You can create wealth if you are healthy!
Let’s understand Government healthcare acts
No Surprise Act
No Surprise act is for consumer protection against excessive medical billing by out-of-network providers/hospitals from January 1st, 2022, for emergency and non-emergency care.
This means excessive billing is not allowed, billing is allowed as per health plan, and the objective is emergency care services should be available to consumers even if service is provided by out-of-network provider at in-network health plan rates.
In case of an emergency people don’t have any choice; when consumer goes to in-network hospital in an emergency but is sent to out-of-network hospital/facility. In this case, the No Surprise Act will protect consumers, Out of network providers and health insurer will solve their billing disputes among themselves; and the consumer is not a party to it.
Earlier out-of-network provider was able to send balance bill to consumers for the difference between total out-of-network service charges and cost covered by the health plan. This difference is required to pay by consumers out of pocket and is generally higher than in-network provider charges (deductible, co-pay, co-insurance). Balance bill sent by out-of-network provider is called surprise billing.
Good faith estimate
From January 1st, 2022 you can request health care service provider an estimated bill called good faith estimate and if you find the actual bill is $400 or more than the good faith estimate, you can raise an online “patient-provider dispute resolution” request by paying $25 Admin charge fee.
You can raise a dispute request by sending the document by post mail with FORM
You Must have
- Good faith estimate printout or email copy
- Actual bill must be $400 or more than good faith estimate
- The date on Good Faith Estimate should not be greater than 120 days
Affordable Care Act
Check Highlights of the act, check more details here
- Children are covered against their parent‘s plant till they are 26 years old.
- Insurance cannot be denied based on pre-existing medical conditions.
- An insurer cannot set annual/lifetime limits on spending.
- Inclusion of fully covered services.
- The premium for women is less than for men and ensures to cover women and child critical services.
- Medicaid expanded to include low-income citizens.
- Healthcare.gov to save money on health plans.
- Affordable health insurance plans are available.
Govt programs
Medicare, Medicaid, CHIP, Veterans Affairs Health Care, or TRICARE.
Medicaid
Medicaid is a government health insurance program; jointly funded by the federal and state governments for low-income families and individuals which includes adults, children, pregnant women, elderly adults, and disabled people.
Medicaid program rules, policies, and regulations are set by the federal government. As per the requirement of the federal government, the program is administered by the state and sets eligibility, service rates, and scope of services. Hence it might have some variation from state to state. Federal funding is a minimum of 50% and can go up to 83%.
Coverage includes doctor fees, hospitalization, Medical related long-term care, custodial care, and other health care costs.
As per federal law, states must provide below mandatory benefits/services
- In & out-patient services
- Family planning
- Early periodic screening, diagnostic, treatment (EPSDT)
- Nursing, physician, home health services
- Rural health clinic services
- Health center services as per federal guidelines
- Lab and x-ray services
- Nurse, midwife, pediatric services
- Patient transportation and
- Pregnant women counseling
You don’t need to buy marketplace insurance if you have Medicaid or CHIP
As per health care law, coverage against Medicaid plans which offers limited coverage and lesser services are not qualified plans.
Eligibility
- The beneficiary must be a citizen of the United States or a lawful non-citizen example permanent resident and eligibility can be due to age, pregnancy, and parenting status.
- Income eligibility is decided based on Federal Poverty Level (FPL), income means MAGI (Modified Adjusted gross income)
- Eligibility depends on the state where you reside. Check income eligibility in Medicaid expanded states find now
- Non-expanded Medicaid states have their own set of eligibility criteria, and each state is different.
- The best way to find out eligibility is to apply for Medicaid, as the situation in every family is different example present pregnancy, children, household size, income, age, disability, and other factors.
How to apply for Medicaid?
- Apply through Health Insurance Marketplace
- Apply to the Medicaid agency in your residing state
When can I apply for Medicaid?
Medicaid can be applied any time of the year.
Check state-wise Medicaid and CHIP program name
Community health centers | Health Centers | Budget health care
If health insurance plans are out of your budget and you don’t qualify for Medicaid then don’t worry community health care centers are here for you to provide quality primary health care services at a low cost on a sliding scale fee structure. It doesn’t matter whether you are insured or not insured you will get services in these centers. Today these centers have become lifelines for many individuals and families. These are non-profit, patient-directed centers. Federal Health Center Program grants are funding these centers.
Find out local Community Health Center
Medicaid Estate Recovery Program (MERP)
When the beneficiary dies, state Medicaid agency recovers cost it has paid for services availed by the beneficiary by initiating estate recovery, generally starts from home.
What is Medicaid spend down?
When income of a medically needy individual is too high to qualify for Medicaid in such situation some income must be spent down to qualify for Medicaid. Additional income is spent down by paying for non-insured medical or health care services, the individual becomes eligible when the remaining income is within state’s eligibility limits.
What is Medicare? | Medicare simplified
The Department of Health & Human Services (HHS) is established for improving health of all US citizens under HHS. Agency Centers for Medicare and Medicaid Services (CMS) is established to administer Medicare federally and Medicaid, CHIP (Children’s Health Insurance Program) is administered with the state’s help.
Medicare is a health insurance program federally operated for improving health of older people age 65+ and people with disabilities.
Eligibility criteria for each individual enrolling for Medicare
- It is for 65+ people
- Individual with disabilities
- For patients with End-Stage Renal Disease, kidney transplant, and dialysis
- You should be a citizen of the United State
- In case of a legal resident, an individual must be stayed in the US for five continuous years before enrolling in Medicare.
How to apply for Medicare
You can visit medicare.gov to apply online or click on apply for Medicare and follow step by step process.
What is Original Medicare? | What is Traditional Medicare?
Government-provided Medicare is called original Medicare or sometimes traditional Medicare which consists of Part A and Part B. You are required to pay premium, deductible, and copay/coinsurance for both parts (A&B).
The good part is Part A premium is generally free for most when you or your spouse pay taxes for a minimum of 10 years else you pay for part A premium.
For part A deductible, copay and coinsurance are only required to pay when you are using services else not charged.
Part B premium is required to pay, but if you are getting social security then it will be deducted from it.
Part B deductible, copay, and coinsurance, most services come with 80% coinsurance, you need to pay only 20%
What is Medicare Part A?
Part A is also called hospital insurance, it covers patient needs while in a hospital stay. It consists of coverage for in-patient care (hospital or nursing facility), room, operating room, meal, nursing services, and care supplies.
What is Medicare Part B?
Part B is called medical Insurance, it covers doctor visits and services when you are out or inside the hospital, clinic visits, out-patient care services, ambulance, emergency room, preventive care some vaccines, and medical devices for home use.
What is Part C? | What is Medicare Advantage? | MA Plan
Medicare advantage plan is often called “Part C” or “MA plan”, it is offered by Medicare-approved companies, it consists of both Part A (hospital insurance), Part B (medical insurance), and additionally, it may offer coverage for vision, hearing, dental, wellness program (fitness program) and most have coverage for prescription drug Part D.
Cost of Medicare Advantage plans
There are some plans with a $0 premium, other costs are copay and coinsurance. An annual Out-of-pocket limit is required to be set by Medicare which provides financial protection. For example, if annual out-of-pocket limit is set on 400$ and is reached then anything above that for the rest of the year will be covered by the MA plan.
Each plan offered has its own coverage and cost terms depending on region and state.
What is Part D? | Medicare prescription drug coverage plan
Part D is a prescription drug coverage plan that is available with MA plans or a stand-alone Part D plan.
Medicare requires part D should cover all types and classes of drugs that are used by beneficiaries, there is a list of drugs set for coverage. So, when you choose any drug make sure that the drug is available in the coverage list.
The cost of the plan includes premium and copay. Copay percentage depends on the plan. Plans have pharmacy network if you get drugs within the network, you get the best price.
What is Medigap? | Medicare supplement insurance
Medigap also called Medicare supplement insurance helps to pay some out-of-pocket costs coming from part A and part B (original Medicare)
There are standardized plans labeled as A through N, plan charges may be different from state to state and may provide additional coverage like dental services.
How to select Medicare plans? | Difference between Original Medicare and Medicare Advantage plan
The choice is depending on health needs, budget, and lifestyle, check below takeout, which might be of help while selecting.
If you want coverage for dental, hearing, and vision then it is better to choose the Medicare Advantage plan.
If you are a frequent traveler, then Original Medicare will be the best choice, as in the US all service providers are covered under Original Medicare.
Medicare Advantage plans normally come with the provider’s network, and you have to choose provider from the network for the best price.
Below Medicare plan combination can be helpful for the selection
- Original Medicare
- Original Medicare + Part D + Medigap
- Medicare Advantage plan
Children’s Health Insurance Program (CHIP) | CHIP Simplified | CHIP 101
The program is for children whose family is not qualified for Medicaid due to high income and not enough for private insurance, income eligibility depends on state rules as this program is jointly carried-out by the federal and state governments and works closely with Medicaid.
Benefits provided by each state may vary, some states also provide coverage to pregnant women. CHIP enrolment is open for a whole year. CHIP name changes state to state
Find out the CHIP name in your state
To find more about it call 1-877-KIDS-NOW (1-877-543-7669)
Who is qualified for state CHIP? | What are the eligibility criteria for CHIP?
- Applicant must be resident of the state where they apply.
- Child age must be 0 to 18 years
- United States citizen or legal non-citizen
- Ineligible to Medicare and uninsured.
CHIP Coverage and benefits
Comprehensive coverage provided by all states are.
- Vaccines/Immunizations
- Doctor visits
- Routine health check-ups
- Prescriptions drugs
- Dental and braces
- Eye check-ups and glasses
- Laboratory test and X-ray services
- Inpatient hospital care/surgery
- Outpatient care
- And emergency services
Benefits may vary from state to state, state may provide additional CHIP benefits.
CHIP Costs
- Well-child and dental visits are free
- Copayments are required for some services
- The monthly premium for CHIP coverage is required to pay in some states, it is a subsidized premium, and the cost is different from state to state.
What is a Well Child Visit and what does it include?
- Well Child visit is a comprehensive assessment to check abnormalities.
- It includes information about the birth history, and a head-to-toe physical check-up with a complete history of diet, sleep, dental, medical, surgical, and mental health.
- Review of growth, immunizations check, and updates.
- Check postpartum depression in mother, and infant breastfeeding.
- Provides an opportunity to answer parents’ questions and provide guidance.
Children’s Health Insurance Program Reauthorization CHIPRA Act 2009
Act provides significant additional funding to the state for children’s health care coverage through Medicaid and Children’s Health Insurance Program (CHIP). It provides flexibility to expand coverage and helps to enroll eligible children who are still not enrolled in Medicaid or CHIP.
Insurance Plans
There are different types of insurance plans HMO, PPO, EPO, and POS, the scope of these are
Health Maintenance Organization (HMO)
HMO plan has a list of doctors (in-network physicians) you can go to them, and you will get coverage; this list includes general and specialist doctors. If you want to go to a doctor outside the network, then you must be referred by in-network doctor only.
- In network doctors meaning PPC (primary care physician)
- You must use in-network providers/doctors
- You must select primary care doctor to get basic care and who can refer you to a specialist
- If you see a doctor outside HMO’s network, you will not be paid except in emergency.
- Doctors or providers are the employees of the HMO, or they might have contract with HMO.
- You must live in the service area of HMO, outside HMO area is only for emergency services.
How much it cost? Normally copay (fixed charges) for each doctor visit and coinsurance (say 20%) for some services.
Preferred provider Organization (PPO)
PPO plan is flexible than HMO for out-of-network doctor/service provider. You get best coverage when you see in-network doctor and if you want to see out-of-network doctor you will get less coverage and visiting out of network doctor do not requires any referrals.
- You are paying less when you are in-network.
- PPO plans are normally more expensive than HMO plans
- Out-of-network doctor is allowed but turns out very costly
- When you go out-of-network, it is advisable to check with PPO what is and how much is covered to avoid surprises.
Exclusive provider Organization (EPO)
EPO is the same as HMO but has a smaller network of service providers
Point of Service (POS)
POS plan is a combination of PPO and HMO, the only difference is, that in POS out-of-network doctors are allowed but still need referral from in-network doctor.
For out-of-network visits, POS will pay to a certain extent whereas HMO does not pay.
How to select an insurance plan?
- Check your health requirement and checklist of doctors you are likely and are required to see.
- Make sure to buy an ACA plan. (Affordable Care Act)
- Before selecting check your doctor is in-network list.
- Some plans provide good coverage if you have been referred by in-network doctor for out-of-network visit.
- Check insurance coverage and provider’s network size.
- It is advisable to buy insurance from the government marketplace (or exchange) irrespective of your income.
- HealthCare.gov is a federal marketplace or exchange
- Some states have established their own insurance marketplace.
Health Insurance Marketplace/Exchange | HealthCare.gov | Budget Health insurance
Anyone can buy health insurance from the government marketplace, thanks to the Affordable care act which led to the creation of a government-run marketplace for affordable health insurance. You should be living in the United States and must be a citizen of the U.S. or a lawful resident to buy insurance from healthcare.gov. The open enrollment period is between November and December and it is the best time to buy health insurance if you are not covered by any health insurance unless there is no life-changing event like relocation, marriage, child, etc.
It is always better to get insurance from a government exchange you can get subsidies if you are eligible, you will also understand if you are eligible for Medicaid or CHIP.
Healthcare.gov is a federal marketplace to buy affordable health insurance plans, in some states you might have to use states’ own exchange.
When you enter the zip code, if your state has its own marketplace then it will redirect you to the state marketplace.
Check if your state has its own insurance marketplace click here
Even if your income is high, you can buy insurance from government marketplace.
You can buy from private insurer but remember to buy ACA compliant plans.
It is always better to compare insurance plans from different insurer.