Taking Your Financial Navigation to the Next Level: Back to the Basics

September 2021 Vol 12, No 9

Every stage in life is a little different from the next, and that’s what makes health insurance in the United States so incredibly complex, according to Clara Lambert, BBA, OPN-CG, director of financial navigation at TailorMed.

As individuals move through life, they go through different stages, and some of these stages require a certain type of health insurance. Perhaps they go through a period of low income and qualify for Medicaid, which works very differently from the private insurance they might later purchase for themselves, or from a plan purchased under the Affordable Care Act (ACA). Different still are employer-sponsored insurance plans, as well as Medicare plans later on in life.

“The American health insurance system is very complicated, and it’s also ever-changing,” she said at the AONN+ Virtual Midyear Meeting. “Just as people start to feel like they’ve got it figured out, they have to learn something new.”

Understanding Insurance Options

According to Ms Lambert, part of financial navigation is helping people understand their insurance, as well as helping them to discern the differences among the plans available to them.

Medicaid is an insurance plan for people with low income. Usually, after a patient is approved for Medicaid, they are asked to choose a managed care program.

“The managed care Medicaid programs can be a complicated choice, because if the patient chooses a program that’s out of network for where they’re receiving treatment, then there is no coverage for their treatment,” she explained. “So it’s really important that they know which choices are in network.”

However, she also noted the importance of not telling a patient which plan to choose. “If my patients ask me which plan they should choose, I make sure they understand which ones are in network for my facility, so that they have the knowledge they need to make the choice on their own,” she added.

When it comes to the ACA, patients are faced with a multitude of plan choices. The plans are ranked by range of affordability, bronze being the most affordable in terms of premiums (but not necessarily the most affordable as far as deductible and out-of-pocket costs). Silver, gold, and platinum plans cost increasingly more in terms of premiums, but with lower out-of-pocket costs.

Premium subsidies can be used with any metal level, but cost-sharing subsidies can only be used with silver plans.

“As far as I’m concerned, this is very complicated, because a lot of people don’t realize that getting a silver plan is sometimes one of the better options,” she said. “This is because if they do have a reduction in income, they can’t change their plan, but they might be able to have better cost savings just by calling up the ACA and letting them know about their income change.”

Employer-sponsored plans can also be incredibly complicated. When faced with numerous plan choices and options, many people make their choice based solely on the premium price, but Ms Lambert advises against doing this. She recommends using the Table below as a helpful guide when assisting patients in learning to differentiate between plans and make an informed choice of employer-sponsored insurance.

Table

“When you’re looking at plans, it’s really important to look at the whole picture, not just the premium,” she noted.

Medicare Choices

Medicare has 2 paths: traditional Medicare and Medicare Advantage. The term “advantage” can be enticing to people, but according to Ms Lambert, these plans don’t always put patients at an advantage. “These plans can be advantageous, because each person has their own unique situation, but I do think everyone needs to look at that situation and find what’s right for them,” she said.

Traditional Medicare includes Medicare Part A (hospital insurance) and Part B (medical insurance). If patients want drug coverage, they can join a separate Medicare drug plan (Part D). There are no networks involved with traditional Medicare, and also no preauthorizations.

A Medigap plan is supplemental insurance that helps to fill in any “gaps.” Ms Lambert encourages patients to look at the benefits of acquiring a Medigap plan when they turn 65; although they will pay a premium, they’ll have almost 100% coverage. Sometimes a traditional Medicare plan, even with the additional costs of Medigap and Part D, results in cost savings for the patient when compared with a Medicare Advantage plan, she noted.

A Medicare Advantage plan is an all-in-one combination of Medicare Parts A, B, and (most of the time) D. These plans may have a large out-of-pocket maximum, and they may have a $0 premium, but patients are responsible for paying the Part B premium, which is taken out of their Social Security check.

“A lot of times with Medicare Advantage plans, preauthorizations need to be done,” she noted. “There might be step therapy, and you might also have networks to be concerned with, as well as referrals.”

Promoting Health Literacy

To add to the already existing confusion around health insurance options in the United States, surveys have shown that patients just plain do not understand basic insurance terms, like “premium,” “deductible,” “coinsurance,” “copay” and “out-of-pocket maximum.”

When individuals don’t have good health insurance literacy, they delay or forego care because they think it will cost too much. “They even forego preventive care, just because they don’t understand that those wellness visits are covered,” she noted. According to Ms Lambert, while this is concerning, promoting health insurance literacy as a financial navigator is one of the biggest first steps in tackling this issue.

Insurance education is available to financial navigators through resources like individual state Medicaid education (which allows for presumptive eligibility for the healthcare system), certified application counselors through the ACA, and the Medicare Learning Network (web-based training on Medicare).

Tools to assist patients include the Cancer Insurance Checklist (https://cancerinsurancechecklist.org), designed to help patients compare insurance plans when shopping on their state’s health insurance marketplace. Although this tool is technically set up to compare plans on the marketplace, according to Ms Lambert, it can also be used to easily compare other types of insurance plans.

“If we help people understand their insurance, they’ll make good choices,” she said. “If they have a good understanding of insurance terms and concepts, they’re going to ask informed questions, find good plans and be able to read and follow instructions. They’ll be able to take good care of themselves.”

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Last modified: August 10, 2023

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