The Affordable Care Act

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Healthcare.gov
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Plan Levels of Coverage
Levels of Coverage Plan Pays On Average Enrollees Pay On Average (In addition to the monthly plan premium)
Bronze 60 40
Silver 70 30
Gold 80 20
Platinum 90 10
Based on average cost of an individual under the
plan and may not be the same for every enrolled
person
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Catastrophic Coverage

• Who is eligible?
• Young adults under 30 years of age
• Those who can not afford coverage and
  obtain a hardship waiver from the
  Marketplace
• 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

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NJ ???? ??

• 3? ???? ?? ????
• 35 ?? ?? ??
• Horizon Blue Cross Blue Shield of New Jersey (5)
• AmeriHealth New Jersey (16)
• Health Republic Insurance of New Jersey (14)

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Essential Health Benefits

1. Prescription drugs
2. Rehabilitative and habilitative services and
   devices
3. Laboratory services
4. Preventive and wellness services and chronic
   disease management
5. Pediatric services, including oral and vision
   care

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder
   services, including behavioral health treatment

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• Monthly ???
• Co-payment
• CoInsurance
• Deductible
• Out of Pocket Maximum
• Network ??? ??, ?? ????

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How does health insurance work?

• ?? ??, ????? 100,000 heart surgery, ???? ???
  medical expense ? pay????
• ??? ?? ?? ??
• 20 Co-payment
• 1,000 annual deductible,
• 20 coinsurance after deductible,
• 2,000 out-of-pocket limit per year.

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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.
• Lets 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.

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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.

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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.
• ?? 20 coinsurance ???,
• ?? 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.

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What is Out-of-Pocket Limit?

• Maximum amount you will pay out of your own
  pocket for covered medical expenses in a given
  year.
• ?? ?? 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.

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How the Insurance Works?
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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
  HMOs 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.

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Preferred Provider Organizations (PPOs) and
Point-of-Service plans (POS)

• In Network or Out of Network.
• With PPO or POS plans, you may use out-of-network
  providers and facilities, but youll 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
  youll need one to visit a provider
  out-of-network.

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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 Limit Self-Only Coverage 3,300 3,250
  Family Coverage 6,550 6,450
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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.

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Horizon Blue

• 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

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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.

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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.

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AmeriHealth 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

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AmeriHealth 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

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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
  

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Amerihealth NJ

• 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

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Health Republic Insurance of New Jersey

• 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

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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.

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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

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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

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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

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Health Republic Insurance of New Jersey

• 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

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7 Gold health plans
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??? Plan HorizonBlue
3? ??(?? 1?) Income 45,000
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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

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?? ?? ?? ??

• Where you live.
• ?? ?? Right state and County first.
• 5 plan categories.
• Bronze, Silver, Gold, Platinum, and
  Catastrophic.
• Age and family situations.
• Single, Couple, Parent with Children, Family.

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?????. Thank You!

• Jae Chun ? ? ?
• 718-306-4176
  j
  
• jchun61_at_gmail.com
• Certified Agent
  for Marketplace NY NJ
• www.healthcarekorean.com