In the US you need some type of public or private insurance
to help pay for your medical bills. Various federal laws provide
the background that controls both public and private insurance.
ERISA
The Employee Retirement Income Security Act of 1974 (ERISA),
provides protection through established minimum standards for
most pension and health plans voluntarily founded in private industry.
ERISA requires plans to provide beneficiaries with plan
information including plan features and funding levels as
well as a grievance and appeals process for beneficiaries to use
to access their benefits. ERISA provides fiduciary
responsibilities for those who manage plan assets and gives
beneficiaries the right to sue for benefits and breaches of fiduciary
duty. ERISA has been amended to expand the protection it offers.
These amendments include COBRA and HIPPA listed in the next section.
COBRA
Consolidated Omnibus
Budget Reconciliation Act (COBRA) offers protection when you
lose healthcare benefits provided through employment. For more
information on COBRA please refer to this guide's section on private
payers.
HIPAA
Health Information Portability and Accountability Act (HIPAA)
provides protection of your personal information while allowing
appropriate use of that information by the healthcare industry
to access payments and treatments, and to conduct necessary business
operations.
FMLA
Family Medical Leave Act (FMLA) provides employees with the
right to take time off to address urgent family medical issues.
Public Payers
The following provides an overview of the public payers.
What is Medicare?
Medicare is a federal program that provides health insurance
coverage to eligible, qualified elderly and disabled individuals.
Coverage benefits vary based on the site of service (i.e. doctors
office, hospital inpatient, hospital out patient, or home health
treatments).
Who qualifies for Medicare?
Currently Medicare provides coverage for:
- People 65 or older
- Some people under 65 with disabilities
- People with End-Stage Renal Disease (ESRD), which is permanent
kidney failure requiring dialysis or a kidney transplant
Traditional Medicare
consists of two parts, Part A and Part B.
What is the difference between Medicare Part A and Medicare
Part B?
Part A is institutional insurance which provides coverage for
inpatient hospital care, skilled nursing facilities (excluding
long term care), hospice and some home health care. (There is
no premium required).
Part B is medical insurance which provides coverage for your
doctor visits and outpatient hospital care. In addition, Part
B also provides coverage for some physical and occupational services,
and some home health care. (A premium is required).
There are two or perhaps more categories of Social Security recipients:
- Social Security Retirement Beneficiaries automatically receive
Medicare Part A and they have the option to pay for Medicare
Part B.
- Social Security Disability Insurance recipients who have
received payments for two years also automatically receive Medicare
Part A and they have the option to pay for Medicare Part B.
What is a Medicare Supplement?
Traditional Medicare does provide coverage for most health care
services and supplies, but not everything. In addition to retirement
options through employers, individuals eligible for Medicare have
the choice of purchasing a Medigap
(Medicare Supplement) policy that would help cover some of
the gaps in traditional Medicare's coverage. There are ten standard
Medigap plans and these plans are named alphabetically from A-J.
The coverage varies between each of the plans and although most
of the plans are available throughout the United States some states
have different standard supplements. Specific information related
to each of these supplements can be found in Appendix C. Contact
the Centers for Medicare and Medicaid Services at 1 (800)-MEDICARE
(1-800-633-4227) or visit www.cms.gov
to learn more about these supplements and those available in your
area.
What is Medicare Part C or Medicare Managed Care?
Part C, which is referred to as Medicare
Advantage, allows members the option to select a managed care
plan. These plans replace traditional Medicare and the benefits
can vary from some of the standard Medicare benefits. Members may
select this type of plan to obtain additional benefits such as prescription
drug coverage. Medicare Advantage plans are available in most areas
of the country. For the most up to date information on plans available
in your geographical location you go to the CMS website www.cms.gov
or call 1 (800)-MEDICARE (1-800-633-4227).
What is the Medicare Discount Card and how can I get one?
Beginning in 2004, individuals have the option to purchase a
drug discount card. The Medicare approved drug discount cards
will offer savings of 10-25 percent on prescription drugs with
a maximum card fee of $30 per year. Discounts may be larger on
mail order drugs and generic drugs. If you are eligible for Medicare
and would like to learn more about the drug discount card (i.e.,
compare cards) call 1 (800)-MEDICARE (1-800-633-4227) or visit
www.medicare.gov.
What is Medicare Part D?
In 2006, Medicare will begin providing prescription drug coverage
through a fourth benefit category, Medicare
Part D. Individuals will have the option to enroll in plans
that provide prescription drug coverage through Medicare. The
prescription drug benefit under Medicare Part D is currently designed
to include a $35 premium,
$250 deductible, and a 25% coinsurance up to $2,250 of coverage.
Individuals would then be responsible for any prescription costs
between $2,250 and $3,600. There is catastrophic
coverage above $3,601 which includes a three tier copayment
structure based on the individual's income levels.
For individuals with income below a certain limit, the premiums
and deductible for prescription drugs will not apply. In addition,
the copayment for each prescription will be lower depending on
income level.
Does Medicare Part D cover drugs or treatments for PH?
Some pulmonary arterial hypertension drugs, such as Flolan and
Remodulin are covered by Medicare. However, coverage for either
one of these drugs is based on the patient's diagnosis.
Medicare also covers Tracleer for some beneficiaries through
the Medicare Replacement Drug Demonstration. This pilot program
provides coverage for certain self-administered drugs and biologicals
for patients who have been diagnosed with pulmonary hypertension
(idiopathic pulmonary hypertension) and other approved disease
states. The drugs that are covered through this program are alternative
treatments to certain medications that are currently covered through
Medicare Part B. For eligible beneficiaries, this coverage will
be available after January 1, 2006 when Part D coverage begins.
How can I contact Medicare?
For additional information on Medicare eligibility, coverage
or benefits, please contact 1-(800)-MEDICARE (1-800-633-4227)
or visit www.cms.gov.
How do I file a claim?
If you are in the Original Medicare Plan, providers (e.g., hospitals,
skilled nursing facilities, home health agencies, and physicians)
and suppliers are required by law to file Medicare claims for
covered services and supplies that you receive. You should not
need to file any Medicare claims.
- If you get your Medicare health care through a managed care
plan or a private fee-for-service plan, Medicare claims are
not filed. Medicare pays these private insurance companies a
set amount every month. Thus, they do not need to file Medicare
claims.
If you visit a physician or fill a prescription, you are responsible
to pay the coinsurance and deductibles to the provider. The provider
then files a Medicare claim, and Medicare pays its portion of
the bill directly to the provider. If your physician does not
accept assignment for covered services, your physician may require
you to pay most or the entire bill at the time you receive the
services or supplies. The physician is still required to file
a Medicare claim on your behalf, and Medicare will pay its share
directly to you. Medicare cannot pay you its share of the bill
until a Medicare claim is filed. Take the following steps if your
physician or supplier does not file the Medicare claim in a timely
manner:
Step One- Contact your physician or supplier and ask
him/her to file a Medicare claim.
Step Two- Contact your local Medicare carrier (their
phone number can be found in the helpful contacts section of the
www.medicare.gov
website). Your local Medicare carrier will then contact the physician
or supplier on your behalf to make sure they are aware of their
responsibility to file a claim.
- There is a time limit for filing a Medicare claim. The time
limit depends on the service received, so it is important that
you ask your local Medicare Carrier what the time limit is for
the claim you are filing.
Step Three- If you have completed steps one and two, your
physician still has not filed a claim, and it is close to the
deadline to file a Medicare claim, then you should file a claim.
What if your claim is denied?
Medicare has a formal administrative appeals process that allows
physicians and patients to challenge a claim denial. Medicare
has five different appeals levels.
With each step in the appeals process, a written request may
be required. Include the following information in your request:
- Patient name, policy number and date of service
- The letter should identify the claim you would like to have
reviewed, and it should clearly state the reasons why you feel
the determination should be changed.
- Include supporting documents you feel will help the reviewer
see why the determination should be changed.
- Include information or explanations that were not included
with the claim the first time it was submitted. This will help
the reviewer see more clearly why the determination was incorrect
the first time.
Stage 1- Carrier Review
If you are dissatisfied with the Medicare's initial determination
and the determination is subject to appeal, your physician may
request a review. There are two types of carrier reviews: telephone
and written reviews. Telephone reviews are completed within the
time frame of the call unless additional information is required.
Written reviews must be completed by the physician and they must
submit the request in writing on a specific form called 'Request
for Review of Part B Medicare Claim.' Medicare will make a decision
regarding the appeal within 45 days.
Stage 2- Fair Hearing
If you remain dissatisfied after the carrier review determination,
and the amount in controversy is at least $100, you may request
a fair hearing. Requests for fair hearings must be filed, in writing,
within 6 months of the date of the carrier review determination.
You may request that a hearing be held in one of two forms. Hearings
in person or by telephone allow personal testimony. "On-the-record"
hearings are based upon the information submitted with the request
and information currently on file in the office. Please address
these requests to the attention of the Hearing Department and
indicate the type of hearing you prefer.
You should receive a decision from the hearing officer within
four months. If a decision has not been made within four months,
call and verify that the information was received and/or if anything
else is required for a decision.
Stage 3- Administrative Law Judge (ALJ) Hearing
If you are still dissatisfied with the determination made by
the hearing officer, and the amount in controversy is at least
$500, you may request a hearing before an Administrative Law Judge
of the Social Security Administration. The request must be in
writing and filed within 60 days of the date of the fair hearing
decision. There are two types of ALJ hearings. "On-the-record"
hearings occur when the ALJ reviews evidence only on paper and
In-Person hearings happen when the case is presented to the ALJ
in person.
Within 30 to 60 days, you should get a written ruling from the
ALJ describing the facts of the case and reason for the decision,
which is based on evidence offered at the hearing or otherwise
included in the record.
|
Real Life-
"Fought Medicare denial for skilled nursing home services
for my paralyzed father. Appeal was denied. Re-appeal was
denied. Went to Administrative Law Judge level and was successful."
|
Stage 4- HHS Departmental Appeals Board
If after going through the carrier review, Fair Hearing and ALJ
process, your claim is still denied or your request for a hearing
is dismissed, you have the option of requesting an administrative
review by the Department of Health and Human Services Departmental
Appeals Board (DAB).
The DAB will conduct its review of ALJ decisions under the existing
regulations governing appeals of Part A and B claims. The DAB
will decide whether the ALJ decision should be upheld, sent back
for a new hearing or outright reversed.
The request must be submitted, in writing, to:
Departmental Appeals Board
Civil Remedies Division
Room 637-D
HHH Building
200 Independence Ave SW
Washington, DC 20201
Stage 5- Judicial Review
If you are still dissatisfied, and the amount in controversy
is at least $1,000, you may seek judicial recourse in US District
Court. This is the highest level in the Medicare appeals process.
Requests for Judicial Review must be filed within 60 days from
the date of the DAB decision.
The provider must file an action in the US District Court for
the judicial district in which the provider is located or in the
District Court for the District of Columbia.
What is Social Security Disability?
Social Security Disability (SSD) is most simply defined as an
insurance plan that helps to cover medical expenses when you are
unable to work. You contribute by paying Social Security payroll
taxes (FICA) over a period of time. This helps you meet an insured
status that enables you to qualify for Social Security Disability
if you are unable to work. The definition of disability is different
under Social Security than other programs because Social Security
pays only for total disability. Disability as defined by Social
Security is based on your inability to work.
Who is entitled to SSD?
You are entitled for benefits if you have worked jobs covered
by Social Security, and you have a medical condition that meets
Social Security's definition of disability. You will be considered
disabled under Social Security rules if you cannot do work that
you did before, and Social Security decides that you cannot adjust
to other work because of your medical conditions. Lastly, your
disability must last or be expected to last for at least one year
or to result in death.
How do I continue to receive benefits?
You will continue to receive benefits as long as you are disabled.
If you health improves or you wish to return to work, you are
no longer qualified for Social Security benefits. Social Security
offers "work incentives" to try to help you transition to gainful
employment. During this transition period, Social Security incentives
include continued monthly benefits and Medicare coverage.
How does Social Security evaluate my condition?
The law requires a review of your case to make sure you are still
disabled. The length of time and how often Social Security reviews
your case depends on the expectation of your recovery. Your case
will normally be reviewed within 6 to 18 months after your benefits
start if you are "expected" to improve, and your case will be
reviewed no sooner than three years if its only "possible" you
will improve. If you are "not expected" to improve, your case
will be reviewed no sooner than seven years.
How will returning to work affect my SSD benefit?
You will be considered no longer qualified for disability benefits
if you work at a level that is "substantial". In 2004, an average
earning of $810 or more per month was considered "substantial".
Lastly, your disability benefits will stop if Social Security determines
your medical condition has improved to an extent you that are
no longer disabled.
What is Medicaid?
Medicaid
is a program that is administered by the federal and state governments.
These programs provide health insurance coverage to individuals
such as the disabled, children, or pregnant women who have low
income. Several states offer managed care plans to individuals
who are eligible for Medicaid. Coverage and benefits vary by state
and site of service. States are required to provide coverage for
the following:
- Inpatient and outpatient hospital services
- Physician, midwife, and certified nurse practitioner services
- Laboratory and X-ray services
- Nursing home and home health care
- Early and periodic screening, diagnosis, and treatment of
children under the age of 21
- Family planning
- Rural health clinics/federally qualified health centers
States have the option to provide additional services which may
include: prescription drugs, clinic services, prosthetic devices,
hearing aids and dental care. Currently all state Medicaid programs
provide coverage for prescription drugs. However, some states
have limits on how many prescriptions an individual may have filled
per month.
Who qualifies for Medicaid?
Many groups of people qualify for Medicaid, but even within these
groups there are certain requirements that must be met. Eligibility
varies from state to state, but the following is a general list
of qualifications for Medicaid:
- Pregnant women
- Children and Teenagers
- Person who is aged, blind, and/or disabled
- Some other situations (e.g., if you are leaving welfare and
need health coverage)
The following websites provide screening tools to help you evaluate
eligibility for a variety of government programs: www.govbenefits.gov
and www.benefitscheckup.org
Does Medicaid cover drugs or treatments for pulmonary hypertension?
If you are on Tracleer or Remodulin, you must keep one prescription
available each month for either of these drugs. Flolan requires
two prescriptions per shipment to be available as both the Flolan
and the diluent are considered separate drugs.
How can I contact Medicaid?
For additional information on Medicaid eligibility, coverage
or benefits, please refer to the contacts listed in Appendix D
of this guide.
How do I apply for Medicaid?
You can apply for Medicaid in the state in which you live. Obtain
and submit an application to your local state Medicaid office
(Appendix D of this guide contains a listing of these offices).
What is Supplemental Security Income?
Supplemental Security Income (SSI) is a federal income supplement
program funded by general tax revenue (not Social Security taxes).
It is designed to help aged, blind, and disabled people, who have
little or no income, and it provides cash to meet basic needs
for food, clothing, and shelter.
Who qualifies for SSI?
Anyone who is:
- Aged
- Blind
- Has a central visual activity of 20/200 or less in the
better eye, even while wearing a correcting contact lens
or glasses in that eye, or has a limitation in the field
of vision of the better eye so that you have a contraction
of peripheral visual fields exists to 10 degrees from the
point of fixation.
- Disabled
Child: An individual under age 18 is "disabled" if he or she
has a medically determined physical or mental condition which:
- Results in marked and severe functional limitations
- Can be expected to result in death
- Has lasted or can be expected to last for a continuous
period of not less than 12 months.
Adult: An individual age 18 or older is "disabled" if he or
she has a medically determinable physical or mental condition
which:
- Results in the inability to engage in any substantial
gainful activity
- Can be expected to result in death
- Has lasted or can be expected to last for a continuous
period of not less than 12 months.
And, who:
- Has limited income which includes:
- Money earned from work
- Money received from other sources such as Social Security,
worker's compensation, unemployment benefits, Department
of Veterans' Affairs, friends and relatives
- Free food, clothing, or shelter
- Has limited resources which includes:
- Cash/bank accounts
- Land
- Vehicles
- Personal property
- Life insurance
*(SSI limits resources that are counted)
- Is a U.S. citizen or one of certain categories of aliens
(An alien who is subject to an active warrant for deportation
or removal does not meet the citizenship/alien requirement)
- Is a resident of one of the 50 States, including the District
of Columbia and Northern Mariana Islands
- Is not absent from the country for a full calendar month
or more than 30 consecutive days
- Agrees to apply for any other cash benefits for whom he or
she may be entitled
- Meets certain other requirements
How do I apply for SSI benefits?
You can apply for SSI benefits by calling 1-800-772-1213 and
making an appointment. You will have to provide information and
sign an application. Most of the forms to apply for SSI benefits
are not designed for self-completion. A representative will help
you apply for benefits. Apply as soon as possible so that you
do not lose benefits. SSI cannot pay benefits for time periods
earlier than your application date. If you call and make an appointment
and file an application, they will use the date of your call as
your application filing date. You have a right to apply for SSI
benefits, and there is no charge to apply.
What are my rights?
- Right to receive help
Social Security will help you get documents you need to show
that you meet the SSI eligibility requirements. If you are applying
for disability or blindness, social security will pay to have
a doctor examine you if they decide that medical information
is needed to make a decision. Social security will also pay
your travel expenses to get this exam.
- Right to representation
You may appoint someone to help you with your SSI claim.
- Right to notice
Social Security will notify you in writing of any determination
about your eligibility or any change in you benefit amount.
Each notice will explain your appeal rights.
- Right to examine your file
You or your representative may examine and get a copy of the
information in your case file, upon request.
- Right to appeal
You may appeal most determinations social security makes about
your eligibility for SSI benefits or changes in your benefit
amount. Social Security administrative appeals process has three
levels.
- Step One- Reconsideration
If you disagree with the initial determination, you may
request reconsideration by writing to social security or
by completing a Form SSA-561 (Request for Reconsideration)
or a Form SSA-789 (Disability Cessation Appeal). You or
your representative must ask in writing for reconsideration
within 60 days of the date you receive the written notice
of the initial determination. If you request reconsideration
within 10 days, any payment being made to you will continue
until a determination is made, providing your income and
resources do not exceed their limits. A notice will be sent
to you of the reconsideration decision.
If you appeal a disability cessation and you want to
continue to receive benefits until a decision is made,
you must make a written request for the benefit continuation
within 10 days of the date you receive the written notice.
You are entitled to a face-to-face hearing with a disability
hearing officer.
- Step Two- Hearing
If you disagree with the reconsideration determination,
you may request a hearing before an Administrative Law Judge
by writing or by completing a Form HA-501 (Request for Hearing).
You must request the hearing within 60 days after you get
the notice of reconsideration. You may review your file
and submit new evidence then. The judge may want you to
have medical exams and tests. If you cannot make it to the
hearing, please contact the judge as soon as possible before
the hearing and explain. If you do not attend, you may lose
your appeal rights and benefits.
- Step Three- Appeals Council
If you disagree with the judge's decision, you may request
an appeal by writing and requesting an Appeals Council review
or by completing a Form HA-520 (Request for Review of Hearing
Decision/Order). You must ask for an Appeals Council review
within 60 days after you get the hearing decision. You may
also submit new evidence.
If you disagree with the Appeals Council, you may file
a civil action with the US District Court in your area.
Social Security cannot help you with this. You may want
to contact a lawyer or legal aid group to help you.
Private payer plans are typically divided into two categories,
indemnity plans
and managed care plans.
Today, virtually all private health insurance payers incorporate
some form of a managed care component. In fact, many public health
care plans such as Medicare Advantage are forms of private managed
care plans.
Coverage and benefit information for these plans is provided
in a very broad and general context since private payer coverage
policies vary on a plan specific basis. For example, large payers
such as Aetna or Cigna offer hundreds of different plans that
include different covered benefit packages and coverage policies.
What are Indemnity Plans?
Indemnity or major medical coverage is what we typically think
of as "traditional" medical insurance. It was originally designed
to protect against the catastrophic losses that major illness
could create. These types of plans do not require members to seek
treatment from a set group of providers. These plans usually have
a deductible, co-insurance, and out-of-pocket
maximum amount. Members typically pay for medical treatments
or services and then submit a claim
for reimbursement
at a fixed rate which is usually a percentage amount. (For example,
the insurance company may reimburse the member 80 percent of allowed
charges).
What are Managed Care Plans?
Managed care coverage can be further broken down into three types
of plans, Health Maintenance
Organization (HMO), Preferred
Provider Organizations (PPO) and Point
of Service (POS) plans. The typical characteristics of each
plan are described below.
HMO
Health Maintenance Organizations (HMOs) provide a network of
physicians and other health care providers to their members. The
structure of these plans requires that a member have a primary
care physician (PCP) who oversees all health care and makes
referrals to specialists for members as needed. These plans typically
have a pre-determined, flat-dollar copayment and no deductible.
Services provided by out-of-network
providers are not covered without a referral.
PPO
Preferred Provider Organizations (PPOs) also provide a network
of physicians and other healthcare providers to their members;
however, there is not a PCP and a referral to specialists is not
necessary as long as they are in-network. Members also have the
option of seeking services from an out-of-network provider, but
services rendered by these providers may have higher out-of-pocket
costs.
Point of Service (POS)
Point of Service plans are a hybrid of HMO, PPO and indemnity
type plans. Members have the option of using in-network or out-of-network
providers. In addition, referrals to specialists within the network
are not usually required. Also, members can use out-of-network
providers, but services rendered by these providers may have higher
out-of-pocket costs.
Within these basic categories there may be multiple plans that
are customized for groups or individuals. Some insurance companies
administer hundreds and even thousands of different plans. It
is important to understand the employer group plan or individual
plan benefits you have. Be sure to get information describing
your benefits in writing. Take time to read the description of
your benefits and if there is something you do not understand,
you should ask the benefit administrator at the employer, your
insurance agent, or the member services representative at the
insurance company for further explanation.
If I can no longer work due to my pulmonary hypertension,
am I still eligible for health care benefits through my employer?
Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA) - Group health plans
with employers of 20 or more people must provide each participant
and their eligible family members the option to pay for continued
coverage for a specified period of time under the plan in the
event coverage is terminated as a result of one of a number of
qualifying events.
Qualifying events are those that would cause an individual to
lose health coverage. The type of qualifying event will determine
who the qualified members are and the required amount of time
that a plan must offer the health coverage to them under COBRA.
A plan may provide coverage for longer periods of time. Following
is a summary of qualifying events and coverage periods by member
type.
For Employees- Voluntary or involuntary termination of employment
for reasons other than gross misconduct (18 months) or reduction
in the number of hours of employment (18 months).
For Spouses- Termination of the covered employee's employment
for any reasons other than gross misconduct (18 months), reduction
in the hours worked by the covered employee (18 months), covered
employee's becoming entitled to Medicare (36 months), divorce
or legal separation of the covered employee (36 months), death
of the covered employee (36 months).
For Children- the types of qualifying events for dependent children
are the same as for the spouse with one addition: Loss of dependent
child status (36 months).
Real Life-
"When I was approved for SSDI it was the Social Security publication,
not my employer or COBRA carrier, that informed me about the
automatic extension of the 18 month COBRA coverage for someone
who is going to be approved for Medicare… That meant I continued
to have all my oral drugs paid for, a condition that ended
of course when I went on Medicare." |
If you would like additional information on whether you may
qualify for COBRA, please follow up with your employer.
What is Department of Veterans Affairs (VA) coverage?
The VA is responsible for providing federal benefits to veterans
and their dependents. The VA provides coverage for basic and preventative
care. Basic care includes the following:
- Hospital inpatient and outpatient services including medical,
surgical, and mental health care
- Prescription drugs, including over-the-counter drugs and
medical and surgical supplies available on the VA formulary
- Emergency care in VA facilities
- Comprehensive rehabilitative services other than vocational
services
- Consultation, professional counseling, training, and mental
health services for the members of the immediate family or legal
guardian of the veteran
- Durable medical
equipment and prosthetic and orthotic devices, including
eyeglasses and hearing aids
- Home health services
If you would like additional information regarding the VA, contact
1-800-827-1000 or visit the VA's website at www.va.gov.
What is the Civilian Health and Medical Program of the Department
of Veterans Affairs (CHAMPVA)?
CHAMPVA is a health benefit program for the families of veterans
with 100 percent service-connected disability, and surviving spouse
or children of a veteran who dies from a service-connected disability.
The VA determines eligibility and processes CHAMPVA claims. There
is no deductible for inpatient services or for ambulatory surgical
facility services. However, there is an annual outpatient deductible
that must be satisfied prior to the payment of outpatient benefits.
To determine if you are eligible for VA benefits, contact 1-800-733-8387
or visit the CHAMPVA website at www.va.gov/hac.
What is Tricare?
TRICARE is the name of the Department of Defense's (DOD) managed
health care program for active duty military, personnel, retirees
and their families.
For additional information on TRICARE, please refer to the TRICARE
website www.tricare.osd.mil/. The DOD Health Services is separated
into regions which you can access at the website to identify your
specific contact information for your region.
What are high risk insurance pools?
High risk insurance pools attempt to fill the insurance gap for
individuals denied health insurance coverage because they are
not healthy and considered a high risk to insurers. These programs
operate similarly to commercial programs in that they charge premiums,
copayments, and deductibles for a defined benefits package. The
premiums are usually higher than those for standard insurance.
Individuals typically utilize these types of programs for a short
period of time until they qualify for other coverage.
If you would like additional information on high risk insurance
pools, contact your state's department of insurance for guidance.
What are State and Community Health Plans?
These groups of programs provide coverage and services with minimal
private commercial and federal involvement. Funding and administration
principally occurs at the state, county, and local level. Client
populations receiving these services frequently are ineligible
for other coverage. To qualify for services, individuals typically
must meet eligibility requirements such as residency, income,
and or diagnosis. Patient financial contributions to care are
frequently minimal or adjusted for income, household size, and
the regional cost-of-living. Programs include county health departments
and state public assistance.
County health departments typically provide services aimed at
the promotion of health and the prevention of disease for the
general public. Basic services usually include: community health
education programs, maternal health, family planning and prenatal
care. Child care services are provided with immunizations and
vision and hearing screening.
State public assistance programs address the more general needs
of the public for a specific geographic region. Some of these
programs are charitable organizations offering financial assistance.
Others are educational in nature. Programs may also offer direct
prescription drug assistance for specific conditions. A major
component of these programs includes state pharmacy assistance
programs. At least 14 states currently administer state drug programs
of which the largest recipient populations are those enrolled
in Medicare and are without adequate prescription drug coverage.
If you would like additional information on the programs available
in your area, please contact your local health department.
This resource was developed in 2004. Some of the content may be out of date or no longer relevant. PHA is working to update and re-organize this guide. We apologize for any inconvenience.
