Health Care: Behind the Debate
Health insurance options
Free clinic patients uninsured for variety of reasons
Uninsured struggle to get specialized care
If you don’t have health care insurance or can’t get it, or if you recently have lost coverage, there are options available.
The federal and state governments provide a range of insurance programs. Following is a list of some of those options and information on what they provide, and what they don’t. All of the information was obtained at the Web sites listed.
COBRA
What is it? COBRA is an acronym for Consolidated Omnibus Budget Reconciliation Act of 1985, which among other things established health care continuation requirements.
Whom does it cover? COBRA requires that if an employee or other qualified beneficiary loses employer-provided health coverage due to termination of employment or another specified event, the group health plan must offer continued health care coverage to the qualified beneficiary.
What does it cost? To retain coverage, the former employee or beneficiary might be required to pay the entire group rate premium for health care coverage. In the past, the employer might have paid a percentage of that cost.
The recently passed economic stimulus plan contains a subsidy that discounts health insurance premiums by 65 percent to laid-off employees and their families who currently are enrolled in COBRA. It also allows those who recently lost their jobs to re-enroll in COBRA even if they were denied coverage in the past.
How long does coverage last: COBRA coverage has limited duration. In most cases, the maximum COBRA period is 18 or 36 months from the date of the qualifying event. You might be able to purchase extended health care coverage under COBRA under certain circumstances.
Medicare
1-800-MEDICARE, 1-800-633-4227
TTY Users, 1-877-486-2048
What is it? The Centers for Medicare & Medicaid Services (CMS) administers Medicare, the nation’s largest health insurance program, which covers nearly 40 million Americans.
Whom does it cover? Medicare covers people ages 65 and older, some disabled people younger than 65, and people of all ages with end-stage renal disease (permanent kidney failure treated with dialysis or a transplant). If you are younger than 65 and disabled, and have been entitled to disability benefits under Social Security or the Railroad Retirement Board for 24 months, you automatically are entitled to Medicare Part A and Part B beginning the 25th month of disability benefit entitlement.
What does it cover?
Medicare Part A — Pays for inpatient hospital, skilled nursing facility and some home health care. For each benefit period, Medicare pays all covered costs except the Medicare Part A deductible, which for 2009 is $1,068, during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days.
Medicare Part B — Covers Medicare-eligible physician services, outpatient hospital services, certain home health services and durable medical equipment. Pays for preventive services such as smoking cessation counseling, screenings for certain cancers and shots such as flu, penumococcal and hepatitis, glaucoma tests and more.
What does it cost?
Medicare Part A — Most people do not pay a monthly Part A premium because they or a spouse have 40 or more quarters of Medicare-covered employment. The Part A premium is $244 per month for people having 30 to 39 quarters of Medicare-covered employment. The Part A premium is $443 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.
For each benefit period you pay a total of $1,068 for a hospital stay of 1 to 60 days; $267 per day for days 61 to 90 of a hospital stay; $534 per day for days 91 to 150 of a hospital stay; all costs for each day beyond 150 days.
Medicare Part B — Most people will pay the standard monthly Part B premium of $96.40 in 2009. Some will pay a higher premium based on their modified adjusted gross income.
Medicaid
www.dhmh.state.md.us/mma/mmahome.html
410-767-5800 or 1-800-492-5231
What is it? Medicaid is a joint federal and state program. In Maryland, the program is run by the state Department of Health and Mental Hygiene (DHMH), which provides medical assistance, or Medicaid, coverage to people who have low income and cannot afford medical care. It provides health insurance for low-income families, children, the elderly and people with disabilities; long-term care for older Americans and individuals; supplemental coverage for low-income Medicare beneficiaries, such as payment of Medicare premiums, deductibles and cost sharing.
Whom does it cover? Medicaid covers those who fall into certain “categories” such as low-income families, children, pregnant women, women with breast or cervical cancer, the elderly and people with disabilities. People who receive money through Supplemental Security Income (SSI) or Temporary Cash Assistance (TCA) automatically receive Medicaid. In addition, people may qualify for Medicaid because of high medical expenses (commonly hospital or nursing home care), if they have low income and assets and are aged, blind or disabled.
What does it cover? Medicaid covers a range of services, including ambulance services and emergency medical transportation; dental services for children; early and periodic screening, diagnosis and treatment (EPSDT) services for people younger than 21; free-standing dialysis facility services; hospice care; hospital inpatient and outpatient care; laboratory and X-ray services and more.
Maryland Children’s Health Program (MCHP)
410-767-6883, 410-767-3641,
1-886-269-5576, 1-800-456-8900
What is it? The Maryland Children’s Health Program (MCHP) gives full health benefits for children up to age 19, and pregnant women of any age who meet the income guidelines. MCHP enrollees obtain care from a variety of Managed Care Organizations (MCOs) through the Maryland HealthChoice Program.
Whom does it cover? Those eligible for MCHP are children younger than 19 who are not eligible for Medicaid, and whose countable income is at or below 200 percent of the federal poverty level; pregnant women of any age, whose countable income is at or below 250 percent of the federal poverty level; and those who are uninsured, although in some cases having health insurance will not prevent eligibility for MCHP.
What does it cover? Benefits for children include doctor visits, both well and sick care. Benefits for pregnant women include doctor visits, prenatal and post-partum doctor visits, hospital care, hospital delivery bill, lab work and tests, dental care, lab work and tests, vision care, immunizations and more.
What does it cost? Premiums are based on income. In 2009, a family of two with an income of $36,425 would pay $48 per month.
Medical Assistance for Families
www.dhmh.state.md.us/ma4families/index.html
1-800-456-8900
E-mail MAExpansion@dhmh.state.md.us
What is it? Medical Assistance for Families provides comprehensive health care to parents and other family members caring for children.
Whom does it cover? Eligibility depends on family size and income. The annual income limit is about $21,200 for a family of three.
What does it cover? Provides low-cost or free prescriptions; doctor visits; emergency room visits; hospital stays; X-ray and lab services; and more.
Maryland Health Insurance Plan (MHIP)
www.marylandhealthinsuranceplan.state.md.us
443-738-0667, 1-888-444-9016
What is it? MHIP is a state-managed health insurance program for Maryland residents who have been unable to obtain health insurance from other sources.
Whom does it cover? Maryland residents who have a qualifying medical condition; have been denied insurance in the past six months for medical reasons; are enrolled in, or have the opportunity to enroll in, individual health insurance that limits, restricts or blocks your coverage for a specific medical condition; children with qualifying medical conditions; or those switching from a high-risk pool in another state. You also may qualify if you lost your employer-sponsored group insurance and the continuation of benefits you elected has run out, among other things.
What does it cover? MHIP offers its participants access to both CareFirst BlueChoice HMO and CareFirst Blue Preferred PPO networks. These plans are administered by CareFirst BlueCross BlueShield and CareFirst BlueChoice Inc. The plans cover a range of services, emergency room visits, hospital care, etc. Has a lifetime maximum.
What does it cost? The plan’s cost depends on the benefit option, coverage level and the age of the oldest applicant. Enrollees have a choice of one of four plan benefit options — HMO Plan; PPO Plan with $500 medical deductible; PPO Plan with $1,000 medical deductible; or High Deductible Health Plan with $2,600 combined medical and pharmacy deductible. The lowest cost option ranges from $245 for a person younger than 30 enrolling in a PPO with $500 medical and $100 drug deductibles to $551 for family coverage in that same category.
Maryland Health Insurance Partnership (HIP)
What is it? HIP provides an incentive for employers with from two to nine employees to offer health insurance for their employees; assists low and moderate income employees of these small employers in obtaining health insurance; and promotes access to health care services and rewards participating individuals for efforts to improve their health and/or manage chronic disease.
Whom does it cover? Under HIP, a small business that has two to nine full-time employees, has not offered health insurance to its employees during the previous 12 months, and meets wage and salary requirements established by the commission, is eligible to receive a subsidy of up to 50 percent of the premium.
The subsidy goes both to the employer and to the employee. Enrollment is capped to stay within the partnership’s approved annual budget.
How is the total subsidy divided? The employer receives the total subsidy in the form of lower premium payments, and passes the employee’s share through to the employee in the form of lower payroll deductions for the health insurance.
How is the subsidy paid? The insurance company will bill the state for the subsidy and will bill the employer for the total premium less the subsidy. The employer collects the employee’s share of the subsidized premium through payroll deduction, and pays the subsidized employer and employee share of the premiums to the insurance company.
Primary Adult Care Program (PAC)
www.dhmh.state.md.us/mma/pac/index.htm
1-800-226-2142
What is it? The Primary Adult Care Program offers health services to people 19 and older who make limited amounts of money each year.
Whom does it cover? It covers people age 19 and older who aren’t on Medicare and who meet the income and assets conditions. For instance, to be eligible, an individual’s assets can’t exceed $4,000; for a household, assets can’t exceed $6,000.
What does it cover? PAC provides free visits to a family doctor, also called a Primary Care Provider or PCP; free outpatient visits to a counselor or psychiatrist for mental health services; and lower-priced or no-cost prescription drugs, although some may require a co-pay.
What doesn’t it cover? PAC does not pay for hospital stays, emergency room visits or specialty care.
Information about COBRA can be found at www.cobrahealth.com. Information about a variety of insurance programs can be found at the Maryland Department of Health and Mental Hygiene Web site at www.dhmh.state.md.us/gethealthcare/index.html.