Navigating the Health Insurance Marketplace Randy Oates (PSC patient) IronHealth Chief Operating Officer (retired)

Sources of Coverage Employer Sponsored Plans Approximately 45% of Americans receive their health insurance coverage through an employer sponsored plan Employers typically pay about 75% of the employee premium and a much smaller portion of dependent coverage Employer selects plan design (co-pays, deductibles, covered services, etc.) as well as the type of plan(s) offered (PPO, HMO, EPO)

Sources of Coverage (continued) Medicare Administered by the Federal Government Provides coverage for citizens age 65+ as well as certain disabled citizens Funded via payroll taxes on the employee as well as the employer Providers (hospitals and doctors) must agree to accept Medicare reimbursement rates which are typically lower than regular commercial reimbursements

Sources of Coverage (continued) Medicaid Administered by each State with funding provided by the Federal Government Provides coverage for lower income and/or disabled adults and children Providers must agree to accept Medicaid reimbursement rates which are typically lower than Medicare reimbursement rates

Sources of Coverage (continued) Health Insurance Exchange Plans (“the individual market”) Commonly referred to as “Obamacare” Requires participating insurance companies to provide coverage on a guaranteed issue basis with a preset list of minimum coverages Insurance companies are not required to participate and must have rates approved in advance of open enrollment periods Potential changes on the horizon (discussed later in this presentation)

What Impacts the Cost We Pay for Coverage? Who is offering the plan Size of the network (participating hospitals and doctors) Out of network coverage (if available) Benefits offered Cost sharing mechanisms (co-pays, deductibles, out-of-pocket limits, etc.) Drug formulary (approved drugs, tiered drugs, mail order drugs) Centers of Excellence Select group of specialty hospitals for procedures like organ transplants that have agreed to reduced charges in exchange for patient flow. Fortunately, these are normally the best facilities in terms of quality and outcomes

Potential Landmines When Selecting a Plan Your provider(s) are not in the network Drug formulary doesn’t cover your medication(s) or considers them Tier 3 medications No out of network coverage available Your covered child will soon reach age 26 and can no longer be covered under your plan Lower premium may be a result of significantly higher cost sharing

Exception Requests Examples Medication not covered by formulary Out of network provider Who is funding your plan will determine the path you need to follow Employer plan exception requests will vary based on how the plan is funded Self insured employer plans are administered by an insurance company but the employer must approve any exceptions Fully insured plans are managed by the insurance company and they will approve/decline exceptions Medicare and Medicaid requests driven by your provider to Medicare/Medicaid Administration Individual plan requests will be determined by the insurance company

Potential Healthcare Reforms Coming This Fall For Individual Market Individual mandate has been repealed so people are no longer required to buy insurance (only those who need it will buy) Costs will most likely increase as a result Pre-existing conditions limitations may be reinstated Could result in reduced or no coverage for pre-existing conditions Current 3x premium maximum may increase to as much as 9x Maximum premium charge for the oldest person cannot exceed 3x the lowest premium currently More carriers may exit the market Fewer or no options available for coverage