The Health Insurance Marketplace: What We Learned and How We Can Educate Our Patients

In the concluding article of my journey navigating the Health Insurance Marketplace, questions are answered and the discussion continues about how as nurses we are able to help our patients navigate the Marketplace.

The Health Insurance Marketplace: What We Learned and How We Can Educate Our Patients

How did it go? Did you enjoy your journey? Were your eyes opened? Did you gain a new perspective of what your patients go through to obtain Health Insurance? Do you now have a greater appreciation for the Health Insurance you have? We will be able to discuss this and much more in the comments section below. Let's complete this journey with all of the educational information I was able to find and learn from regarding the Health Insurance Marketplace.

First, let's get some of the confusing terminology out of the way,

HMO

"Health maintenance organizations (HMOs) cover only care provided by doctors and hospitals inside the HMO's network. HMOs often require members to get a referral from their primary care physician in order to see a specialist."1

PPO

"Preferred provider organizations (PPOs) cover care provided both inside and outside the plan's provider network. Members typically pay a higher percentage of the cost for out-of-network care."1

POS

"Point of Service (POS) plans vary, but they're often a sort of hybrid HMO/PPO. Members may need a referral to see a specialist, but they may also have coverage for out-of-network care, though with higher cost sharing."1

EPO

"Exclusive provider organizations (EPOs) are a lot like HMOs: They generally don't cover care outside the plan's provider network. Members, however, may not need a referral to see a specialist."1

Copayment

"A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service."2

Coinsurance

"Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance 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 coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount."2

Deductible

"The amount you owe for health care services your health insurance or plan covers before your health insurance or 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."2

Out Of Pocket Maximum

"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 must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits. The maximum out-of-pocket cost limit for any individual Marketplace plan for 2015 can be no more than $6,600 for an individual plan and $13,200 for a family plan."2

Now that we have gotten that out of the way, the rest should flow a little more smoothly. Let's discuss the different Marketplace Insurance Categories:

Bronze: "Your health plan pays 60% on average. You pay about 40%."3

Silver: "Your health plan pays 70% on average. You pay about 30%."3

Gold: "Your health plan pays 80% on average. You pay about 20%."3

Platinum: "Your health plan pays 90% on average. You pay about 10%."3

Catastrophic: "Catastrophic coverage plans pay less than 60% of the total average cost of care on average. They're available only to people who are under 30 years old or have a hardship exemption."3

As nurses, we can play a key role in working with our patients to help them choose which Marketplace Insurance Category will best suit their needs.

First, start with their current medical history. Are they currently being treated for numerous medical conditions that would require them to access the healthcare system frequently? Do they only see their primary care doctor once a year? Is this the first time they will have access to see a healthcare provider in 10 or 15 years? How many times did they visit the Emergency Room last year? Did those Emergency Room visits lead you to get admitted to the hospital? And how many times? Do they plan on having a surgery this year? How many medications do they take on a daily basis?

Using these questions as a guideline for how frequently they will be accessing the healthcare system will help guide your Marketplace Insurance Category selection. The more times you could see them accessing the healthcare system, the higher health plan paying percentage you would want to guide them towards.

If you did not see them accessing the healthcare system at all, or maybe just for their annual visits then a lower health plan paying percentage might be a better option for them. Also, you will have to take into account what your patient might be able to afford and guide them to the best solution given their financial status.

I will warn nurses to tread lightly when it comes to finances. I trust your judgment, and as nurses, we are able to tell how comfortable our patients are with us. Just to be safe, ask if they don't mind sharing these specifics. You might be surprised that they do not have a problem with it, but if at all you sense they are getting uncomfortable, just stay generic to be safe.

If your patient does feel comfortable sharing their financial information with you, I would encourage you to ask them this question. Do you have a saving account or enough liquid cash that you will be able to pay your Out Of Pocket Deductible today with? If you sense you have to tread lightly, you can also use a general statement here as well. A way to "plant the seed", would be to offer a suggestion about how you save your money for this situation. This way the conversation is being had, but they are not directly being asked the question. Hopefully, fingers crossed, they will revisit the conversation you had with them and they will develop a plan of action to figure out a reasonable solution.

The next question that I thought Americans would like to know would be, does it truly matter what insurance company I bought my plan from? The short answer is, a big YES!

This choice of insurance company determines what hospitals are covered under their plan and what doctors under their plan take this specific type of insurance. Also, the copays vary, the medical management programs they offer vary and what "other" services will be covered vary from insurance company to insurance company.

Just because you have selected a Bronze HMO, does not mean that what is covered under this plan is all the same. The MAJOR difference here is the insurance company you are buying the plan from. When I was sorting through the different plan options, a way I stayed organized was to use the compare function. This way I could flip back and forth easily to compare and contrast plans. I cannot stress enough that what insurance company you choose for your plan and the huge impact it has on what will and will not be covered when you need to use it.

With all of this being said, I can honestly say that this has been a positive and motivating journey. One that I believe my patients will benefit from along with all of the nurses who are reading and interacting with this article. I believe there is an educational gap between healthcare providers, patients and the Health Insurance Marketplace. As nurses, have the ability to help close this gap by taking the time to educate ourselves, and in turn, educate our patients. Making the transition of obtaining Health Insurance and accessing the healthcare system a smoother process.

Now, let's get to work!

To see how this journey began, go to The Health Insurance Marketplace: One Nurse's Journey - Part 1

References

HMO, PPO, EPO: How's a Consumer to Know What Health Plan is Best?

How to Choose Marketplace Insurance: Comparing health plans

How to Choose Marketplace Insurance: Marketplace insurance categories

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Michael M. Heuninckx

About Michael M. Heuninckx

Nurse Practitioner / Author
11 Articles   43 Posts

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Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

Thank you for this information. This will enable us to better help our patients as they attempt to navigate the confusing marketplace.

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.

Thank you for posting this. Because I've been working an on-call position, I've been buying my own health insurance. I got a letter recently from my insurer stating they are getting out of the individual plan business. I have already checked the Marketplace website and did find it confusing. Thanks for helping to clarify and streamline the process. This will also help me to help others who are confused and overwhelmed.

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AGAIN I WILL SAY AS NURSES WE HAVE NO PLACE NOR DUTY to educate people on their health plan choices. It is not in our job description or expected duties. Furthermore on this litigious society, you direct someone towards a plan and they have problems with it, they can and will sue you personally and your won't cover you. They will.simply ask where is your financial planners license and drop you. Heck, here in Houston a lady is suing a neighbor after HERE_URL pit bull got into the neighbors fenced yard and attacked and killed their dog. The pit bull owner got bit when pulling her dog off the neighbor. She is suing the neighbor for goodness sake for failure to secure her dog...it was secured behind her own fence. So helping with someone else's insurance plan info when not doing such as you're regular job can get you sued.

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Specializes in Home Health Case Manager.

Surely not if you offer the information as an educational offering. If need be include a disclaimer. Like " the information I provide to you is not meant as a substitute for advice from your insurance adjuster Nor is it meant as advice or to. tell you what decisions to make"! Or just plain this is meant as information only any decisions you make are solely your responsibility!

How can you NOT help your patient's to understand how the insurance is supposed to work?

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Specializes in Emergency Department.
Surely not if you offer the information as an educational offering.

Nurses play a vital role in educating our patients. One that is critical to the overall welfare of their health. It saddens me that a nurse would fear an opportunity to educate a patient for fear of litigation.

Michael M. Heuninckx RN-BSN

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It saddens me that a nurse would fear an opportunity to educate a patient for fear of litigation.

Michael M. Heuninckx RN-BSN

It is not just a case of being afraid of litigation, which is a real possibility if the patient is unhappy with the plan they select with your assistance, or suffers what they consider to be a bad outcome; it is a question of, in my opinion, not being appropriately qualified to offer such advice. The last time I read the Nurse Practice Act and associated regulations for my state, assisting patients with choosing their health plan was not part of my scope of practice.

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Specializes in Emergency Department.
The last time I read the Nurse Practice Act and associated regulations for my state, assisting patients with choosing their health plan was not part of my scope of practice.

Thank you for your very informative post, it adds an interesting perspective given the topic of conversation. I think that it is important for all nurses to be comfortable with their nursing scope of practice in the state they practice in. I still do see value in nurses becoming educated on the ACA and the Health Insurance Marketplace. Through this awareness, nurses can then help with at least being a resource for direction to places that patients could educate themselves on. Also, could not discuss or advise the patient, but speak to the patient from your perspective and not tell your patient what to do, but share with them what you would do and the questions you would ask yourself when you are looking at purchasing health insurance. So it looks like there is a way, but some creativity might be needed. What do you think?

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I think this was a great way to provide some very confusing information. I might be shopping the marketplace myself next year so any insight on what is offered is a great help. As a side note I offer general advice to my patients about insurance on a daily basis. I explain copays, deductables, premiums, etc. I would NEVER suggest a plan for them to pick, but do offer information about choices. And there will ALWAYS be some story of someone suing someone for something crazy. It happens. Anyone can sue anyone for anything. It doesn't mean the lawsuit goes anywhere.

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Specializes in Critical Care.
AGAIN I WILL SAY AS NURSES WE HAVE NO PLACE NOR DUTY to educate people on their health plan choices. It is not in our job description or expected duties. Furthermore on this litigious society, you direct someone towards a plan and they have problems with it, they can and will sue you personally and your malpractice insurance won't cover you. They will.simply ask where is your financial planners license and drop you. Heck, here in Houston a lady is suing a neighbor after HERE_URL pit bull got into the neighbors fenced yard and attacked and killed their dog. The pit bull owner got bit when pulling her dog off the neighbor. She is suing the neighbor for goodness sake for failure to secure her dog...it was secured behind her own fence. So helping with someone else's insurance plan info when not doing such as you're regular job can get you sued.

This has to be one of the most wildly inaccurate posts I've ever seen here.

It is absolutely within a nurse's scope to both educate the patient about their healthcare as well as to address barriers the patient may face in getting the appropriate care, this is why our role is generally defined as a patient advocate.

Technically you can be sued for anything, although the chances of a lawsuit moving forward against you because someone doesn't like their healthcare plan is basically non-existent. Such a suit would be directed at the insurer. The potential problem that could arise is if you were to guide people toward a particular insurer and that insurer was also paying you to recruit customers. That could certainly potentially threaten your license but even then an actual lawsuit would have no real basis.

Financial planners actually have nothing to do with choosing health plans.

I'm not sure how you feel a dog attack lawsuit has anything to do with this.

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Specializes in Emergency Department.
Technically you can be sued for anything

I could not agree more. Moving forward, I would not worry about losing any sleep if I was to have a conversation with my patient about the Health Care Marketplace. I appreciate your input and perspective.

Michael M. Heuninckx RN-BSN

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Specializes in Vents, Telemetry, Home Care, Home infusion.
AGAIN I WILL SAY AS NURSES WE HAVE NO PLACE NOR DUTY to educate people on their health plan choices. It is not in our job description or expected duties.

Totally disagree with this statement. As a bedside nurse, it may not be in your job description to educate people on health plan choices, however you should be aware of health plan types and who in your organization questions can be addressed. Case Management/Utilization Review and Discharge planning nurses need to be aware of ALL insurance plans in area to help make effective discharge plans + explain how patients insurance covers these services.

In my former role as Central Intake Manager in a home health agency, it was my job to compile yearly list all insurance plans agency accepted, list benefit limits + copays for home care, obtain home care authorizations and price negotiate with non contracted payers. Almost daily, I gave advice to patients on what services their insurance plans covered, offered advice regarding other health insurance plans in their area, how to obtain medicaid, medicare, etc.

This is all part of nursing advocate role.

Telling a patient with fractured hip "upon hospital discharge you will probably go to a nursing home for followup care", with patient/family only to learn that under Medicare, their 2 day stay was listed as "observation status" -- all care considered as out-patient services and doesn't count towards Medicare's 3 day hospital stay in order for Medicare to pay for SNF services. Patients and family then question if other advice nurses provided accurate and can cause headache "service recovery" for shift team leader/nurse manager/nurse supervisor.

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