Health Insurance Jeopardy Part 5: Summary of Benefits and Coverage


Hello. My name is Karl Cooper and I am the Project Manager for the National Disability Navigator Resource
Collaborative at the American Association on Health
and Disability and this is our presentation Health Insurance Jeopardy Part 5 Summary
of Benefits and Coverage. For those of you who are unfamiliar with
the National Disability Navigator Resource Collaborative or NDNRC, it’s the mission of the end the NDNRC to
provide cross disability information and support to navigators and other enrollment specialist thereby
ensuring people with disabilities receive accurate information when selecting and
enrolling in insurance for the Affordable Care Act
Marketplaces. I always say when consumers looking at plans on the ACA Marketplace it is like playing a game on Health
Insurance Jeopardy and I say that because those of you who are familiar
with the game show know that in Jeopardy it’s not about the answer it’s about
asking the right question. Consumers need to make sure they’re
asking the right questions about the plans being offered in order to make an informed choice. So
let’s play our game. Today we’re looking at the category
Summary of Benefits and Coverage. So we’ll start out, the individual your meeting
with wants to know if the plan will cover a specialist that he sees. In this instance you need to ask the
question, “Does the Summary of Benefits and Coverage say whether or not the plan uses a
network of providers?” The Summer of Benefits and Coverage will
make it clear if the plan uses a network and if it does use
a network you’re going to want to make sure you’re checking the physician directory to see if this particular specialist that
the individual sees is on that directory because if they’re not then they might
want to consider another plan. Moving on, if the individual has a
condition that requires that she take a specific
drug then you need to ask the question, “Does the Summary of Benefits and
Coverage say what drugs are covered and what the drug copays are?” This is
important because drugs will be dealt with on the Summary of
Benefits and Coverage and specifically saying what copays are
and specifically how they’re handled with respect to
certain tiers. We talked a lot about tiering in the other video that deals specifically with prescription
meds and there’s a link below in the description if you want to access that
video. But for purposes here all you need to know
is a Summary of Benefits and Coverage will say how these drugs are handled and this is
going to be where you’re going to want to check out to find that information. The next, if the individual that you’re meeting with uses
rehabilitation therapy you’re going to want to ask the question, “Does
the Summary of Benefits and Coverage say what the cost would be for
rehabilitation therapies and if there are any limitations?” Once again if you want to learn more
about rehabilitation therapies you can check the video out that we have on that
specific category and there’s a link below in the description that you can
get that information specifically about rehab. But for purposes once again here, all you
need to know is a Summary of Benefits and Coverage is going to answer some of
those questions that we address in that specific video. Moving on to the
next situation, if the individual you’re meeting with is a wheelchair user you’re going to want to know whether the
Summary of Benefits and Coverage says what the cost will be for services such as, durable medical equipment. Once
again there is a video that deals more with medical devices and I encourage you
to check that out if you want to get more information about this, but for purposes of this video the
Summary of Benefits and Coverage is going to be where you’re going to get some the answers to the questions the we don’t
deal with in that the specific video. It’s important to know that on all of
these issues, whether it’s prescription drugs, rehab therapies, durable medical
equipment, or whatever it is the specific need of the individual is the cost many times is something that’s
got to really be factored in to get an accurate idea of what the financial
burden is going to be for the individual. So if the individual is signing up for the
plan it’s going to be more than the premium that’s going to be the cost; if there’s high copays or deductibles
that are related to these specific areas it could end up being a much more cost
prohibitive than maybe paying a little bit more of a premium and paying less for some of these other
costs on an ongoing basis so that ultimately their costs are you
less over the course of the year. Now what happens if the Summary of Benefits
and Coverage is unclear about the coverage of or limitations on durable medical
equipment or really any of the areas that were
doing with? This could become a problem. In this
instance you have to ask,”Where can you get the answers on this coverage when
they’re not covered in the Summary of Benefits and Coverage?” We have a series of Fact Sheets that deal with
all these issues in much greater detail and I would
encourage you to go to our website and check those out. They deal with the Summary of Benefits and
Coverage, there’s another document that you can look at to find some of
these answers which is the Evidence of Coverage document that’s
available from the insurance company. And ultimately you might end up having
to contact customer service and we have a Fact Sheet that deals with that in the terms of getting some
of these answers I’d like to point out my own personal story
when it comes to this area, because it’s important for you to realize the importance of these issues.
Specifically in my situation I use a wheelchair and I looked at the coverage available on the Maryland Exchange where I
live on some of the plans that were offered to see how durable medical equipment was
handled and I have to say as someone who knew
what questions to ask I still had a hard time getting answers to these
questions. That’s why it’s imperative that you’re
making sure that the people you’re dealing with are asking the right questions in the first
place because if they’re new to insurance they may not even know what questions
they should be asking. Its your position as an assister or
navigator to make sure that they’re asking the right
questions so they can make an informed choice about what is going to be the
best plan for them. If you are interested in finding out
more about the NDNRC or want to access those fact sheet I talked about earlier you can check out our web site which is.
www.NationalDisabilityNavigator.org You can also find my contact info on the
slide you can feel free to reach out to us if you have questions as you’re assisting an individual with a
disability enroll in health insurance. Also please subscribe to our YouTube
channel to get more helpful videos like this one. If you’re interested in learning more
about the other categories listed as I mentioned in the video be sure to check the links on the
description below to access those videos. Thank You

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