After the start of the recession in 2008, many Americans in their 50s and 60s felt economic pressure. They were nearing retirement, were experiencing financial setbacks in the form of layoffs and unemployment, and were facing increased health care needs like diabetes and cancer. Are there any government health insurance options?
Glenn Nishimura, aged 64, faced such pressures head on. One night he went to the emergency room in extreme pain, only to find out that his gallbladder needed to be removed. Instead of following through with the operation, he chose to go home. He was self-employed and had inadequate health insurance. After leaving his job in 2007, he signed up for COBRA. Once the coverage expired, he had to buy his own insurance. Now, with the new Affordable Care Act, he is able to purchase a comprehensive plan. Nishimura remarked, “Now there’s the peace of mind of knowing the limits of my obligation if I have catastrophic health needs.”
The United States federal government runs a variety of different health care insurance programs for those with unique needs, low income, and certain demographic groups. The following article provides a brief overview of each program, along with a specific look at an example of state-run health care programs in Minnesota.
Affordable Care Act
At the end of 2013, Americans were permitted to begin buying health care insurance through the Affordable Care Act. Although this type of government-funded insurance is discussed in greater detail in a different article, a summary will be provided here.
Right now, the rules for purchasing this plan are as follows:
- Must be 30 years of age or younger, but also some low-income people who qualify
- Will cover only minimal services
- 3 annual primary care visits and preventative services are included at no cost
- Deductibles can only be up to $6,400
- After the deductible is met, 10 essential health benefits will be covered. This does not include shots or prescription drugs.
The 10 essential health benefits outlined in the Affordable Care Act include items and services under the following categories:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care.
In the new “Health Insurance Marketplace” created by the Affordable Care Act, insurance companies must include policies these benefits. These will also be covered under Medicaid in 2014.
Medicare is a government-run program for three groups of people:
- Americans 65 years of age or older
- People under 65 how have certain disabilities
- Those with end-stage renal disease (permanent kidney failure)
Some may be confused about their coverage since new laws were enacted under the Affordable Care Act. Medicare is not part of the Health Insurance Marketplace, but is completely separate. If you already have Medicare, you are considered covered and there is nothing additional that you need to purchase.
Medicare has four parts:
- Part A: Hospital Insurance. This insurance is generally free of charge to those who had at least 10 years of Medicare-covered employment, otherwise it is available for purchase. It covers hospital care, nursing facility care, nursing home care, hospice, and home health services.
- Part B: Medical Insurance. Most people have to pay a monthly premium for Part B, or it is taken out of your social security or retirement checks. This insurance covers medical services needed to diagnose or treat a medical condition as well as preventative services like the flu shot. It also covers clinical research, ambulance rides, durable medical equipment, mental health services, second opinions before surgical operations, some outpatient prescription drugs.
- Part C: Medicare Advantage. This covers emergency and urgent care visits, as well as all of the Original Medicare services except hospice care. This plan gives you choices to enroll in a Medicare managed plan and/or add additional coverage like dental and vision.
- Part D: Prescription Drug Coverage. This plan includes a monthly premium and has its own list of covered drugs. People that are covered under the Federal Employees Health benefits Program don’t need to pay the monthly premium. The program lists different tiers for different types of drugs, meaning that some cost more than others.
The government recommends that you enroll in Medicare 3 months prior to turning 65. To apply, you simply need to call the Social Security Administration at 1-800-772-1213 to set up an appointment and apply.
In order to qualify for Medicaid, you must meet certain qualifications. A family of four needs to have an income of $29,700 or less. It also covers non-elderly disabled people, low-income seniors, and low-income caretakers. While the federal government sets certain standards for eligibility and benefits, states are in charge of administration and adhering to the requirements. They can also add optional benefits to Medicaid beneficiaries living within their state.
The following benefits chart explains the mandatory and optional benefits, according to Medicare.gov.
The Children’s Health Insurance Program is directly related to Medicare. It provides coverage for children living in the “middle ground”: their family income is too high to be covered under Medicare, yet they are unable to afford private health insurance. Also like Medicaid, the program is administered by the state and funded at both the national and local level.
Though there are some variations between states, all cover routine check-ups, immunizations, hospital care, dental care, and x-rays.
The Federal Employees Health Benefits Program is available to current federal employees, retirees, and their families. The plans vary based on the state that you live in. Certain insurance companies within each state will have benefit plan and payment options.
The Consolidated Omnibus Budget Reconciliation Act can provide a temporary continuation of your health care coverage after you have left your current job. COBRA itself isn’t an insurance plan, it’s a law which allows you to have your same employer-sponsored health benefits, even after you lose your job. There are variables in qualifying for this type of health care insurance, including why you left your job. Depending upon the reason, you may be required to pay the entire premium for continued coverage.
Below is a chart provided by ehealthinsurance.com that notes all qualifying events in which you would be offered coverage under COBRA.
It is important to note that losing your job does not automatically guarantee that you will be covered under COBRA. Your former employer must have had an employer-sponsored health care plan and have at least 20 employees.
The advantage of COBRA is that you can continue on the exact same health care plan beginning the day after you end your current employment. It will also cover you, regardless of any pre-existing conditions. The disadvantage is that it can be quite expensive, requiring you to pay up to 102 percent of the health insurance premium for the first 18 months and the 150 percent for the next 11 months.
The Pre-Existing Condition Insurance Plan is a government program for those with pre-existing conditions who have been without health insurance for the last six months. In order to qualify, you need to provide an insurance or agent/broker denial letter that has been dated within the past 12 months or an offer of insurance coverage that didn’t cover your medical condition.
Due to the requirements under the Affordable Care Act, people cannot be denied for health insurance regardless of any pre-existing conditions. Therefore, PCIP is going through a transitional phase. It is encouraging current beneficiaries to apply for different health care through the Health Care Marketplace. Those with PCIP can have transitional coverage until March 31, 2014, however, you have to choose your own new plan. PCIP will not do it for you.
Children and Youth with Special Health Care Needs is a program for those who don’t qualify for Medicaid and have little or no other health insurance. This program is specifically designed for children who have long lasting conditions due to physical, intellectual, developmental, behavioral, and/or emotional disabilities.
Each state administers the local CYSHCN, but some examples of the benefits included with program coverage include:
- Assistive technology
- Case management
- Early intervention and screening for health risks
- Family support services
- Nutrition counseling
- Special education support services
With these benefits, CYSHCN hopes to ensure that no child with special needs goes without the healthcare that they need.
The U.S. Department of Veterans Affairs provides all military personnel, either active or retired, with health care benefits. It is not an insurance program in and of itself, however. When you visit the doctor, your primary insurance will be billed first. The left over balance is then covered by the VA, except for the co-payment.
There are many benefits to being a part of the VA program, including inpatient hospital visits and outpatient services. When visiting a veteran’s hospital, all traditional services will be offered, such as mental health, pharmacy, lab tests, physical therapy, and radiation.
TRICARE is another program for both active and retired military personnel and their families. Funded through the Department of Defense, there are three levels of health care insurance options: standard, prime, and extra.
Under the TRICARE Standard program, eligible beneficiaries have the most flexibility. It provides the widest network of providers, but you need to pay a deductible, co-payment, and additional fees if the provider is out of network.
With TRICARE Prime, your health care would come from a military treatment facility and those within the preferred provider network. There are small fees for civilian providers, and limited provider choices, but you have no balance billing and always have guaranteed appointments.
TRICARE Extra is similar to the standard option in that you will have a deductible, but the copayment is 5 percent less than Standard. It differs in that there is no balance billing.
State Example: Minnesota
In addition to the federal programs, each state often provides additional options for consumers. In the example of Minnesota, there are five health care programs:
- Medical Assistance: Minnesota’s Medicaid program. It is publically funded and provides health insurance for low-income Minnesotans.
- MinnesotaCare: Minnesota’s response to the Affordable Care Act, it is subsidized health care for those who can’t otherwise afford health care insurance. Beneficiaries must pay a monthly premium based on family size and income.
- Minnesota Family Planning Program: Provides family planning services and supplies. In order to qualify, you must be between the ages of 15 and 50, a Minnesota resident, meet monthly income limits, not be pregnant, and not be covered under any other health insurance programs.
- Home and Community-Based Waiver Programs: Also part of Minnesota’s Medicaid program, it is a way to provide assistance to people with disabilities and chronic illnesses. It is a creative alternative to placing people in hospitals, nursing homes, or other care facilities.
Medicare Savings Programs: This is Minnesota’s way of helping low-income beneficiaries pay for their Medicare insurance. Depending upon your qualifications, the program may pay your Part A premium, Part B premium, copayments, or other health care costs.Other Enhanced Insurance articles related to Special Healthcare:Cancer InsuranceGovernment Health Insurance Programs
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