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Health Care Insurance - FAQs:
Families who earn too much to qualify for low-income Medicaid insurance may be able to qualify for the State Children's Health Insurance Program (SCHIP). The Centers for Medicare & Medicaid Services administer funds to States who are responsible for the program at the local level.
Families that do not currently have health insurance are likely to be eligible, even if not working. The states have different eligibility rules, but in most states, uninsured children under the age of 19, whose families earn up to $36,200 a year (for a family of four) are eligible. For little or no cost, this insurance pays for:
- doctor visits
- immunizations
- hospitalizations
- emergency room visits
For contact information for your state or to read specific information regarding eligibility in your state please access the Insure Kids Now site.
Good health is important to everyone. If you can't afford to pay for medical care right now, Medicaid can make it possible for you to get the care that you need so that you can get healthy and stay healthy.
Medicaid is available only to certain low-income individuals and families who fit into an eligibility group that is recognized by federal and state law. Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state's rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services. In general, you should apply for Medicaid if you have limited income and resources. You must match one of the descriptions below:
Pregnant Women
Apply for Medicaid if you think you are pregnant. You may be eligible if you are married or single. If you are on Medicaid when your child is born, both you and your child will be covered.
Children and Teenagers
Apply for Medicaid if you are the parent or guardian of a child who is 18 years old or younger and your family's income is limited, or if your child is sick enough to need nursing home care, but could stay home with good quality care at home. If you are a teenager living on your own, the state may allow you to apply for Medicaid on your own behalf or any adult may apply for you. Many states also cover children up to age 21.
Person who is Aged, Blind, and/or Disabled
Apply if you are aged (65 years old or older), blind, or disabled and have limited income and resources. Apply if you are terminally ill and want to get hospice services. Apply if you are aged, blind, or disabled; live in a nursing home; and have limited income and resources. Apply if you are aged, blind, or disabled and need nursing home care, but can stay at home with special community care services. Apply if you are eligible for Medicare and have limited income and resources.
Other Situations
Apply if you are leaving welfare and need health coverage. Apply if you are a family with children under age 18 and have limited income and resources. (You do not need to be receiving a welfare check.) Apply if you have very high medical bills, which you cannot pay (and you are pregnant, under age 18 or over age 65, blind, or disabled).
Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services. To contact your Medicaid office, look up your State or Territory in the Contacts Database.
A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.
If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).
Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non?emergency or non-urgent care). These rules can change each year.
Learn More with this Medicare.gov information:
- Medicare Advantage (Part C)
- Your Guide to Medicare Private Fee-for-Service Plans (PDF - 28 pages)
- Your Guide to Medicare's Preferred Provider Organization (PPO) Plans (PDF - 32 pages)
- Your Guide to Medicare Special Needs Plans (PDF- 20 pages)
- Use Medicare's Information on Quality to Help You Compare Plans (PDF - 5 pages
The Centers for Medicare and Medicaid sponsor Medical Savings Account (MSA) plan is a type of Medicare Advantage plan that combines a high-deductible health plan with a medical savings account. Enrollees of Medicare MSA plans can initially use their savings account to help pay for health care, and then will have coverage through a high-deductible insurance plan once they reach their deductible.
Medicare MSA plans provide Medicare beneficiaries with more control over health care utilization, while still providing coverage against catastrophic health care expenses. In Demonstration MSA plans, some MSA provisions are waived to make the plans more like other consumer-directed health plans, such as health savings accounts (HSAs) available in the private sector.
For more information see:
A medical loss ratio is the percentage of dollars paid out as benefits to policyholders in relation to the premiums collected for the policies. For example, a state may require that an insurer spend at least 75 percent of the premiums they collect on medical claims. Loss ratios can be calculated for a particular policy form or design, a line of business, or a health insurer’s overall business.
Only a handful of states require all insurers in the individual market to spend at least 75 percent of every premium dollar on medical care (Families USA, June 2008). Some states establish minimum loss ratios and reserve the right to review or approve the rates submitted by state-licensed insuring organizations. Insurers must estimate what they will spend on medical claims over the course of a year and set their premiums accordingly.
To learn more see the Regulation of the Individual Health Insurance Market.
You may want to consult the HHS Health Resources Services Administration (HRSA) directory of health centers at http://findahealthcenter.hrsa.gov/ - these health centers provide care on a sliding fee scale so it is affordable for anyone. You can receive care even if you are uninsured or cannot pay. Search the directory by zip code to find the centers nearest you.
The Hill-Burton program, while limited in scope, provides funds to hospitals and other health care facilities in exchange for their provision of a specified amount of free or reduced cost health care to low-income people. To find out if you qualify for Hill-Burton assistance you must apply at the admissions or business office at a Hill-Burton facility. For more information and a directory of facilities, please see the HRSA Frequently Asked Questions about the Hill-Burton program .
Medicare Part A helps cover your inpatient care in hospitals, critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions to get these benefits.
Cost: Most people don't have to pay a monthly payment, called a premium, for Part A. This is because they or a spouse paid Medicare taxes while they were working. If you (or your spouse) didn't pay Medicare taxes while you worked and you are age 65 or older, you may be able to buy Part A.
If you aren't sure if you have Part A, look on your red, white, and blue Medicare card. If you have Part A, "Hospital (Part A)" is printed on your card. You can call Social Security at 1-800-772-1213, or visit your local Social Security office for more information about buying Part A. If you get benefits from the Railroad Retirement Board (RRB), call your local RRB office or 1-800-808-0772.
Eligibility: To learn if you are eligible for Medicare, use the Medicare Eligibility Tool.
Also, see Medicare.gov Part A (Hospital Insurance)
The State Children's Health Insurance Program (SCHIP) expands health coverage to uninsured children whose families earn too much for Medicaid but too little to afford private coverage. For more information, visit www.insurekidsnow.gov or call toll free 1-877-KIDS-NOW (1-877-543-7669). This Web site and toll free number also provides information on Medicaid.
Community health centers provide health care regardless of your ability to pay and even if you have no health insurance. Find the community health center closest to you. Phone the community health center for more information or to make an appointment.
