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Your Road Map to Health

Based on the CMS publication
by

Elizabeth Burton

on 30 March 2015

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Transcript of Your Road Map to Health

Your Road Map to Health
Very important to your health is health coverage.
Health coverage

pays for provider services, medications, hospital care, and medical equipment when you're ill.

It is also important when you are well.

Most coverage includes preventative care. We know preventative care helps to keep us healthy. Most coverage includes in this; immunizations, obesity screening and counseling and other services for free.
Know Where to go for Care
You can get health care from many different places like the emergency room - for routine care and recommended preventive services, it is best to see a primary care provider.
Find a Provider
Choosing the right provider is one of the most important decisions you'll make about your health care, and finding the right one can take a little work.
First - make your health a priority - it is important to you and those you care about, and those who care for you.
Hi, I'm Elizabeth!
p. 434-316-4252
513 Church Street
Lynchburg, Virginia 24504
elizabeth@enroll-virginia.com

I'm here to share some ideas with you about better care and a healthier you!


Be sure you eat right, exercise, relax and get a good nights sleep.
Be sure you get the appropriate preventative services.
Be involved with your health choices
Learn more about how to stay healthy and share this information to help your loved ones stay healthy too.
Preventative Health Care includes screenings, check-ups, patient counseling that helps prevent health problems and screenings to detect illness early for best treatment. It is VERY important!
You should have a provider that knows your health needs, he/she can help . . .
to ensure that you get health services that will prevent problems later on.
you make healthy choices, like best nutrition, exercise and medicinal programs
improve your mental and emotional well-being
reach your health and wellness goals.
A good practice is to keep all your health information in one place for easy access.
If you do not have it already - be sure to ask me for a "From Coverage to Care" booklet. The back pages have a place for you to keep a record of this information.
Important health information would include:

Health Plan Name
Policy Number
Group Number
Health Plan Phone Number
Primary Care Provider (telephone and address)
Other Providers (telephone and address)
Allergies
Emergency Contact (telephone and address)
Medications (names and amount)
Pharmacy
Allergies
Emergency Contact(s)
This is VERY IMPORTANT!!!!!

Keep your personal information safe, whether it is on paper, online, or on your computers and mobile devices. Store and dispose of your personal informatiosecurely, ESPECIALLY your SOCIAL SECURTITY NUMBER.
If you have a smart phone - there are various apps available that make it easy to store your health information and easy to bring up when in the doctors office. Be sure to store this information in a secondary place so that your emergency contact can find it should the need arise.
For example: I keep mine on my phone and my emergency contact knows my pass-code - but I also keep a copy in a file cabinet - also known to my emergency contact.
Idea
Other things you might want to keep track of are:
Height and Weight
Body Mass Index (BMI)
Blood Pressure
Cholesterol
Vaccinations and Immunization
Pap Test (women)
Colonoscopy
Mammogram
Other

*include dates and results (be sure you understand the results and the action you need to take based on these results.
You can make a checklist specific to your needs based on your age, gender and pregnancy status by going to:

http://healthfinder.gov/myhealthfinder/

Oh - one more thing, this is a cost tip:

You might be able to receive an annual visit or some recommended preventative services for free like the flu vaccine, obesity screening and counseling for depression screenings. Talk to your provider about what's right for you.
You can get coverage through a broker or through the ACA Marketplace

You can keep your coverage by paying a monthly premium (if you have them)
Insurance plans will differ, by the providers you see and how much you have to pay.

Check with your insurance company or other program (Medicaid and CHIP vary from state to state).
Make sure you understand what services your plan will pay for and how much each visit or medicine will cost.
You should ask your insurance company a
Summary of Benefits and Coverage document
that summarizes the key features of the plan or coverage, such as the covered benefits, cost sharing provisions, and coverage limitations and exceptions.
Are we on the same page?

The term
provider
in this presentation is a health care professional - like a doctor, nurse practitioner, behavioral health care professional.
A
Primary Care Provider
will be the provider you see the most, they will get to know you and will help you keep track of your health over time.

There are some terms that your are going to hear and read over and over when dealing with your insurance coverage.
Let's review them - we want to be on the same page!
A Network-
is the facilitaties, providers, and suppliers your health insurer has contracted with to provide health care services
Contact your insurance company to find out which providers are "in-network". These providers may also be called "preferred-providers" or "participating providers".
If a provider is "out-of-network" it might cost you more to see them.
Networks can change. Check with your provider each time you make an appointment, so you know how much you will have to pay.
A Deductible - is the amount you owe for health care services your health insurance or paln covers before your health insurance of plan begins to pay.
For example, if your deductible is $1,000, your plan won't pay anything until you've met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Co-insurance - is you share of the costs of a coverd health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe.
For example, if the health insurance or plan's allowed amount for an office visit is $100 and you've met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
A Co-payment - or copay is an amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or prescription drug. A co-payment is usually a set amount, rather than a percentage.
For example, you might pay $10 or $20 for a doctor's visit, lab work, or prescription, Co-payments are usually between $0 and $50 depending on your insurance plan and the type of visit or service.
A Premium - is the amount that must be paid for your health insurance or plan. You and /or your employer ususally pay it monthly, quarterly, or yearly. It is not included in your deductible, Your co-payment, or your co-insurance. If you don't [ay your premium, you could los your coverage.
Out-of-pocket maximum is the most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits.


This limit includes deductibles, co-insurance, co-payments, or similar charges and any other expenditure required of an individual for a qualified medical expense. This limit does not have to include premiums or spending for non-essential health benefits.
The maximum out-of-pocket cost limit for any individual Marketplace paln for 2014 can be no more thatn $6,350 for an individual plan and $12,700 for a family plan.
Explanation of Benefits (EOB) - is a summary of health care charges that your health plan sends you after you see a provider or get a service. It is not a bill. It is a record of the health car you or individual covered on your policy got and how much your provider is charging your health plan. If you have to pay more for your care, your provider will send you a separate bill.
This is a sample EOB
Membership Package and Insurance Card
You will probably receive a membership package. This has information about your coverage from your health plan. Be sure you read this and if there is anything you do not understand be sure to call you insurance company and ask them to explain it to you.
The other item you should receive is a
card
or some other form of document that is used as
proof
that you have insurance.
Insurance cards
all look different but have much of the same type of information. If you don't receive a card-call the insurance company and ask them what
document
you should have to show
proof
of this insurance.
Your card will have your name and date of birth
This number is used to identify u so your provider know how to bill your health plan. If your family member are on you coverage, your member numbers will look very similar.
The group number is used to track the specific benefits of your plan. It's also used to identify you so your provider know how to bill your insurance.
Your card might have a lable like HMO,PPO,SA, Open, or another word to describe the type of plan you have. These tell you what type of netsork your plan has and which providers you can see who are "in-network" for you.
Co-payment. These are the amounts that you will owe when you get health care.
Phone numbers . You can call your health plan if you have questions about finding a provider or what your coverage includes. You might find these on the back instead of the front.
Prescription co-payments. These are the amounts that you will owe for each prescription you have filed.
OK, so I told you to call your insurance company and ask questions - but sometimes knowing what to ask is hard, and if you can't think of a question - well, having the conversation about your insurance can't get started.
I am going to give you a list of "starter" questions. Look them over and if you don't know the answer to them, you can contact your insurance and ask. Once you start the conversation - it will be easier.
1. How much will I have to pay for a primary care visit? A specialty visit, A mental/behavioral visit?
2. Would I have to pay a different amount if I see an "in-network" or "out-of-network provider?
3. How much do I have to pay for prescription medicine?
4. Are there limits on the number of visits to a provider, like a behavioral health provider or physical therapist?
5. How much will it cost me to go to the Emergency Room if it's not an emergency?
6. What is my deductible?
7. Do I need a referral to see a specialist?
8. What services are not covered by my plan?
By the way,
If someone else uses your insurance
card or member number to get
prescription drugs or medical care, then
they're committing fraud. Help prevent health care fraud.
Never let anyone use your insurance card.
Keep your personal information safe.
Call your insurance company immediately if you lose your insurance card or suspect fraud.
Ok - All health plans mus provide you with a Summary of Benefits and Coverage. This will have some examples of how the plan might help pay for services. Remember - these are example so look and numbers will be different. You will need to call your health plan to get up-to-date and accurate information.
Where you get help will affect things such as cost, time waiting for care, and follow up.
Remember!!!!

If you find your self in a life threatening situation - call


9-1-1
Not all types of providers and facities take all insurance plans or types of coverage. Call the office before you go to make sure they see patients with your coverage.
Depending on your coverage and personal circumstances, you might find a primary care provider in:
Private medical groups and practices
Ambulatory care centers and outpatient clinics
Federally Qualified health Centers
Community clinics and free clinics
School-based health centers
Urban Indian clinics and tribal health centers
Veterans Affairs medical centers and outpatient clinics
Primary care providers work with patients every d to ensure they get the right preventive services, manage their chronic conditions, and improve their health and well being.
Some places may offer services and supports that vary based on the needs of the community they serve, like community-based services and supports, mental health, dental, vision services, transportation, and language interpretation.
Take time to think about what you need - you're looking for a partner you can trust and work with to improve your health and well-being.
If your health needs are complicated you might have to see more than one type of provider. Let's talk about two common provider types.
Primary Care Provider
is who you'll see first for most health problems. They will also work with you to get your recommended screenings, keep your health records, help you manage chronic conditions, and link you to other types of providers if you need them. If you're an adult, your primary care provider may be called a family physician or doctor, internist, general practitioner, nurse practitioner , or physician's assistant. Your child or teenager's provider may be called a pediatrician. If you're elderly, your provider may be called a geriatrician.
** In some cases your health plan may assign you to a provider. You can usually change providers if you want to. Contact your health paln for how to do this,
Specialist
will see you for certain services or to treat specific conditions, Specialist include: cardiologists, oncologists, psychologist, allergists, podiatrists, and orthopedist.
You may need a
referral
from your primary care provider before you go to a specialist in order to have your health plan pay for your visit.
For some services, your health plan may require you to first get
Pre-authorization
- a decision by your coverage or health plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. This is also called
prior authorization, prior approval or pre-certification.
The right provider
It might take more than one visit to figure out if a provider is the right one for you.
These are the four steps you should follow to find a provider that you can trust. Remember, you need to
TRUST
your provider, you need to
ACTIVELY PARTNER
with your provider.

Your provider and you will work
TOGETHER
so that you can live a long, healthy life.
Cost Tip
Ask your plan if you need prior authorization before you visit your provider. If you don't get pre-authorization, you may be charged for things your health plan would have paid for.
Make an appointment

When you make your appointment, have your insurance card or other documentation handy and know what you want.
Following are some things you might mention to your provider's office and some things they might ask you . . .
Your name and if you're a new patient
Why you want to see the provider (looking for a new provider, yearly exam, wellness visit or you are not feeling well).
The name of your insurance plan (remember to check information about providers in your network)
The name of provider you want to see - if you need to come in quick, they will give you an appointment with a network provider in office that has the soonest opening
If you have a specific need
Days and times that work for you within their office hours.
Also ask
If they can send you any forms you need to fill out before you arrive (this will save time)
What you should bring to the office the day of the appointment.
What to do if you need to change or cancel.
Some offices charge a fee for missed, late or canceled appointments if you don't let them know within a certain time.
Be Prepared for your visit
When you get to your provider's office, check in with the front office staff. Be prepared to give them the following:
Insurance card or other documents
Photo ID
Completed forms (if any)
Your copay, if you have one - get a receipt for your records.
You might have a few more forms to fill out and you will be asked to read and sign off on the privacy policy as required by law.
When you see your provider, tell her:
your family history (show medical records if you have any)
Medications (bring the bottles)
about any concerns or if you have questions (it helps to write them down)
sometimes bringing a family member or a friend who knows you well can help
Know your Rights
You should always be treated with respect and your information kept private. If not speak with someone at the office - this may not be the provider for you.
When you leave this office, you should be able to answer these question:
1. How is my health? What can I do to stay healthy
2. What do I do next? Do I need blood work or another test? so, what is this for? When and how will I get the results?
3. If I have an illness or chronic condition, what are my treatment options? What are the benefits and concerns for each option? What will happen if I don't take care of it?
4.If I need to take medicine, when do I take it and how much do I take? Are there any side effects? Is a generic available?
5. Do I need to see a specialist or another provider? Did I ask my provider for a suggestion? Do I need a referral?
6. When do I need to come back for my next visit?
7. What do I do if I have questions when I get home?

Ask your provider for written materials you can take home to read and a phone number in case you have questions.
If you have medicines to take, tell your provider if you have cost concerns. They may have less expensive alternatives or know of programs that can help you pay for your medicines.
http://doctor.webmd.com/find-a-doctor/specialty/general-practice/virginia/lynchburg
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