Welcome to the Patient Financial Navigator Foundation Inc

Welcome to the Patient Financial Navigator Foundation, Inc. A community outreach program PFNF Education 2017 1

The PFNF Advisory Board is committed to attacking and transforming the hassle factor --thru education & outreach. Day Egusquiza, Founder and President Daryl Wert, Vice President Jenyfer Stokes, Director Jayme Ketterling, Secretary Vision for healthcare= Integration /Innovation Jodyi Wren, Director Jeremy Egusquiza, Director Karla Carter, Director Rosemary Fornshell, Ad -hoc Special thanks to Kody/Facebook and Jeremy/Webpage Special thanks to the volunteers +CSI/strategic partner – location +St Luke’s /strategic partner – Navigator Resource Library Collaboration = reducing anxiety thru education PFNF Education 2017 2

A Community Outreach Program The Patient Financial Navigator Foundation, Inc with its home base in Twin Falls, Idaho, is thrilled to present free educational programs for patients to attack the hassle factor in healthcare. Day Egusquiza, President, with over 37 years’ experience in healthcare including 20 years at an Idaho hospital, will guide the Patient Financial Navigator Foundation which will create a pathway for patients with multiple educational efforts – thru employers, payers, boot camps– while developing networks and a Resource Library to help navigate thru the maze called healthcare. Transforming healthcare one patient at a time. An advocate for all! NO cost to the Employer for any employer programs. NO cost to the community for any community programs. NO cost to the community for the Boot camps NO cost to the community for the Navigator Resource Library 3

Why create the Patient Financial Navigator Community Outreach Program No one really understands their healthcare insurance until they need it. No one realizes the ‘next steps’ once the medical incident has occurred/been ordered. When a family is in a healthcare crisis, their life is disrupted, scared and vulnerable coordination/communication is required to reduce the hassle factor. PFNF Education 2017 4

The Patient Challenges with Health. Care • No one ‘asks’ to come to a hospital. • Patient’s lives are impacted – they are scared, they feel out of control, they are lost with the overwhelming factors of cost/unknown, multiple providers, and continuing frustration with ‘who knows all of this? ” • Patients are unaware of the many changes with their insurance, government programs, employer’s coverage and all the ‘rules’ associated with getting services paid. • Patients historically access hospitals once a year or less. Healthcare is very personal! 5

But Patients Don’t Speak the Language of Health Insurance Today… 6

…and They May Not Identify with the Language of Value-Based Care Tomorrow We say… Consumers said… Medical home “It sounds just like a nursing home. ” “First you go to the medical home, then you go to the funeral home. ” Integrated care “It sounds like a sales pitch in a cheap brochure. ” Accountable “It’s kind of scary. I am going to go there and something bad is going to happen and someone has to be held accountable for it. ” Value “It means things are cost effective. They are going to keep the value down. You aren’t getting the best care. ” Source: M. Ross, T. Igus, and S. Gomez, “From Our Lips to Whose Ears? Consumer Reaction to Our Current Health Care Dialect. ” The Permanente Journal. Winter 2009, Vol. 13, No. 1. http: //www. thepermanentejournal. org/files/Winter 2009/dialect. pdf 7

Additional ‘factors’ influencing the patient experience= confused=hassle factor Electronic medical record /EHR – incentive and penalties Integrated systems between providers/doctors and hospitals but safety with data sharing a concern. Quality reporting systems –with rewards and penalties Physicians new payment system- MACRA & MIP Alternative payment systems for hospitals, doctors, long term care, DME , home health – all in the midst of rolling out with the goal of increased quality, reduced costs and more engaged patients. What about a change to ‘privatizing’ Medicare? Voucher program -means? 8

IMPROVE THE EXPERIEN Take the Hassle Out of the Experience Hassle Map: Elective Surgery for an Insured Patients- who knows to do this? Get a referral to a surgeon Find out if the surgeon, anesthesiologist, pathologist, and radiologist are in your network Find out if the hospital is in your network Call to get a preauthorization from your health plan (or realize later that you forgot) Worry about whether you will have to pay anything in advance, and if so, how much Figure out where your out -of-pocket costs for preop tests will be lowest (or don’t think about this until you get the bill) Have the surgery Find out how much the operation will cost you out-of-pocket (or hold your breath until the bill comes) map construct developed by Slywotzky (2011). Spend a month dreading getting the final bill in the mail Source: Based on the hassle 9

What is a Pt Financial Navigator program Every hospital /health provider can do any or all three of the unique components. Community Outreach – Boot Camps Employer Outreach – Lunch and Learn for employees Navigator Resource Library- personal pt/family As significant healthcare changes occur along with ongoing ‘healthcare buzz’ updates= PFNF Education 2017 10

Three components of this dynamic program- A community outreach program • Employer program • Build historical info • Lunch & Learn-onsite education with employers • Health. Care Buzz • EOB – how to read • New healthcare changes -national and local • Q&A –as requested by the site • Community programs • Networking with existing services • Creating unique trainings • Identify community healthcare legislative changes -educate • Turning 65 Bootcamp • National ‘new terms: HSA, ACO, Quality based, Managed, Medicare, etc. • Health. Care Buzz • Navigator Resource library * located at local hospital • Employer specific guides • Medicare & ME • Traditional vs Mgd • Translating ‘ease’ • What to expect when? ? • General Education • How to appeal? • Networking with existing services 11

1 st) Example of Community Outreach Education – Boot Camps 1) 2) 3) 4) 5) Identify community leaders to participate in the boot camp trainings Identify thru existing community services, additional healthcare related ‘hassle factor’ training. Provide education to high schools, colleges, regional and others as requested. Join with existing educational efforts – clinical in nature – to add the financial ‘translation’ for ease of understanding ‘what happens now. ” Innovation lab – creating community specific ed. 12

Population Health means… As we look to the transforming nature of healthcare – moving from sickness to wellness including quality/value based services with measurable outcomes vs volume/paid for all services with no quality outcomes required PLUS new commercial payer rules… The Navigator Foundation is in the tent with a multi-disciplined/clinical approach to healthcare – Population Health – managing the chronic, social-economic determining factors, while remembering the pt didn’t ask to get sick, didn’t ask to have their life disrupted and didn’t ask their insurance to pay so little (high deductibles and co-payments) or no insurance at all. Triple Aim. . 1 st=Pt engagement/empowerment. ‘Integration of clinical health and financial health for the holistic approach to population health. ’ PFNF Education 2017 13

Humana’s – Bold Goals program Major % of market is Seniors- Part C Medicare* (HEALTHCARE BUZZ EX) 65% of Seniors have multiple chronic conditions 1/3 have diabetes 1/4 have mental health 10% live below the poverty level 6 doctor visits yearly 27 prescriptions yearly High cost to the healthcare system for ‘navigating thru’ alone. Social-economic issues. EX) Depressed? Not taking chronic meds. EX) Can’t afford meds = ED is next. (Medicaid? ) *Population Health Colloquium. March 27, 2017 Philadelphia PFNF Education 2017 14

Upcoming Community Outreach Boot Camps 2017 2 nd 2017 Boot Camp: “Medicare 101, Social Security Benefits, and Assistance for Seniors” July 6 th CSI Fine Arts 3 rd 2017 Boot Camp: “Turning 65” Oct 28 th 4 th 2017 Boot Camp: “The Language of Insurance” CSI Fine Arts Feb 3 rd CSI All classes are available on the PFNF webpage prior to all trainings. Available for anyone to use. . no cost. 15

2 nd) Example of Employer. Specific “Lunch & Learn” 1. Meet with the HR staff to learn about the employer’s insurance plan. 2. Outline the key elements for education to be covered during the 30 min employee ‘Lunch and Learn. ’ 3. Hot spots for education (usually): EOB education, out of network, what happens when you are scheduled for a surgery and ‘Health. Care Buzz’ ++ Q&A. 4. Innovation lab – taking the education to the employer. 16

Employer Insurance Costs/Changes Healthcare spending 2015 -16 Average Health Savings Account balance for 2015 = $1844 (Can have up to $3400/single; $6750/family) Spending averaged $5141 per individual. Out of pocket rose 3% to aver $813 per capita Average contribution by individuals = $1864 Prescription drugs increased 3. 5 -9% Women of all ages spent $236 more out of pocket than men. Average employer contributions =$948 Average high deductible plan: $2600 -13, 100 /family; $1300 -6550 /single Benefit: Amt deferred for tax impact. Con: Family would have to pay premiums, deductible $, coinsurance $ AND have enough left to put money in the HSA. $649 per capita was spent on brand prescriptions. The price of an ER visit jumped 10. 5% to an aver of $1, 863 Employers contribute about 73% toward the monthly premium for individuals. 38% for dependents. *MCOL 3 -17 17

So now you need healthcare – Outpt surgery (Sample) – in network Surgeon’s office will contact your insurance carrier to get the surgery preauthorized. Insurance carrier has their own criteria for medically necessary services. Many times requires ‘negotiation’ with provider and payer. Routine bills for an outpt surgery- usually each sent separately: Surgeon Pre-op testing ctr) Anesthesiologist Procedure location (Hospital, free standing IMPORTANT: Validate all of the above are within the network that is part of Cigna’s plan. IN NETWORK 18

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Think like a pt – out of network (means what to the pt or family? ) • • • 40 year old has had emergency foot /ankle surgery approx 8 years ago and taken to a Boise hospital. The surgeon specialized in this type of foot surgery. Both in network at that time. 3 surgeries later –still problems with rebuilding the foot to allow the pt to walk. July 2013, employer changes plans and now the doctor and hospital who employees the doctor is out of network. The pt continues to go to the surgeon who does another surgery Oct 2014 and a follow up minor surgery in 2015. Pt was aware of the change but did not know to do anything different as he was in continuing care. Insurance pays significantly lower – no adjustment from charges as out of network/no contract. Pt pays all charges except actual payment to doctors, hospitals, tests. Huge financial hit. What does the employee or pt know of the a) ramifications of out of network, b) prior notice to get approved and c) appeal rights? 21

PFNF Education 2017 22

Let’s look at out of network. Surgery done at out of network hospital • Surgery done at an out of network hospital. • Billed charges: $8000 • Out of network deductible applied: $2000 individual • Hospital bills Cigna; Cigna pays ‘reasonable amt’ that would be paid to IN network providers. • Amt eligible for payment from Cigna: $4400 • LESS $2000 out of network deductible • LESS 50% out of network coinsurance after deductible: $2400 x 50% = $1200 • $4400 -$2000 ded- $1200 coins = $1200 paid to out of network provider/hospital. But the hospital is NOT contracted. Therefore, the hospital accepted the $4400 but left due on the account for the pt to pay: $8000 – $1200 = $6800 from pt. **Out of network deductible: $2000 (Separate from any in network deductible) TOTAL AMT PD BY CIGNA: • **PLUS 50% copayment: $1200 **PLUS balance billing due to no contract: $8000 - $4400 =$3600 TOTAL DUE FROM PT: $6800 23

Making it real – Small Employer Premium “Hits” Small employer in Idaho Premiums have had 23 -25% increase each year/3 years. Currently for 2 employees: *Exchange was not cheaper/similar* $1200 monthly premiums High deductible person: $7000 70/30 coinsurance “Age “ rated … 60 year old Annual $14, 400 in premiums !! UNSUSTAINABLE This was before the new GOP plan for up to 5 x higher than younger premiums. It is capped at 3 x under ACA. BUT WHAT ABOUT INSURANCE REFORM? Rethink the PFNF Education 2017 impact to small employers. No ability to ‘risk share. ’ 24

Health Care Buzz (Ex) 55% of Americans are paying more than last year for insurance. 1 of 4 Americans health worsened after delaying care because of cost concerns 30% said their health insurance coverage has gotten worse in the past year. 1 in 4 lost access to their doctors last year due to insurance networks. (out of network huge costs!!) 3 in 10 delayed emergency care in the last year out of fear of costs Daily. Factoid / MCOL 10 -16 Morning consult PFNF Education 2017 Biggest changes Doctor’s expect to result from Millennial patient habits in coming years. Increased use of telemedicine (28%) Proliferation of walk-in clinic settings (27%) Growth in online scheduling and extended hrs (24%) Greater transparency for out of pocket costs (11%) Easily portable electronic health records (10%) Sprocket Rocket 12 -6 -16 “Millennial patients challenging status quo, over 2900 US doctors say. ” 25

Employment “Norms” in Huge Flux AARP & MIT Agelab (Population Health 3/17) By 2020: 1 in 5 students will be 35 yrs or older. By 2020: 10, 000 will be turning 65 every day By 2020: 1 out of every 5 adults will be over 65; more than under 5 yrs. 57 year old's are the primary owner of IPad. 50% of over 60 year old's use the internet Over 50 years of age = 1/3 of the work force. Family Care Giver: 42 M adults , age 45 -64, providing care for older family/parents. 17%/ 24 M are providing in addition to their ‘day job. ’ Multi-generations in the work force. Norm: 3 -4 generations. (BB and Millennials = both approach ‘work’ differently. ) Health. Exec. Mobile -Multiples 18. 4% of US adults had a mental illness in the past year. 8. 6% reported substance abuse/dependence in the past year Almost 40% had at least one chronic medical condition during their lifetimes 1. 2% had all three conditions: mental illness, substance abuse/dependence and at least one chronic medical condition. AND more than 50% of Americans now have at least ONE chronic health condition, mental disorder or substance use issue. (Taylor & Francis group news – “Psychology, Health, and Medicine” Oct 2016. ) Employees/Pts look different – ages (317) Baby Boomers 51 -69 74. 9 M Generation X 35 -50 74. 2 M – to Surpass BB by 2028 Millennials 18 -24 75. 4 M – HAVE surpassed BB 26

Plus more working past 65… “More Americans age 65 & over are still punching the clock and the last time the percentage was this high was when John F Kennedy was in the White House, 1962. “ “Last month, 19% of Americans age 65 and over were still working, according to government data released Fri. That’s the highest rate since, 1962 and it caps a long trend higher since the figure bottomed out at 10% in 1985. ” Why? Some work to feel engaged. Others do not have enough money to retire. Employee Benefit Institute survey: Nearly 1/3 of all workers with less then $10, 000 in savings will work until 70. *Associated Press 5 -7 -17 Medicare Secondary Payer Older workers care giving for other adults PS By 2020 – 10, 000 people will be turning 65 daily! WOW! PFNF Education 2017 27

3 rd) Examples from the Hospital Navigator Resource Library 1) 2) 3) 4) 5) 6) Thru employer specific meetings, build data base of insurance plans, how to read the EOB, deductibles, etc. 1 on 1 intervention with the patient/family – complete work paper Create glossary of terms Create reference guide for additional community resources Create networking ‘handoffs’ with existing hospital team payment options, social work, estimates, patient experience, physician offices, others Innovation Lab: After Hours Q&A – Weds 5: 00 -6: 00 p. m. ; using patient portal; tracking and trending improvements/feedback; integration with medical community; face to face and automation. 28

Think like the family who is scared with a new ER visit w/insurance, employer specific • Daughter has just been admitted thru the ER. (Inpt vs obs means what to the pt? ) • Parents are scared and distraught about the health of their daughter with the unplanned ‘admit. ’ • As comforting as the care givers are, the financial questions loom large. What happens now? • Who has insurance? What was done with the insurance? What is my coverage? “I have never had to use it before, so I don’t know anything! “ • Think Pt Financial Navigator Program 29

Think like a patient – Medicare Part C/Managed Care – comes to the ER 86 year old with Humana. What is done in the ER to inform the pt this is not traditional Medicare? If the pt is ‘admitting/obs or inpt” – what happens so the pt understands the difference between Traditional Medicare and Part C/Mgd Medicare? Now they are in a bed, what happens so the 86 year old understands their out of pocket, what coverage there is with Humana that may be different than Traditional, is this obs or inpt? Who has this information for our sick, confused Sr who does not have anyone to ask? Care givers/family – who do they ask about the above? Think Pt Financial Navigator Program 30

Included in Every Event/Training“Health. Care Buzz” • Factoid: Health Exec Mobile Mon, March 27, 2017 “Although only 4% of all doctors are emergency physicians, they provide care for: 28% of all acute care visits 50% of all Medicaid and CHIP (children) visits 67% of all acute care to the uninsured patients. • Healthcare Bulletin. The Slate Group. March 30, 2017 “An annual health survey conducted by states and Medicare/CMS found that the full ACA reduced the uninsured rate by 44% while also reducing the number of people without a primary care doctor by 12% and those not having an annual check up by 10%. ” 31

It is all doable. . • Have the vision and the passion to make a difference in the hassle factor in healthcare • Remember – all the automation does not replace the human touch. • Remember – our families are the core of healthcare. • It is very personal! Thanks, Day Egusquiza Founder/President Webpage: Http: //PFNFInc. com Like us on Facebook. com/PFNFInc 32

Welcome to the Patient Financial Navigator Foundation, Inc. “MEDICARE PFNF Education 2017 101” 33

Introduction What Is Medicare? Created 1965 - tax funded n A health insurance program for People 65 years of age and older People under age 65 with certain disabilities People with End-Stage Renal Disease (ESRD) n Administered by Centers for Medicare & Medicaid Services (CMS) (July 1965) n Enrollment by Social Security Administration (SSA) or Railroad Retirement Board (RRB) 3/16/2018 34

Introduction Applying for Medicare n Apply 3 months before age 65 Don’t have to be retired Contact the Social Security Administration n Enrollment automatic if receiving Social Security or Railroad Retirement benefits 3/16/2018 35

Introduction Traditional Medicare Basics Part A Hospital Insurance Part B Medical Insurance Outpt Hospital Services Part D Prescription Drug 3/16/2018 36

Original Medicare The Medicare Card Effective 4 -18, new #-Medicare Beneficiary Identifier/MBI # will be a combination of numbers & uppercase letters Jane Doe 3/16/2018 37

Introduction Medicare Coverage Basics Part A Part B Part D 3/16/2018 n n Inpatient hospital care Skilled nursing care Home health care Hospice care n n n Doctors’ services Outpatient hospital care Preventive services Diagnostic tests Non-hospital based therapies, imaging, surgery centers, labs n Durable medical equipment n Outpatient prescription drugs 38

Introduction Medicare Part A n Most people receive Part A premium free- must have 40 worked quarters n People with less than 10 years of Medicare (3039 quarters)- covered employment Can still get Part A if worked less 30 quarter • Will pay a premium of $248/$441/$407/$411 per month/2012/13/15/16 $413/2017 n For information about Part A entitlement Call SSA • 1 -800 -772 -1213 3/16/2018 39

Introduction Enrolling in Medicare Part B n Pay monthly Part B premium Base with higher amt based on income /beginning in 2007. $99. 90 2012, down from $115 2011, $104. 90/15&16. Average monthly premium for Part B $134 per month 2017 n Initial Enrollment Period (IEP) 7 months starting 3 months before month of eligibility n General Enrollment Period (GEP) January 1 through March 31 each year Coverage effective July 1 Premium penalty • 10% for each 12 -month period eligible but not enrolled • Paid for as long as the person has Part B 3/16/2018 40 • Limited exceptions

Introduction Enrolling in Medicare Part B n Some people can delay enrolling in Part B with no penalty If covered under employer or union group health plan. “Credible Coverage” • Based on current employment – Person or spouse • Will get a Special Enrollment Period (SEP) – Sign up within 8 months after coverage ends 3/16/2018 41

Introduction Paying the Part B Premium n Taken out of monthly payments Social Security /SSA Railroad retirement/RRB Federal government retirement (Plan: Federal BX) Income adjustments can impact the monthly premium. n For information about premiums –call who enrolled them Call SSA, RRB, or Office of Personnel Management n If no monthly payments paid by the above-- Billed every 3 months if no retirement payment Medicare Easy Pay/auto deduced bank acct 3/16/2018 42

Original Medicare Original/Traditional Medicare Plan – Medicare Costs n Go to any health care provider that accepts Medicare - nationwide n Patients are responsible for out of pocket amounts Part A – Inpt deductible • $1156 deductible/2012 /$1184 in 2013/$1260 in 2015 , $1288 in 2016. $1316 for 2017. • Deductible is due every 60 days that the pt is out of the hospital. If out of the hospital/Part A for 60 days = another $1316 inpt deductible is due. If 2 admits within the same 60 day period = 1 -$1316 deductible for the 1 st admit only. – Additional costs after 60 days if no break in services. Coinsurance days 61 -90 $289 per day. /$296 2013/$315 2015, $322 2016. – 91 -150 Lifetime Reserve days $578 per day/$592 2013. /$630 2015 ; $644 2016 – Pt pays 100% after 150 days without a 60 day break • Different costs for other Part A services- with criteria Home Health under Part A if part of a Hospital service - $0 due from pt Home Health under Part B if a ‘free-standing/not part of hospital services. ’ Hospice - $5 for associated meds; small amt for inpt respite; no cost other Mental Health inpt stay - $1316 every 60 days out of the hospital 3/16/2018 43

Additional Payment Issues Part B • $140 yearly 1 x deductible in 2012; $147 2013; $147 2015; $166 2016 $183 yrly 2017 • Physician services – ‘accept assignment’ = accept Part B Medicare payment and only bill the pt the ‘yearly deductible amt & coinsurance amt, per CPT code (visit) • Outpt hospital payment program – “frozen” coinsurance amt per CPT code • Critical access hospitals/under 25 beds –outpt 20% of billed charges for outpt hospital. Same inpt deductible for inpt stays. Same co-payment amount for the physician visit. • Free standing/not hospital based services and physician’s not accepting Medicare ‘assignment ‘ – there can be a balance billing amt. This is the difference between the allowed amt and the payment amt. This amt is in addition to the Co-Insurance per CPT code. This is a choice for this group of providers. 3/16/2018 44

Let’s make this real n Medicare Traditional/Original Inpt: n n Hospital billed for 4 day medical inpt stay. Billed Medicare $16, 900. Medicare pays a flat fee for the entire stay based on the diagnoses that were treated during the stay. *DRG Hospitals are required to ‘accept assignment’ with inpt services and must absorb/write off all charges beyond the DRG payment with consideration of the $1318 inpt deductible. The total payment from Medicare to the hospital: DRG payment *no consideration for charges* less the inpt deductible due every 60 days = Total payment from Medicare. All remaining charges are absorbed. EX) DRG payment collected from the pt TOTAL Medicare $` Amount written off: 3/16/2018 $16, 900 $10, 000 --- from which the inpt deductible of $1, 316 is withheld and $ 8, 684 $ 6, 900 ($10, 000 - $1, 316= $8, 684) 59% of billed charges (difference between DRG payment and billed charges. Required) 45

Another “Real” Example n Outpt Hospital Services - Traditional n n n Outpt Xray is ordered as part of an ER visit Doctor ordered; medically necessary due to the nature of the ER visit Chest Xray 2 V CPT code 77110 Charge: $200 ER level 4 visit CPT code 99284 Charge: $400 Total: $600 Medicare pays according to the CPT code. (Same process with provider offices) Payment: 77100 charges 99284 charges Medicare flat payment: $44. 00 of which the pt pays a froze amt/regardless of $9. 00 ($35. 00 left) Medicare payment: $230 of which the pt pays a frozen amt/regardless of $12. 00 ($218 left) TOTAL Medicare payment: $253 plus pt portion $21. 00 = TOTAL FROM ALL: $274 46% Hospital accepts assignment and absorbs/writes off: Difference between charges $600 - $274 = $326 ***Different for critical access hospitals/under 25 beds 3/16/2018 46

Skilled Nursing Facility + Critical Access = Swing Beds n Requires 3 clinically appropriate days as an inpt to have SNF coverage n 100% coverage of skilled care up to 20 days n 21 -100 days, SNF per day out of pocket of $144. 50 2012/$148 2013/$157. 50 2015/ $161 2016 $164. 50 per day 2017 n Very difficult to meet ‘skilled’ up to 100 days a year. n Long term care/LTC = maintenance = no coverage n Many seniors “ spend down” and live in LTC on Medicaid benefits. 3/16/2018 47

Medigap/Supplemental Insurance Medigap n Health insurance policy to cover the out of pocket deductibles and coinsurance. Sold by private insurance companies Must say “Medicare Supplement Insurance” Covers “gaps” in the Original Medicare Plan/not Medicare Advantage/Part C • Deductibles, coinsurance, copayments • Average monthly premium of $150 3/16/2018 48

Making it real – SS $ with Medicare Monthly Reductions n Women live to 85 yrs n Ave SS $1182 n - Part B premium $134 n - Part D premium $50 n - Plan F supplemental insurance for out of pocket $150 3/16/2018 n Total premium monthly reductions: $334 n Remainder to live on: $848 **Without Supplemental Insurance, all Part A & Part B deductibles and coinsurance would be due from pt –as used. 49

Medicare Advantage/Part C/Managed Medicare n Created from the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. n Private insurance companies are paid a per member-per month fee to manage the Medicare pt. Higher risk based pt = higher monthly fees. n Maximum amt out of pocket to be paid by a pt. $6, 700 2017 $5000 2016. n No ability to purchase Medicare Supplemental insurance for out of pocket n Each insurance plan has their own package of 3/16/2018 50 services; out of pocket; coverage limitations

Medicare Advantage and Other Medicare Plans Medicare Advantage Plans/Part C/Managed – Multiple types n EX) Health Maintenance Organization (HMO) Plans Referral to see specialist Out of network impact for non-emergent care Medicare Part C DOES NOT follow Traditional Medicare rules. Part C is contract driven. Each plan has its own premiums and deductibles. Part C/Advantage is sold by private insurance companies. Healthcare providers must request approval for most services on behalf 3/16/2018 51 of the pt.

What is the Regulation for Managed Medicare? (Dr Ronald Hirsch/Accretive Health, 2016 PA & UR Boot camp**) Medicare Advantage/Part C plans must provide their enrollees with all basic benefits covered under original Medicare. Consequently, plans may not impose limitations, waiting periods or exclusions from coverage due to preexisting conditions that are not present in original Medicare. MA plans need not follow original Medicare claims processing procedures. MA plans may create their own billing and payment procedures as long as providers – whether contracted or not – are paid accurately, timely and with an audit trail. Medicare Managed Care Manual, Ch 4 1 -17 Privately run health plans have enrolled more than 17 M elderly and disabled people – about 1/3 of those eligible for Medicare –at a cost to tax payers of more than $150 B a year. **Same article as slide 21 /added NOTE: Most hospitals have less then 1/3 of their business Managed Medicare – less in rural setting/shared risk too high. 2017 52

Complexity from all directions. Patients impacted • Patients unaware they are ‘seamlessly converted ‘ to the Mgd Medicare Plan when they had the same carrier as a Commercial plan. HOLY MOLY! • See www. washingtonpost. com/national/health-science/senior-surprise-getting-switchedwith-little-warning-into-Medicare-advantage/2016/07/26. • Patients received letter /one of many as they approach 65. They MUST opt OUT of the plan or they are seamlessly being enrolled. “With Medicare’s specific approval, a health insurance company can enroll a member of its marketplace or other commercial plan into its Medicare Advantage plan…which takes effect within 60 days unless the member opts out. ” • Many pts without their doctor and more money out of pocket 2017 53 as didn’t know they were part of a Mgd Plan!!!

BREAKING NEWS - HOLD • Oct 24, 2016 CMS has temporarily stopped accepting new proposals from health insurance companies seeking to automatically enroll their commercial or Medicaid patients into their Medicare Advantage/Part C plans. • CMS disclosed 29 Medicare Advantage companies – including Aetna, United, and several Blue Cross and Blue Shield insurers. Half of the companies received their approval this year. • Members currently are AUTO enrolled unless they opt out. • Dialogue want the pts to OPT IN. . so they have choice. Doctor relationships are huge when the pt is AUTO enrolled. • • www. modernhealthcare. com/assets/pdf/CH 1075661021. pdf www. modernhealthcare. com/article/20161004/news/161009981 2017 54

Medicare Drug Coverage Medicare Prescription Drug Coverage/Part D n Coverage began January 1, 2006 n Available to all people with Medicare A and/or B n Must enroll, not automatic n Provided through Medicare Prescription Drug Plans Medicare Advantage and other Medicare plans Insurance Plans sell Part D 3/16/2018 55

Medicare Drug Coverage Enrollment Periods-Part D n Initial Enrollment Period (IEP) 7 months Starts 3 months before month of eligibility n Annual Coordinated Election Period (AEP) November 15 through December 31 each year Can join, drop, or switch coverage • Effective January 1 of following year n Special Enrollment Period (SEP) – moved out of plan’s service area, LTC, change in 3/16/2018 56 credible coverage.

Medicare Drug Coverage Late Enrollment- Part D n People who wait to enroll may penalty Additional 1% of national base premium for every month eligible but not enrolled Must pay the penalty as long as enrolled in a Medicare drug plan n Unless they have other coverage at least as good as Medicare drug coverage “Creditable coverage” (EX: VA, TRICARE, Retiree drug coverage, Fed Employees) 3/16/2018 57

Medicare Drug Coverage Prescription Drug Plans- Sold thru private insurance companies n At a minimum, must offer standard benefit n Check list of drugs against formulary and tiers Members may pay • Monthly premiums – based on income with the base of $31. 17 per month/2013 - varies by plan going forward. Average $50 monthly • Annual deductible, no more than $320 (plan specific) • True out of pocket/Tr. OOP. Pt pays out of pocket drug costs to $4950 yrly 2017. Met Tr. OOP/donut hole /covr gap • Move to Catastrophic coverage of Part D. Cost reduced to $3. 30 generic and $8. 25 brand. n Can be included in Part C package pricing. 3/16/2018 58

Medicaid and Medicare Savings Programs Medicaid- after Medicare n Joint Federal and state program For Seniors with limited income and resources n If eligible, most health care costs covered n Eligibility determined by state n Application processes vary n Some Medicare/Medicaid pts – low income. Must apply for Medicaid benefits. Potentially pays coinsurance and other out of pocket expenses. n Medicaid is payer of last resort. 3/16/2018 59

Why Is Coordination of Benefits/COB Necessary? n Prior to 1980, Medicare was primary n Federal law changed Medicare Secondary Payer (MSP) • Certain employers’ insurance pays as primary • Determination based on all available insurance Medicare Modernization Act (MMA) 2003 • Requirements for plans providing drug coverage • Improved oversight and communications 60

What Is MSP? n Medicare Secondary Payer/MSP mandates Certain insurance pays health care bills before Medicare pays Identify other insurance that may pay first n Medicare is primary In the absence of other insurance Includes prescription drug coverage 61

Initial Enrollment Questionnaire/IEQ n Improves how MSP information is gathered n Mailed to people About 3 months before Medicare entitlement Requests other health insurance information Five different questionnaires Information entered in Common Working File/CWF • Maintains record of person’s data 62

Other Possible Payers primary to Medicare n No-fault or liability insurance n Workers’ compensation n Federal Black Lung Program n COBRA continuation coverage n Employer group health plans /EGHP Working Aged *19% working over 65 2017* Military coverage (VA and TRICARE For Life) Others 63

Working thru ‘who is primary payer” n Medicare is the only insurance n When the pt is retired. . No MSP n Other source of coverage is Medicaid- payer of last resort Retiree benefits Indian Health Service Veterans benefits and TRICARE for Life COBRA continuation coverage • Except 30 -month coordination period for people with End-Stage Renal Disease (ESRD) 64

Medicare is Secondary n To Employer Group Health Plans (EGHP) Working aged: EGHP with 20 or more employees Disability: EGHP with 100 or more employees ESRD/End Stage Renal Disease= EGHP of any size • 30 -month coordination period n To non-EGHP involving Workers’ Compensation (WC) Black Lung Program No-fault/liability insurance 65

EGHP…Working Aged n Age 65 or older AND Working and covered by EGHP or Covered by working spouse’s EGHP n Medicare is generally secondary payer If employer has 20 or more employees For self-employed, if covered by EGHP of employer with 20 or more employees 66

Large EGHP…Medicare Due to Disability n Have Medicare based on disability AND Working and covered by large EGHP (LGHP) or Covered by LGHP of working spouse • Or other family member n Medicare is secondary payer If employer has 100 or more employees or Self-employed, if covered by LGHP of employer with 100 or more employees 67

EGHP…End Stage Renal Disease/ESRD n Have Medicare and ESRD AND Covered by EGHP of any size Coverage through self or family member Need not be based on current employment n Medicare is secondary payer During 30 -month coordination period Unless Medicare already primary to retiree plan 68

Important Considerations for People With Retiree Coverage n Most retiree plans offer “generous coverage” for entire family Employer/union must disclose how its plan works with Medicare drug coverage Talk to benefits administrator for more information n People who drop retiree drug coverage May lose other ‘creditable” coverage/has 63 days to find comparable coverage with no penalty May not be able to get it back Family members may lose coverage Impact of Part D & recession to Retiree packages 69

For More Information n 1 -800 -MEDICARE (1 -800 -633 -4227) TTY users call 1 -877 -486 -2048 n www. medicare. gov n www. cms. hhs. gov n State Health Insurance Assistance Program (SHIP) n Medicare & You handbook Other publications 3/16/2018 70

When Can I Sign Up for Medicare Part B? Medicare Enrollment Periods: Ø Initial – at age 65 Ø Special – if still working Ø General – January-March 7171

Medicare Has Four Parts Part A - Hospital Insurance Ø Covers most inpatient hospital expenses Ø 2017 deductible $1, 316 Part B - Medical Insurance Ø Covers 80% doctor bills & other outpatient medical expenses after 1 st $183 in approved charges Ø 2017 standard monthly premium $134. 00 72

Medicare Has Four Parts Part C – Medicare Advantage Plans Ø Health plan options offered by Medicare-approved private insurance companies Ø When you join a Medicare advantage plan, you can get the benefits and services covered under Part A, Part B, and in most plans, Part D – Medicare Prescription Drug Coverage Ø Covers a major portion of your prescription drug costs Ø Your out-of-pocket costs—monthly premiums, annual deductible and prescription co-payments—will vary by plan Ø You enroll with a Medicare-approved prescription drug provider not Social Security 73

Time to learn more about Medicare Advantage in our area PLUS MEDICARE SUPPLEMENTAL INSURANCE OFFERINGS 74

MEDICARE COVERAGE Medigap Supplement Medicare Advantage – Part C Medicare vs Employer Plans Welcome Scott Standley, Trudy Dane, Toni Price Hub International © 2017 HUB International Limited.

Medigap Supplement • Original Medicare is good coverage, but it was never designed to cover everything. • Often, people with original Medicare Part A and B want additional coverage for things that are not covered by Medicare, such as deductibles and coinsurance. • Medigap Supplement and Medicare Advantage Part C plans were intended for just that purpose – to supplement Medicare coverages, providing you with a more complete health care package. M e d i c a r e 1 0 1

Medigap Supplement • First determine what you need, picking the plan is for you. • Chronic conditions that require frequent doctor visits, Medigap Supplemental Plan F could be a good choice. • Rarely needed care, Medigap Supplemental Plan A or K (lower premium plans). • Travel outside the United States – Med Advantage Plan C or a Medigap Supplemental Plan F. • As you think about what plan to choose, take a look at your past medical bills to see what kinds of costs you might have in the future. M e d i c a r e 1 0 1

Megigap Supplement Plans • First, the claim is applied to Medicare and if Medicare pays, then these policies will pay according to their coverages. If Medicare does NOT pay the claim, then the Medigap - Supplement plans do NOT pay either. • Medigap Supplemental plans do NOT have prescription drug coverage. You will need to purchase a Part D RX policy. • The following plan examples are Medicare - Supplemental to Original Medicare: (Medigap Supplement plans premiums are age rated, they change every year. ) M e d i c a r e 1 0 1

Medicare (Part A) Hospital Service-per Benefit Period • A benefit period begins on the first day you receive service as an inpatient in a hospital facility and ends after you are out of the hospital and don’t receive skilled nursing care in any other facility for 60 days in a row. The following chart outlines coverage limits for Blue Cross of Idaho Prime 65 A, F, K, M and N. M e d i c a r e 1 0 1

Medicare Advantage Plans Part C • Medicare Advantage Part C plans are an HMO (Health Management Organization) plan. • You will need to declare a Primary Care Physician (PCP). • Some plans require referrals to see any other physician even for in network providers. • Medicare Advantage Part C plans have a network of doctors and facilities for which you will obtain your services. M e d i c a r e 1 0 1

Medicare Advantage Plans Part C • Most Medicare Advantage Part C plans have prescription drug coverage. If they do not, you can not buy a Part D plan. You will need to have VA or other prescription coverage. M e d i c a r e • Medicare Advantage Part C Some have extra benefits not included in original Medicare – Gym Memberships, Vision and Dental options. 1 0 1 • Medicare Advantage Part C plans have copays for services, maximum out of pocket limits and can have deductibles. • Emergency and urgent care is covered as if in network regardless of where you obtain care.

Medicare Advantage Plans Part C • Open Enrollment is October 15 th thru December 7 th for a January 1 effective date. This is the only time you can change your Medicare Advantage Plan Part C. • If you do not like your Medicare Advantage Plan Part C during the year, you can dis-enroll from January 1 st thru February 14 th, buy a Medicare Supplement and a Part D RX card. After February 14 th you can buy a Medicare Supplement, the insurance company can underwrite you and only offer certain plans or deny you coverage. You can NOT purchase a Part D Rx Drug policy after February 14 th. • Medicare Advantage Part C plans are available only in specific counties. Examples are on the next slide. M e d i c a r e 1 0 1

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Cost Comparison • Medigap Supplement plan premiums cost between $190 to $230 per month for a 65 year old depending on the company you purchase from. If you do not have other RX Drug coverage with a Medigap Supplement, you will need a Part D RX policy and premiums range from $25 to $150 per month. • Medicare Advantage plan premiums will cost between $0 to $150 per month depending on your county and can include the Part D RX coverage. Average Premium for a 65 yr. Old Type Part A Part B Medigap Med Adv Part D Rx Drugs Monthly Total Medigap Supplement Free $134 $205 $30 $369 Med Adv Free $134 $74 Included $208 M e d i c a r e 1 0 1

Medicare vs Employer Plans • If an employer has a group plan in place and you turn 65, you can stay on the group plan. It is your option. • It is important to know if your employer plan has creditable prescription coverage. You should receive a creditable or non-creditable prescription letter from your employer. • If your employer plan has non-creditable prescription coverage, you will need to purchase a Part D RX plan. M e d i c a r e 1 0 1

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For More Information Visit Hub International’s table located in the CSI Eagles Nest. Individual or Medicare Plans Contact: Scott Standley- 208 -737 -6875 scott. standley@hubinternational. com Group Plan Contacts: Trudy Dane- 208 -737 -6418 trudy. dane@hubinternational. com Toni Price- 208 -737 -6438 toni. price@hubinternational. com M e d i c a r e 1 0 1