Transcription:

Intro: You're listening to another episode of Living Well with Eisenhower Health, healthcare as it should be.

Caitlin Whyte: As open enrollment begins this fall, we're here today to offer you a refresher on insurance plans. And there's a lot to catch up on joining us with this information is Katie Amegin, the Director of Payer Relations at Eisenhower Health. And I'm your host, Caitlin Whyte.

Katie, there are a lot of insurance plans out there. So can you explain a little bit about what's out on the market now?

Katie Amegin: Of course, I mean, it can be extremely overwhelming as an individual trying to navigate the insurance world, particularly the health insurance world. And there's a lot out there. So in the brief segment we have, we'll do an overview of the different types of plans in the market. So first off, there's government plans. Probably the most common in our area would be Medicare and that's the federal government plan for individuals over 65 years of age. There's also Medicaid plans and those are federal and state plans regulated by the states themselves. In California, our Medicaid program is called Medi-Cal and that program covers low-income residents of California. And the Department of Healthcare Services or the DHCS website has additional information to determine what individuals qualify for those programs. There's also managed care plans, and those are government plans offered through a private sector health insurance. So there's Medi-Cal managed care plans and there's also Medicare managed care plans often referred to as Medicare Advantage plans or MA plans. And Medicare Advantage plans offer Medicare benefits through, like I said, the private sector health insurers, and those are approved by Medicare. And they're also subject to oversight by CMS. These MA plans can offer multiple plan types, including HMO plans or PPO plans.

Then, we move on to commercial plans. There's a plethora of options when you go into the market for insurers. There's PPO plans, HMO plans, narrow network plans. And, you know, there might be other plans that some individuals may not be aware of that an insurer comes up with themselves or sets up for their own individual members, so lots of options. The best thing to do when looking at commercial plans is just to work directly with different insurers to understand their plan offerings, what kind of benefits are included in certain types of plans and, you know, how those can be utilized, whether you're in or out of network for the area that you live in.

Caitlin Whyte: So, can you tell us a bit about also Covered California and what that is?

Katie Amegin: Sure. Covered California is the result of the Affordable Care Act that set up state insurance exchanges. The Covered California exchange is a government agency platform that offers plans to satisfy the ACA requirements. So commercial insurers can offer their plans through these state-run healthcare exchanges, and people have the option to buy them. Depending on your household income levels, you may also qualify for subsidies or discounts.

Caitlin Whyte: And now I know that Eisenhower Health, you have an influx of a seasonal population during the winter as well. So do you also see insurance plans from out of the area?

Katie Amegin: Yes, we do. That's very common. We do have visitors that come throughout the state and throughout the country, and we do see different members with different plans and insurances. What really matters is the patient's plan coverage and what's included in their plan benefits. So we know what contracts we have in place with the health insurance companies in our area. But what we don't know is, you know, what a person's plan includes and what coverage requirements they may have from out of area.

So our best piece of advice is always for members, if they're going to be traveling or out of the area, to make sure they call the customer service line on the back of their insurance card and understand what's covered with their out-of-area network benefits or in-area network benefits as well. Because depending on a patient's a member's plan type, maybe our hospital is still considered in-area with them and it's really dependent on the plan and what's included based on the premiums that individual members pay every month.

Unfortunately, as a hospital, we do not have insight into those offerings that the insurance companies have for those plans.

Caitlin Whyte: So, like you said, plans can vary by state, but plans can also vary by region here in California. So let me ask you this, for people who have two homes, for instance, they can have coverage, let's say in Palm Springs, their winter home, and then coverage in a second location with many of the major plans. Tell us about those options.

Katie Amegin: Absolutely. It's a great question. And I'll refer back to, you know, the previous answer and that's about knowing your network benefits and understanding what your plan's coverage entails. So it's always best to work with your insurer to understand what regions are included in your in-network benefits and what might be considered out-of-network.

Now, the premiums you pay on a monthly basis may very well have an effect on that. A lower monthly premium might mean that you have less flexibility in your plan or your region that you're able to access under that in-network coverage. So again, always encourage members to understand their plan documents, work with the insurance companies, so that they know what is covered and what is not. And if you don't have access to your plan documents, you can always request them at any time through your insurance.

Caitlin Whyte: Well, research seems to be the key here. I know there's a program at Eisenhower that really requires patients to do their homework with the Eisenhower Primary Care 365 Program. There are some insurance providers that won't cover it and others that don't list it on their website that physicians in the program are covered when in fact they are. So can you tell me a little bit about what you've experienced with that program?

Katie Amegin: The Eisenhower 365 Program is a specialized primary care program that includes some added benefits and it has a very reasonable annual fee associated with it. Some members enjoy the added benefits and choose to participate in the program while others don't. And, you know, because of that added fee and those added benefits, some plans don't recognize the program and they choose to exclude it from their plan offerings. So depending on which plan you have, you'll need to know if the E365 doctors are included or not. And we have a great phone number and resource line that members can call for our E365 program and learn more, have their questions answered, so they really know what options work best for them, and that number is (760) 360-3366.

Caitlin Whyte: And now that Kaiser has contracted with Eisenhower, what things might be changing?

Katie Amegin: That's a great question. We're very excited about the new relationship that we have with Kaiser that just kicked off this fall. You know, it's been a long time coming and a long time in the making, and we're so happy to offer the Eisenhower Network to those members. So what does it mean? For any non-Kaiser members, nothing is changing. You'll continue to receive the same great care and services that you always have at Eisenhower. For Kaiser members, you are part of Eisenhower's network of care and have access to our medical center as an affiliated hospital as well as access to our urgent care facilities in Palm Springs, La Quinta and Rancho Mirage.

Now as Kaiser members, Kaiser is still an HMO and will continue to be managed as such. What that means for the affiliation with Eisenhower is that Kaiser members will still need to coordinate all of their care through their primary care physician. That means they will not be able to call in and make an appointment directly with a specialist. They will have to coordinate that care with their Kaiser team.

Caitlin Whyte: Now, if I have a Medicare Advantage HMO plan, can I receive care at Eisenhower?

Katie Amegin: So Eisenhower is contracted with local Medicare Advantage HMO plans for hospital services, and that includes inpatient stays, outpatient surgeries or emergency visits. However, Eisenhower is not contracted with HMO plans for physician services, which would include primary care and specialty services at our physician clinics.

So, similar to what I mentioned with Kaiser, HMO plans have their own network of physicians as part of their plan. And EMC would be out of network with those HMO plans in the majority of cases. Most individuals would need to switch to traditional Medicare to have access to all Eisenhower services. There are also Medicare supplemental plans available to cover certain co-pays and deductibles. But again, because everyone's individual healthcare needs are different and specific, we recommend that you speak with a local healthcare insurance broker to discuss your individual needs and options.

Caitlin Whyte: In the fall, we see open enrollment for Medicare. This is another complex system, particularly for those who are new to Medicare and have to make elections about drug coverage and more. Are there any unbiased nonprofit organizations that help seniors understand these options?

Katie Amegin: Yes, actually, there are. The HICAP Program or the Health Insurance Counseling and Advocacy Program is part of the national network of State Health Care Assistance Programs. And it's made up of trained counselors that are California state registered staff and volunteers. And they can really help seniors navigate what is right for them and what they need to include in their coverage. There's a number that can be called for residents of San Bernardino and Riverside counties to learn more and get assistance, and that number is (909) 256-8360.

Caitlin Whyte: And as we wrap up, Katie, is there anything else we didn't cover that you want people to know when enrolling this fall?

Katie Amegin: I would always encourage people to just continue to do their homework, understand what plans are offered in their area. And if they do plan on traveling a lot, understand their out-of-network or out-of-area benefits as well. The more you know, the more empowered you will be and the more prepared you'll be if you ever need to utilize your health insurance coverage.

Caitlin Whyte: Well, I know we just went through a lot of information in this short time, and all of it is just so important. So thank you, Katie, for breaking it down for us. For more information about insurance plans accepted at Eisenhower Health, go to eisenhowerhealth.org.

If you want to learn more about Eisenhower's community education events, including lectures from HICAP representatives, visit eisenhowerhealth.org/calendar. If you found this podcast helpful, be sure to share it with friends and family and subscribe as well. Thanks for listening to Living Well with Eisenhower Health, healthcare as it should be.

I'm Caitlin Whyte. Stay well.