we have it.
Stay back with us, we'll be right back after these breaks.
- We're joined now by Kristen Schuster, a project manager with Mountain Pacific.
Kristen's going to talk about some of the exciting things happening in primary care
today and how you, as a patient, can benefit.
Thanks, Kristen, for being with us.
- Thank you.
- Absolutely.
Earlier in the show, we talked about the importance of establishing a relationship with a physician
and developing that plan.
Can you talk a little bit more about how you would go about doing that as patient?
- Absolutely.
I think one of the important things to think about, especially if you have Medicare Part
B, is looking at your annual wellness visit for AWV.
You'll hear that kind of thrown around in the clinics, so that does stand for annual
wellness visit.
It's a 100% covered benefit for you to truly sit down and talk with your provider and make
a plan for the upcoming year.
This could involve preventive maintenance, some chronic care management, as well as care
management services for things that may come up over the year.
It's really a talking visit, it's not a physical exam visit.
So, it's a little bit different than, say, an annual physical.
- [Janet] Okay.
So, you gave kind of a fairly large list of things that would happen.
Can you tell us what else a patient might expect in that annual wellness visit?
- Absolutely.
So, as I said, it's really a talking visit, so you're going to have some information that
is discussed back and forth with your provider.
This could include tobacco screening questions, maybe depression screenings, asking about
your diet, goals for your healthcare and really getting to know you at a deeper level as a
patient.
- [Janet] So, is there something that a patient could prepare for before they go so they can
be ready to talk about some of these things with their healthcare provider?
- Absolutely.
Questions are a great place to start, so if you're new to Medicare, it's a great time
to sit down and talk with your provider about what you can expect with this new insurance.
Medicare is a little bit different than some of the commercial policies that are out on
the market.
Another good place to start is medications.
So, if you're on an extensive list of medications, it's great to either bring a list or, better
yet, bring the bottles with the instructions.
And keep in mind, this isn't just medications that your primary care provider has provided
to you, this could be medications if you were recently discharged from a hospital or if
you're seeing another specialist.
- Okay.
So, when you go in and have this visit with your physician, you're probably seeing other
people within the clinic or the office.
How can these other people, like the receptions and, receptionist and the nurse, how are they
part of this annual wellness visit?
How would that interaction take place?
- Yeah, great question.
So, I think what's really important is with care now moving forward, we're going past
just the nurse and provider being involved in your care.
It's really extended to all people located in the office, so you may find that the registration
process takes a little bit longer because the front desk person may be asking you some
additional questions.
You may find that there's a care manager that comes in the room that does a screening before
the provider comes in the room.
Don't be alarmed, this is just a growing of the care team to provide more comprehensive
care to the patients.
- Okay, so that's great advice.
For some of us, that is going to be a big departure than what we have been used to,
so it's great to know that and help people prepare.
So, I'm understanding, and we hear the term patient centered medical home, is that really
what you're talking about here is that concept in action in this clinic?
- Absolutely.
So, Montana has been really expansive with patients that are medical home over the last
seven years or so.
The medical home is really moving from one-on-one provider to patient care to really incorporating
whole patient care and team care.
So, this is really looking at you, the patient, as a whole and how can these other care team
members really deliver in all areas of your care?
This can include comprehensiveness and coordination with other providers that you may be seeing,
care management, if you've got a complicated condition, like diabetes or high blood pressure,
and really just bringing kind of more team members on board to provide support.
- [Janet] Well, that sounds like a really comprehensive approach and it seems really
wonderful.
One thing that comes to my mind is the cost associated with that.
Is there, does this inflate the cost or can you tell us a little bit more about the cost
for a patient centered medical home encounter?
- Right.
So, the importance has really been to stress treating patients for preventive care versus
treating patients for just sick care.
So, less reactive medicine and more proactive medicine.
With that, providers are receiving greater reimbursement to provide this service from
the insurance companies, like CMS, Medicare Part B and commercial payers in the state.
This isn't adding any additional cost to the patient, it's just giving the providers some
financial support to build these very robust care teams.
- Okay.
So, with a patient centered medical home model, you may not go to all of these different people
or you may not see them at one visit.
Can you tell me a little bit about how your physician or your primary care provider coordinates
all of this in the, maybe in the background that you're not even aware of?
- Yeah.
I think technology plays a huge factor in that.
So, you'll notice now that providers aren't writing in their paper charts anymore, they
have computers.
So, they're documenting in that, so the care team members behind the scenes can really
see what's going on in your overall care.
So, if you're referred out to a cardiologist, the care team members are going to be able
to see that.
You may not need to take advantage of all of the care team members, say, in one visit,
but if you transition care from a hospital setting, maybe you need some additional support.
You may receive a phone call from a care team member that you may not be familiar with.
Maybe a care manager, a nurse case navigator, something like that, but all of those people
are there behind the scenes to meet your needs when you need them.
- So, in a nutshell, is this really what care management is?
- Absolutely.
- Okay.
- Yup.
- So, is there anything more that you would like to share with us on what care management
is or does that basically, is that a good definition for us?
- Well, I think that's a starting point, right?
It's a pretty big, right, pretty big topic.
One of the areas of care management that I think is really evolving and growing is getting
the patients to be very active in developing what we call a care plan.
And so, the patients that are care planned is incorporating not only the clinical goals
of improving your health, but also asking what is important to you.
So, we all know that keeping your diabetes is important, but what's important to you
may be playing with your grandkids or your kids.
- Absolutely.
- So, that's a more meaningful goal for patients and we want to incorporate that into those
care plans and that's really the core of care management.
- [Janet] Great definition, thank you so much.
- Yeah, absolutely.
- [Janet] And thank you for the great information that you shared with us.
- Thank you, thank you.
- I'd like to thank Kristen and Meg and thank you at home for watching.
Until we meet again, stay fit, stay well and stay healthy for life with Healthy Living
for Life.
- [Male Narrator] Healthy Living for Life is brought to you by Mountain-Pacific Quality
Health.
We'd love to hear from you.
If you have suggestions for future programs, visit our website at mpqhf.org or call us
at 406-443-4020.
You can also catch us on YouTube by visiting our website and clicking on the YouTube icon.
Special thanks to Fire Tower Coffee House and Roasters.
Production facilities provided by Video Express Productions.
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