Vol. IV, July 2010 The U.S. Directory of Health Coverage Options
U.S. Directory of Health Care Options A state-by-state guide to helping Americans navigate their public and private health coverage options
FHCE
How to use this Directory: Use the Income Worksheet(page “v”) to determine the Federal Poverty Level percentage of you or the person whom you are trying to assist. This percentage usually determines if an individual is eligible for various public programs. Find your state’s Health Care Options Matrix for a complete list of private and public health coverage programs, along with additional valuable resources. Consult the Appendices for COBRA subsidy information, state-by-state program contact information, uninsured statistics for each state, as well as the glossary of terms found within this book.
Foundation for Health Coverage Education “Coverage for All Through Education” 101 Metro Drive, Suite 250 • San Jose, CA 95110 • www.coverageforall.org ISBN-13: 978-1-42432862-8 © Copyright 2010 by Philip Lebherz and the Foundation for Health Coverage Education All Rights Reserved. Printed in the U.S.A.
Printing for this version of the U.S. Directory of Health Care Options provided by the generous support of Pfizer, Inc.
U.S. Directory of Health Care Options A state-by-state guide to helping Americans navigate their public and private health coverage options
Created by
Phil Lebherz 2010
Dedication I want to dedicate this book to the thousands of workers in the private and public health insurance systems across the country who are attempting to reach our goal of lowering the number of uninsured people in America. I especially want to thank Leonard Schaeffer who provided his knowledge, inspiration, and vision to this project. - Phil Lebherz
table of contents Acknowledgements About the FHCE Income Worksheet Federal Poverty Level Table Health Care Options Matrices by State
ii
New Jersey
59
iii
New Mexico
61
iv
New York
63
v
North Carolina
65
North Dakota
67
Alabama
1
Ohio
69
Alaska
3
Oklahoma
71
Arizona
5
Oregon
73
Arkansas
7
Pennsylvania
75
California
9
Rhode Island
77
Colorado
11
South Carolina
79
Connecticut
13
South Dakota
81
Delaware
15
Tennessee
83
Florida
17
Texas
85
Georgia
19
Utah
87
Hawaii
21
Vermont
89
Idaho
23
Virginia
91
Illinois
25
Washington
93
Indiana
27
Washington, D.C.
95
Iowa
29
West Virginia
97
Kansas
31
Wisconsin
99
Kentucky
33
Wyoming
101
Louisiana
35
Maine
37
Maryland
39
Massachusetts
41
Michigan
43
Minnesota
45
Mississippi
47
Missouri
49
Montana
51
Nebraska
53
Nevada
55
New Hampshire
57
Appendices How to Understand the COBRA Subsidy
104
Other Services (by State)
105
State-by-State Comparison
112
The Uninsured In America
113
Glossary of Terms
114
i
Acknowledgements The following individuals and associations generously donated their time, energy, and resources to creating this book: Aetna Foundation
Health Coverage Foundation, Inc.
The Poizner Family Trust
Alain Enthoven
Health Net of California
Anthem Blue Cross Foundation
Kaiser Foundation
Portland Association of Health Underwriters
Beere & Purves, Inc.
Los Angeles Unified School District
Blue Shield of California
Larry Glasscock
CAHU Charitable Community Foundation
Leonard Schaeffer LISI
Cal Locket
Saint Joseph Health Center Foundation
Massachusetts Association of Health Underwriters
Schmitt Family Foundation
National Association of Health Underwriters
Sharp Health Plan
California Association of Health Underwriters California State Legislators
Professional Exchange Service Company Inc. Rio Grande Association
San Diego Office of Education
North Nevada Association of Health Underwriters
Spahr Insurance
Oregon Association of Health Underwriters
The Sugg Group
Peter and Renuka Patel
Warner Pacific
Peter Farrell
George and Clare Schmitt
Pfizer, Inc.
Washington Association of Health Underwriters
Greater Washington Association of Health Underwriters
Philip and Vivian Reed
WellPoint Foundation
Cathay Post No. 384 David and Nancy Helwig Dickerson Employee Benefits, Inc. Ernie Ramirez Florida Association of Health Underwriters
The Rauser Agency Word and Brown
Placer County Office of Education
Collaborative Efforts We would like to recognize the following organizations for their collaborative efforts in helping lower the ranks of the uninsured by referring individuals to FHCE’s resources: Aetna Inc. American Cancer Society American Diabetes Association American Heart Association American Lung Association Anthem Blue Cross of California Blue Shield of California
Catholic Healthcare West Hospitals California Department of Insurance Community Medical Centers Daughters of Charity Hospitals E-Health Insurance Google, Inc. NAHU
NAIC Robert Wood Johnson Foundation Sharp Health Care United Way of the Bay Area United Health Care WellPoint, Inc.
Appreciated Media Support The FHCE’s resources have had over 2 billion media impressions thanks to the following media outlets: AARP ABC View From The Bay ABC News American Medical News CBS Bay Sunday Chicago Tribune CNN Consumer Digest Costco Connection Kiplinger’s Personal Finance
ii
KTLA TV Channel 5 Los Angeles Times Men’s Health Magazine MSNBC New York Daily News Parenting.com Parents Magazine San Francisco Business Times San Francisco Chronicle Self Magazine
Smart Money, AOL Money & Finance The Angie Strader Show The New York Times The Wall Street Journal The Washington Post USA Today U.S. News & World Report
the Foundation for Health Coverage Education (FHCE) FHCE is a non-profit 501(c)3 organization with a mission to provide simplified public and private health insurance information in order to help more people access coverage. We offer a variety of health coverage resources to help consumers, health care professionals, employers, and the uninsured navigate the complex health insurance system. This directory of Matrices from all 50 states and the District of Columbia represents the entire health insurance system in our country. Different states have different approaches to insurance. Certainly California, with a population of 37 million, has different needs than Idaho where approximately 1.5 million people reside. The FHCE views the uninsured as a humanitarian issue, as well as a public health issue. Proper education of the public could improve our country’s health and save our health care system billions of dollars in claims. We have the infrastructure and capacity to take care of everyone. The U.S. has world class providers, hospitals and technology. We need to improve the administration, financing and distribution of publicly-funded programs, so that everyone who is eligible signs-up for health coverage. Together, we can lower the ranks of the uninsured.
FHCE Resources U.S. Uninsured Help Line™ The U.S. Uninsured Help Line (800-234-1317) provides live, one-on-one assistance to individuals with questions about their health coverage options. The Help Line is staffed 24/7 with friendly information specialists and interpreters who speak over 140 languages and provide basic screening for both public and private health coverage.
CoverageForAll.org All of FHCE’s resources and guides, including the Health Care Options Matrix, are available to download for free on CoverageForAll.org. The online Health Coverage Eligibility Quiz provides visitors with a personalized list of the public and private health coverage options for which they may qualify, along with each program’s signup check list and application link.
Disclaimer: An online version of this Directory is updated regularly for your convenience. Download the most recent version on www.CoverageForAll.org.
iii
iNCOME WORKSHEET Step One Use this worksheet to calculate your family or household total income after deductions.
Step Two Look for the income amount closest to the number in step one within the chart on the opposite page to determine which percentage of the Federal Poverty Level(FPL) you are.
Step Three Remember this percentage, as it will help you determine for which public programs you are eligible. Your monthly income + __________________ Spouse’s monthly income + __________________
TOTAL INCOME = __________________
Please fill in the following information, separate from amount that you just calculated: Begin with $0. For each working parent in the household, add $90.
+ __________________
If you pay for childcare for children under the age of 2, add $200 for each child. + __________________ If you pay for childcare for children over the age of 2, or for a child with disabilities, add $175 for each child. + __________________ If you receive child support, add $50 for each child. + __________________ If you pay alimony and/or child support, enter the amount. + __________________
Total Deductions = __________________
Now, subtract your Total Deductions from your Total Income.
TOTAL INCOME
__________________
TOTAL DEDUCTIONS -
__________________
TOTAL INCOME AFTER DEDUCTIONS =________________ Find an amount closest to this total within the chart on the opposite page to determine your Federal Poverty Level (FPL) percentage.
iv
Note: This income worksheet is only intended to serve as a guide. Some factors in determining your eligibility may not be represented above. Deductions listed here are typical for most public programs, but may vary by agency.
Federal Poverty Level Your Federal Poverty Level (FPL) Based on monthly family gross income
Family Size (Household)
100%
133%
175%
200%
250%
300%
400%
1
$903
$1,200
$1,579
$1,805
$2,256
$2,708
$3,610
2
$1,214
$1,615
$2,125
$2,428
$3,035
$3,643
$4,857
3
$1,526
$2,029
$2,670
$3,052
$3,815
$4,578
$6,103
4
$1,838
$2,444
$3,216
$3,675
$4,594
$5,513
$7,350
5
$2,149
$2,858
$3,761
$4,298
$5,373
$6,448
$8,597
6
$2,461
$3,273
$4,306
$4,922
$6,152
$7,383
$9,843
7
$2,773
$3,687
$4,852
$5,545
$6,931
$8,318
$11,090
8
$3,084
$4,102
$5,397
$6,168
$7,710
$9,253
$12,337
Based on yearly family gross income 1
$10,830
$14,404
$18,953
$21,660
$27,075
$32,490
$43,320
2
$14,570
$19,378
$25,498
$29,140
$36,425
$43,710
$58,280
3
$18,310
$24,352
$32,043
$36,620
$45,775
$54,930
$73,240
4
$22,050
$29,327
$38,588
$44,100
$55,125
$66,150
$88,200
5
$25,790
$34,301
$45,133
$51,580
$64,475
$77,370
$103,160
6
$29,530
$39,275
$51,678
$59,060
$73,825
$88,590
$118,120
7
$33,270
$44,249
$58,223
$66,540
$83,175
$99,810
$133,080
8
$37,010
$49,223
$64,768
$74,020
$92,525
$111,030
$148,040
• A pregnant woman counts as two for the purpose of this chart. • Add $311/month for each additional family member after eight. • Contact individual programs for deduction allowances on child/dependent care; working parent’s work expenses; alimony/child support received or court ordered amount paid. Source: Federal Register Vol. 74, No. 14, January 23, 2009, pp. 4199-4201. Monthly percentage data calculated by FHCE and rounded to the nearest dollar. Federal Poverty Levels for Hawaii and Alaska are slightly higher. Please visit www.coverageforall.org for further details and updates on the 48 continuous states, Hawaii and Alaska FPL charts.
Reminder
There is no universal administrative definition of income that is valid for all programs that use the poverty guidelines. The office or organization that administers a particular program or activity is responsible for making decisions about the definition of income used by that program (to the extent that the definition is not already contained in legislation or regulation). To find out the specific definition of income used by a particular program or activity, you must consult the office or organization that administers that program. v
Demographic
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Program
800-234-1317
Group Health
Alabama Association of Health Underwriters 703-276-0220 www.nahu.org www.alanahu.org
And then
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
800-234-1317
Individual Plans Alabama Association of Health Underwriters 703-276-0220 www.nahu.org www.alanahu.org
Individuals with pre-existing, severe or chronic medical conditions
Low-income individuals & families
AHIP
Medicaid (SOBRA & MLIF)
Alabama Health Insurance Plan 866-833-3375 334-263-8311 www.alseib.org
334-242-5000 800-362-1504 https://insurealabama.adph. state.al.us
HIPP
(Health Insurance Premium Payment Program) 334-242-3722 www.medicaid.state.al.us If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply
Coverage
Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
COBRA: Coverage available for up to 18 months depending on qualifying events, must have 20 employees or more. Benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Assorted plans depending on medical needs There is a 6-month look-back and 12-month exclusionary period limit for pre-existing conditions in traditional individual market health insurance products in Alabama Limits on pre-existing health conditions may apply
HIPP: Benefits are the same as what you had with your previous employer, HIPP is a premium assistance program
Two plans are available for member and certain dependents - a Blue Cross and Blue Shield of Alabama Traditional Indemnity Plan and a Managed Care Plan through United HealthCare Both plans provide doctor visits, prescription drugs, outpatient and in-hospital care, maternity, labs and x-rays, transplants, rehabilitation, durable medical equipment, and mental health and substance abuse, also emergency care while away from home and more Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Eligibility
Owner can count as an employee Owner name on business license must draw wages from the company
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for AHIP, see next column
GUARANTEED COVERAGE
GUARANTEED COVERAGE
You must have chosen to extend coverage under COBRA, group health plan, government plan, or church plan and exhausted those benefits and submitted your application within 63 days of your last day of coverage to sign up for AHIP
Medicaid Pregnant Women-133% of FPL Children (ages 0-5)-133% of FPL Children (Ages 6-19)-100% of FPL Supplemental Security Income Recipients-74% of FPL Working Parents-19% of FPL Non-Working Parents-13% of FPL Asset limits for some people
Must be a permanent Alabama resident with at least 18 months of continuous healthcare coverage without being terminated due to fraud or failure to pay
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even with pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA.
SOBRA: pregnant women ONLY get pregnancy related services covered Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
Among some of the services: ambulatory surgical center, birth center services, child health check-up, chiropractic care, durable medical equipment and supplies, federally qualified health centers, home health, hospital inpatient/outpatient care, laboratory, licensed midwife, physician, podiatry, prescriptions, rural health clinics, therapy, X-Rays
Legal Alabama resident
AHIP is specifically aimed at those who have purchased coverage from their employer and whose benefits have run out.
SOBRA: Must not be in an institution; must not be eligible for dependent coverage under state employees' insurance (including Public Schools)
Traditional Indemnity Plan premium could range between $169 to $957 depending on age, sex, smoker or non-smoker, and plan you choose. Managed Care Plan premium could range between $247 to $862 depending on age, sex, and smoker or non-smoker.
Medicaid: $0 to $3.00 for office visits, prescription drugs and some other services
Monthly Cost
HIPP: You may be eligible for HIPP if you have a high-cost health condition Costs depend on employer contribution and ± 20% of the insurance company’s index rate
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Costs for individual coverage varies
SOBRA: $50 co-payment for each inpatient hospital stay
HIPP: $0 or minimal share of cost
1
Alabama
800.234.1317
Children in moderate income families
Women
ALL Kids
Breast and Cervical Cancer Prevention
877-252-3324 www.adph.org/earlydetection
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
800-633-4227
Alabama State Health Insurance Assistance Program
800-726-2289 https://insurealabama.adph. state.al.us/
800-243-5463
A pelvic exam and a Pap smear A clinical breast exam An appointment and voucher for a mammogram if 50 and over Certain diagnostic services if needed, such as ultrasound, diagnostic mammogram, colonoscopy or biopsy
Pre-Existing Health Conditions Covered
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer)
ASHIAP is a Medicare counseling service
Pre-Existing Health Conditions Covered
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Coverage
AL Child Caring Program: outpatient services only
Veterans
Medicare Prescription Drug Program
AL Child Caring Program
All Kids: regular check-ups and immunizations, sick child doctor visits, prescriptions, dental and vision care, hospital and physician services, limited mental health/substance abuse services, and a toll-free 24 hour nurse line for health questions, and more
Trade Dislocated Workers (TAA recipients)
Program
888-373-KIDS 888-373-5437 334-206-5568 877-774-9521 https://insurealabama.adph. state.al.us or www.adph.org/allkids
Seniors and Disabled
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Both: Be Under the age of 19 and an Alabama resident. Not be covered by any other health insurance; Be ineligible for Medicaid
Women age 40 - 64
Age 65 and older
Women under age 40 who have a problem with their breast can undergo a clinical breast exam to determine if they are eligible to receive a free breast cancer screening through the program
Disabled people of all ages
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
All Kids: Be a U.S. citizen or eligible immigrant; Not be in an institution; Family incomes between 101-200% FPL
Both: $0 or small co-pays
Income eligibility at or below 200% of FPL
Not enrolled in certain state plans Individuals who are eligible for the federal Health Care Tax Credit can also use their credit funds to purchase a private health insurance product developed by Blue Cross Blue Shield of Alabama
Women without insurance or who are underinsured
$0 or minimal share-of-cost
Must not have access to employer plan that pays 50% of coverage cost
$0 and share of cost for
certain services; deductibles for certain plans
20% of the insurance premium
Certain veterans must have completed 24 continuous months of service
$0 and share of cost and co-pays depending on income level
www.coverageforall.org Alabama
Monthly Cost
All Kids: Yearly costs range from $50 to $100 per child, per year up to the first 3 children (no cost for additional children). Small co-pays are required at the time of service. There are no co-pays for preventive services
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)
Eligibility
AL Child Caring Program: Not be eligible for ALL Kids and all other plans; Be enrolled in school (if of age)
Demographic
Publicly Sponsored Programs
2
Demographic
Private Health Insurance Small businesses (2-50 employees) U.S. Uninsured Help Line
Program
800-234-1317
Group Health 703-276-0220 www.nahu.org
Click on Consumer Info then Find an Agent/Member
Group Coverage as selected by employer with a variety of plan designs available
Coverage
If uninsured for previous 63 - 90 days, a waiting period for coverage of pre-existing conditions may apply Pre-Existing Health Conditions Covered
Eligibility
Then convert to
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer, but paid by the individual
U.S. Uninsured Help Line 800-234-1317
Individual Plans 703-276-0220 www.nahu.org
Assorted deductible and plan design options for selection Limits on pre-existing health conditions may apply
COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Name on license must draw wages
Monthly Cost
COBRA
(Consolidate Omnibus Budget Reconciliation Act)
Individuals & families
No Guarantee Issue for group sized 50+
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for an Alaska Comprehensive Health Insurance Association plan, see next column
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Costs depend on employer contribution and ± 35% of the insurance company’s index rate
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Alaska
Individuals with pre-existing, severe or chronic medical conditions Alaska Comprehensive Health Insurance Association
Low income children and families Medicaid
907-465-3347 800-780-9972 www.hss.state.ak.us/dpa/ programs/medicaid
888-290-0616 www.achia.com
ACHIA offers six different comprehensive PPO plans with different deductibles ACHIA also offers a Traditional non-PPO plan. This plan pays 80% of the allowed charges after the $1,000 annual deductible has been satisfied. Once the deductible and out of pocket maximum have been satisfied, ACHIA will pay claims at 100% Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Owner can count as an employee, proprietor
3
Individuals recently covered by an employer health plan
Inpatient and outpatient hospital services, prenatal care, vaccines for children, physician services, nursing facility services for persons aged 21 or older, family planning and supplies, rural health clinic, home health care for persons eligible for skilled-nursing, laboratory and x-ray, pediatric and family nurse practitioner, nurse-midwife, early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21 Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Individuals unable to obtain private health insurance for reasons other than cost; You are an Alaska resident, You have at least 18 months of prior health insurance coverage without a 90 day or more break in such coverage; Your most recent health insurance coverage was under a group plan; You are not eligible for other group health insurance coverage including Medicare, Veteran’s benefits, Native Health Care or Medicaid; Your most recent health insurance coverage was not terminated due to nonpayment of premium or fraud; You have elected and exhausted any COBRA or similar coverage; You do not have other health insurance coverage
Family Income can be up to 185% of the FPL Working Disabled - 250% of the FPL Contact your local Division of Public Assistance office or your community’s village fee agent for more information
This is also the option for TAA recipients
Costs vary dependent on age and medical underwriting
Costs vary dependent on age and plan selection
$0 for families below 100% of the FPL
Rates are set at 150-175% of average standard risk rate for health insurance sold in Alaska with similar benefits
800.234.1317
Moderate income children and families Denali Kid Care
Native American Indians
CAMA
Indian Health Services
(Chronic and Acute Medical Assistance) 800-780-9972 www.hss.state.ak.us/ dhcs/cama
(Alaska Area) 907-729-3686 www.ihs.gov/FacilitiesServices/ AreaOffices/Alaska/index.asp For eligibility information visit: www.ihs.gov/GeneralWeb/ HelpCenter/CustomerServices/ elig.asp
All programs offer a variety of prevention and treatment services such as: doctor's visits, check-ups & screenings, vision exams & eyeglasses, dental checkups, cleanings & fillings, hearing tests & hearing aids, speech therapy, physical and mental health therapy, substance abuse treatment, chiropracty, foot doctor's services, hospital care, laboratory tests, prescriptions, medical transportation
Prescription drugs and medical supplies, limited to 3 prescriptions per month and no more than a 30day supply of any drug
IHS services are provided directly and through tribally contracted and operated health programs. Health services also include health care purchased from more than 9,000 private providers annually. The Federal system consists of 36 hospitals, 61 health centers, 49 health stations, and 5 residential treatment centers. In addition, 34 urban Indian health projects provide a variety of health and referral services
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Physician services Chemotherapy and radiation services for a recipient with cancer requiring chemotherapy, if provided in an outpatient setting Outpatient laboratory and X-ray services
Trade Dislocated Workers (TAA recipients)
Medicare
Health Coverage Tax Credit
800-MEDICARE 800-633-4227 www.medicare.gov
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
Medicare Prescription Drug Program 800-633-4227
Medicare offers to standard plans Part A: Hospital Insurance and Part B: Medical Insurance, as wells several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D Pre-Existing Health Conditions Covered
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Coverage through Alaska high-risk health insurance pool, the Alaska Comprehensive Health Insurance Association Pre-Existing Health Conditions Covered
HS-funded, tribally-managed hospitals are located in Anchorage, Barrow, Bethel, Dillingham, Kotzebue, Nome and Sitka. There are 37 tribal health centers, 166 tribal community health aide clinics and five residential substance abuse treatment centers
Coverage
Or contact the Division of Public Assistance office nearest you or the fee agent in your community
Seniors and Disabled
Program
Toll Free Outside Anchorage 888-318-8890 Anchorage Area 269-6529 www.hss.state.ak.us/dhcs/ DenaliKidCare
Adults with chronic medical conditions
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
You are an Alaskan resident
Must be a U.S. Citizen or legal alien; have one of following: a terminal illness; cancer requiring chemotherapy; chronic diabetes or diabetes insipidus; chronic seizure disorders; chronic mental illness; chronic hypertension
Must be regarded by the local community as an Indian or Alaska Native; Is a member of an Indian or Alaska Native Tribe or Group under Federal supervision; Resides on taxexempt land or owns restricted property; Actively participates in tribal affairs; Any other reasonable factor indicative of Indian descent; Is a non-Indian woman pregnant with an eligible Indian's child for the duration of her pregnancy through post partum (usually 6 weeks); Is a non-Indian member of an eligible Indian's household and the medical officer in charge determines that services are necessary to control a public health hazard or an acute infectious disease which constitutes a public health hazard.
Age 65 and older
Must be receiving TAA (Trade Adjustment Assistance)
$0 for an IHS qualified
$0 and share of cost for
ou are a child 18 or younger Y Children with other health insurance < 150% FPL Children with no Health Insurance < 175% FPL
Denali KidCare income guidelines are based on family size. Assets do not count towards Eligibility. It's best to apply, but call Denali KidCare to ask about the income guidelines
Youth who are 18 years-old may be required to share a limited amount of the cost for some services
Household income must be: < $300/mo. for one person < $400/ mo. for two people add $100 for each additional person < $500 in countable resources that could be used to pay medical bills: cash, bank/credit union accounts, or personal property, your home, one vehicle, income producing property, property that is used for your job (boat, fishing gear, etc.), or a fishing permit
$0 and $1 per prescriptions or medical supplies
beneficiary
Must not have access to employer plan that pays 50% of coverage cost Not enrolled in certain state plans
certain services: deductibles for certain plans
20% of the insurance premium
www.coverageforall.org Alaska
Monthly Cost
$0 for eligible children, teens and pregnant women
No other resources to meet the health care you need
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)
Eligibility
ou are pregnant and can Y provide proof of pregnancy from your health care provider Pregnant Women with or without Health Insurance < 175% FPL
Disabled people of all ages
4
Demographic
Private Health Insurance
Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Program
800-234-1317
Group Health
Coverage
HIPAA
Arizona Association of Health Underwriters 480-292-7746 www.aahu.net
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
HCG
And also...
(Health Care Group of Arizona) 602-417-6755
All group health insurance carriers can impose a 6-month look-back/ 12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium
Arizona Association of Health Underwriters 480-292-7746 www.aahu.net
Usually up to $5M, assorted deductibles depending on age and ZIP code Limits on pre-existing health conditions may apply
Pre-Existing Health Conditions Covered
Company size 2-50 employees (or self-employed)
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Owner name on business license must draw wages from the company
Individual Plans
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
GUARANTEED COVERAGE
Owner can count as an employee
800-234-1317
AHCCCS
Low income families and adults
AHCCCS
Arizona Health Care Cost Containment System (Medical Expense Deduction Program) 800-352-8401 www.ahcccs.state.az.us
Arizona Health Care Cost Containment System (Arizona’s Medicaid Program) In State: 602-542-9935 Out Of State: 800-962-6690 800-352-8401 www.ahcccs.state.az.us
The Medical Expense Deduction (MED) program provides medical coverage for individuals who do not qualify for other AHCCCS programs because their income is too high; they may be eligible for MED if they have medical expenses in the month of application (or the previous month) that reduce their monthly income to 40% of the Federal Poverty Level (FPL)
Offers health, dental, vision, and prescription coverage
Conversion Policies
GUARANTEED COVERAGE
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Eligibility
And then
Individuals with pre-existing, severe or chronic medical conditions
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Eligibility is subject to medical underwriting
Must not be eligible for other AHCCCS programs
Ages 0-5 up to 133% FPL
If you are denied coverage for a medical condition, you may be eligible for the Medical Expense Deduction program of AHCCCS, see next column
Monthly income can not exceed $707 for a family of four, after deducting medical expenses. Other deductions include childcare and each person employed
Ages 6-19 and childless adults: Up to 100% FPL Pregnant women - 150% FPL Arizona residents
Resources can not exceed $100K. (Only $5K may be liquid assets: cash, bank accounts, stocks, bonds, etc.) Home equity is counted toward the resource limit, but one vehicle is not counted
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Must be an Arizona resident
Church organizations may be excluded
Monthly Cost
Must live in Arizona
5
Costs depend on employer contribution or health condition of self-employed and ± 60% of the insurance company’s index rate
Arizona
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Costs for individual coverage varies
$0 or minimal share-of-cost
Both: $0 or minimal shareof-cost
COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
800.234.1317
Publicly Sponsored Programs
Women
Pregnant women & children
Native American Indians
KidsCare
Well Woman Health Check
Baby Arizona
Indian Health Services
877- 764-5437 602- 417-5437 www.kidscare.state.az.us
888-257-8502
800-833-4642 www.babyarizona.gov
Phoenix Area 602-364-5179 http://www.ihs.gov/ FacilitiesServices/AreaOffices/ Phoenix/Index.cfm
Medicare
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program 800-633-4227
Program
(An enrollment cap is in place for KidsCare due to a lack of funding. Individuals and families can still apply and be placed on a waiting list, and they will be contacted when funding becomes available)
Navajo 928-871-4811 http://www.ihs.gov/ FacilitiesServices/AreaOffices/ Navajo/
Seniors and Disabled
Demographic
Children in moderate income families
Tucson Area 520-295-2405 http://www.ihs.gov/ FacilitiesServices/AreaOffices/ Tucson/index.asp Provides treatment for breast and/or cervical cancer or precancerous cervical lesions
Provides a simple, faster way for pregnant women to apply for AHCCCS medical coverage
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Choose one of the doctors; Make an appointment for a prenatal (pregnancy) visit; at your first visit, the office staff will assist you in completing an application for AHCCCS medical coverage; you will be asked to take information with you to your first visit to show you are eligible for the Baby Arizona program
Available programs vary depending on health center and may include primary and child care, prenatal and post delivery care, family planning (birth control), minor surgical and orthopedic care, pharmacy, dental and orthodontics, optometry, nursing, mental health, laboratory and radiology.
Medicare offers to standard plans Part A: Hospital Insurance and Part B: Medical Insurance, as wells several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Coverage
A wide array of medical services including behavioral health services
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Children under age 19
At or below 250% FPL No limit on resources
Provides medical coverage to pregnant women, and children up to the age of 19 years.
Must be ineligible for no-cost Medicaid or employer-based coverage
Arizona resident and qualified resident
Pregnant women - 150% FPL
No access to other health insurance including Medicare
Ages 1-6: 133% FPL
Must be regarded by the local community as an Indian; Is a member of an Indian or Group under Federal supervision; Resides on taxexempt land or owns restricted property; Actively participates in tribal affairs; Any other reasonable factor indicative of Indian descent; Is a non-Indian woman pregnant with an eligible Indian’s child for the duration of her pregnancy through post partum (usually 6 weeks); Is a non-Indian member of an eligible Indian’s household and the medical officer in charge determines that services are necessary to control a public health hazard or an acute infectious disease which constitutes a public health hazard.
Age 65 and older
At or below 200% FPL
$0 or minimal share-of-cost
$0 and share of cost for
No limit on resources Arizona residents Parents also qualify with a income of 200% of the FPL
Ages 6 and older: 100% FPL
$0 or minimal share-of-cost
$0 or share-of-cost
No limit on resources or property that may be owned
certain services: deductibles for certain plans
www.coverageforall.org Arizona
Monthly Cost
$10 to $25 a month for one child or $15-$35 a month for two or more children
Women who are screened by the Arizona Department of Health Services Well Women HealthCheck Program, Hopi Women’s Health Program, and Navajo Nation Breast and Cervical Cancer Prevention Program are eligible for AHCCS
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)
Eligibility
No health insurance for the last three months at time of application
Children < age 1: 140% FPL
Disabled people of all ages
6
Demographic
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA/Mini-COBRA
U.S. Uninsured Help Line
Program
800-234-1317
Group Health
Arkansas Association of Health Underwriters 703-276-0220 www.arkansas-ahu.org
Coverage
All group health insurance carriers can impose a 6-month look-back/ 12-month exclusionary period for preexisting conditions on enrollees that do not have prior creditable coverage Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
And then
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
COBRA or Mini-COBRA: Coverage available for 12 to 18 months depending on qualifying events for COBRA, Mini-COBRA for up to 120 days. Benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage
800-234-1317
Individual Plans
Individuals with pre-existing, severe or chronic medical conditions CHIP
(Comprehensive Health Insurance Plan) 800-285-6477 www.chiparkansas.org
Arkansas Association of Health Underwriters 703-276-0220 www.arkansas-ahu.org
Assorted plans depending on medical needs There is a 12-month look-back and 24-month exclusionary period limit Limits on pre-existing health conditions may apply
Pre-Existing Health Conditions Covered
Low income individuals and families Medicaid
(Including ARKids A) 800-482-8988 800-482-5431 501-682-8233 www.medicaid.state.ar.us
Safety Net Benefits Program 800-540-7566 www.arhealthnetworks.com
$1M lifetime benefits offering: comprehensive coverage of doctor visits, prescription drugs, outpatient and inhospital care, ambulance, labs and x-rays, skilled nursing care, home health visits, maternity, preventive care, transplants, rehabilitation, durable medical equipment, mental health and substance abuse, and physical and occupational therapy among other services Pre-Existing Health Conditions Covered
Medicaid & ARKids A: Family planning, home health inpatient, laboratory and x-ray nurse-midwife, nursing facility outpatient, physician, ambulatory surgical center, hearing, chiropractic, dental durable medical equipment, ElderChoices, Prescription Drugs, Prosthetics, Psychology Services, Rehabilitative Services for Persons with Mental Illness and Physical Disabilities, Targeted Case Management, Transportation Services, Ventilator Equipment, Visual Services …and more Safety Net Benefits: You get limited benefits each 12 months including: 7 inpatient days a year, 2 major outpatient services (emergency room and major services performed in the office), 6 physician office visits, 2 prescriptions a month, maximum annual benefit of $100,000 Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE Company size 2-50 employees (including owner)
Monthly Cost
Eligibility
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
7
Owner name on business license must draw wages from the company Most small group carriers also require 75% employee participation and accept employees who sign a waiver indicating other coverage as counting towards the 75%
Costs depend on employer contribution and ± 25% of the insurance company’s index rate
Arkansas
GUARANTEED COVERAGE COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for CHIP, see next column
COBRA is for businesses with 20+ employees, Mini- COBRA is for business with under 20 employees HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. For HIPAA, you cannot be eligible for Medicare or other public or group insurance programs
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Resident of Arkansas for at least 90 days or resident for at least 30 days with evidence of coverage under a Qualified High Risk Pool of another state
Medicaid: Pregnant women & children ages 0-19: 200% FPL Supplemental Security Income Recipients: 74% FPL Parents: 15% FPL
Not be enrolled in or eligible for Group Health Plan, Part A or B of Medicare or the Arkansas Medical Assistance Program (Medicaid and ARKids). Cannot be eligible for group coverage or COBRA, or government programs (must have exhausted this option)
ARKids A: Children under age 6 with family income up to 133 FPL; children ages 6 through 18 up to 100 FPL; also covers children between 133 and 200% FPL who do not meet certain ARKids B eligibility
May need to prove denial of coverage or offer of higher premium
Safety Net Benefits: Must live in Arkansas, Employees must be between the ages of 19-64, Must be a U.S. Citizen, Income at or below 200% of the FPL
May also be federally-eligible for CHIP
Costs for individual coverage varies
$1000 out-of-pocket
deductible and $1000 outof-pocket annual maximum for in-network care Monthly rates are determined by Age, Gender, and Tobacco Usage
$0 or minimal share-of-cost Safety Net Benefits: $100 annual deductible (does not apply to office visits & Rx) After deductible, 15% co-coverage will be required $1,000 maximum out of pocket annually, including deductible
800.234.1317
Children in moderate income families
Women
ARKids First B
Breast Care
877-670-CARE 877-670-2273 501-661-2513 www.arbreastcare.com
Arkansas MotherInfant Program 501-661-2154 www.adhhomecare.org/ maternal.htm
Maternity Program 501-661-2480
Pre-Existing Health Conditions Covered
Breast Care: Mammograms, pap tests and pelvic exams, breast exams, colonoscopy, colonoscopy with biopsy. Free information about how to find breast and cervical cancer early Arkansas Mother-Infant Program: Skilled home nursing visits for new mothers and infants to meet their medical, social and nutritional needs Maternity Program: Prenatal and postpartum care including a medical, nutritional and social assessment and case management, education on pregnancy, nutrition, labor and delivery, infant care, reproductive
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
800-633-4227
Senior’s Health Insurance Information Program (SHIIP) 800-224-6330 501-371-2782
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer)
SHIIP is a Medicare counseling service
Pre-Existing Health Conditions Covered
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Coverage
Two plans that include many of the following: ambulance (emergency only), chiropractor, dental care (orthodontia included) durable medical equipment, ER services, EPSDT screens, family planning, hearing, home health, hospice, immunizations, inpatient hospital, inpatient, psych laboratory and x-ray, midwife outpatient mental and behavioral health, physician, psychology, podiatry, drugs, prescription therapy services (speech), occupational, and physical transportation, vision
Trade Dislocated Workers (TAA recipients)
Program
(Children’s Health Insurance Plan) 501-682-8269 888-474-8275 www.arkidsfirst.com
Seniors and Disabled
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
ARKids B covers uninsured children through age 18 with family income up to 200% FPL
All: No health insurance, or your health insurance does not cover the services
Both: Age 65 and older
Must be receiving TAA (Trade Adjustment Assistance)
Age restrictions for each service
People with End-State Renal Disease (permanent kidney failure requiring dialysis or kidney transplant
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Under approximately 180% FPL
Disabled people of all ages
Must not have access to employer plan that pays 50% of coverage cost
Certain veterans must have completed 24 continuous months of service
20% of the insurance
$0 and share of cost and co-pays depending on income level
Eligibility
Not enrolled in certain state plans
of durable medical equipment and inpatient hospital care, which both require a 20 percent coinsurance payment for ARKids B
$0 or minimal share-of-cost
$0 and share of cost for certain services; deductibles for certain plans
premium
www.coverageforall.org Arkansas
Monthly Cost
$0-$10 with the exceptions
8
Demographic
Private Health Insurance Small Businesses (2-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA or Cal-COBRA
U.S. Uninsured Help Line
800-234-1317
Program
Group Plans
California Association of Health Underwriters 800-322-5934 www.cahu.org
Then convert to
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov
800-234-1317
Individual Plans California Association of Health Underwriters 800-322-5934 www.cahu.org
Individuals with pre-existing, severe or chronic medical conditions MRMIP
Medi-Cal
(Major Risk Medical Insurance Program) 800-289-6574 www.mrmib.ca.gov
California’s Medicaid Program 800-952-5253 888-747-1222 www.medi-cal.ca.gov
Due to changes in the program, MRMIP has opened up a waitlist
Or contact local county social services agency www.dhs.ca.gov
AIM
HIPP
Access for Infants & Mothers 800-433-2611 www.aim.ca.gov
(Health Insurance Premium Payment) www.dhcs.ca.gov/
Different plans cover different medical services
Coverage
Sometimes coverage is limited to $1M in a lifetime; often $5M and some plans have no limit
COBRA or Cal-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium
These factors affect the monthly premium and deductibles
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply
HIPP: Benefits are the same as what you had with your previous employer, HIPP is a premium assistance program
Pre-Existing Health Conditions Covered
Low income families & medically needy
Different plans will cover different medical services There may also be a lifetime maximum of benefits, for example $5M Limits on Pre-Existing Health Conditions May Apply
MRMIP is a 36 month program. After that, subscribers can enroll in guaranteed coverage with private health plans Under MRMIP, there is a $75K annual limit and $500 annual deductible Coverage increases to $200K per year (with a $750K lifetime limit) once subscriber moves to a GUARANTEED COVERAGE private insurance individual plan MRMIP offers a variety of medical services provided by HMOs and PPOs.
Pre-Existing Health Conditions Covered
Medi-Cal: Offers health, dental, vision, and prescription coverage; Treatment for special health problems like breast cancer, kidney problems, nursing home needs, and AIDS AIM: comprehensive medical care for mother provided (not just maternity); mothers continue coverage up to 60 days after delivery; after birth, infant is automatically enrolled in Healthy Families Program up to age 1 Pre-Existing Health Conditions Covered
MRMIP has a 3 month exclusion period for pre-existing conditions. Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA or Cal-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Eligibility
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage Owner can count as an employee Owner name on business license must draw wages from the company
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for MRMIP, see next column
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Monthly Cost
COBRA or Cal-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Cal-COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
GUARANTEED COVERAGE
Eligible if previous coverage was terminated for reasons other than non-payment of premium or fraud (such as a pre-existing condition)
Medi-Cal: Age < 1: Up to 200% FPL Ages 1-5: Up to 133% FPL Ages 6-18: Up to 100% FPL If you are pregnant, your income can be up to 200% FPL; Children under 21 in foster care, parents: Up to 107% FPL If you are elderly or disabled, your income can be up to 133% FPL
Must prove denial of coverage or offer of higher premium than MRMIP Cannot be eligible for COBRA, CalCobra, or government programs (except “end stage renal disease” covered under Medicare)
Cal-COBRA: Applies to small businesses with less than 20 employees
Live in California Subscriber must select from health plan carriers that offer post-MRMIP GUARANTEED COVERAGE Cannot be eligible for both Part A and Part B of Medicare
HIPP: You may be eligible for HIPP if you have a high-cost health condition (e.g., pregnancy, HIV/AIDS), and are eligible for Medi-Cal Cost depends on the employer contribution and ±10% of the insurance company’s index rate
GUARANTEED COVERAGE
Costs for individual coverage varies
Costs vary depending on age, region in CA, and program $2,500/year out-of-pocket max for subscribers. Annual out-ofpocket limits per household (subscriber + dependents) is approximately $4,000
AIM: 200%-300% FPL for AIM Pregnant less than 31 weeks; Live in California; California resident for at least 6 months; legal immigration status; You cannot be receiving no-cost Medi-Cal or Medicare Part A and Part B benefits as of the application date; Cannot be covered by private insurance costing $500 or less
Medi-Cal: $0 or minimal share of cost AIM: 1.5% of family annual income for AIM
HIPP: $0 or minimal share of cost
9
California
800.234.1317
Children in low income families or undocumented children Healthy Kids Plans
(County based program) www.partnershiphp.org www.champ-net.org/programs/hkLA.cfm
CaliforniaKids
Kaiser Permanente Child Health Plan
800-464-4000 http://info.kp.org/childhealthplan/
Children Health and Disability Prevention (CHDP)
Medi-Cal
California’s Medicaid Program 800-952-5253 888-747-1222 www.medi-cal.ca.gov
AIM
Access for Infants & Mothers 800-433-2611 www.aim.ca.gov
Healthy Families Program
800-880-5305 888-747-1222 www.healthyfamilies.ca.gov
Adults without dependents
Immigrants awaiting legal status
County Medical Services Program (CMSP)
Restricted Medi-Cal
Contact local county social services agency www.cmspcounties.org
Genetically Handicapped Persons Program (GHPP)
916-327-0470 800-639-0597 www.dhcs.ca.gov/services/ ghpp
California’s Medicaid Program 800-952-5253 www.medi-cal.ca.gov
Family PACT
(Family planning) 916-650-0414 www.familypact.org For local programs contact www.dhs.ca.gov
Adults in need of cancer screening IMPACT
800-409-8252 www.california-impact. org
Breast and Cervical Cancer Screening & Treatment 800-824-0088 www.dhs.ca.gov/ cancerdetection
Program
818-755-9700 www.californiakids.org
Pregnant women, infants, & moderate income children
Demographic
Publicly Sponsored Programs
Call your local CHDP provider www.dhs.ca.gov/pcfh/cms/chdp/ Healthy Kids, California Kids & KPCHP: All programs offer a variety of health, dental, and vision plans from which to choose, includes hospitalization KPCHP: Effective July 17, 2009, enrollment is now closed to new membership from Southern California. A future re-open date has not been determined.
Pre-Existing Health Conditions Covered
AIM: comprehensive medical care for mother provided (not just maternity); mothers continue coverage up to 60 days after delivery; after birth, infant is automatically enrolled in Healthy Families Program up to age 1 Healthy Families Program: Offers a variety of health, dental, vision, and prescription plans from which to choose Pre-Existing Health Conditions Covered
CMSP: Program availability varies by county, Medically necessary physician and hospital-related services; Depending on county, may provide coverage for other services such as dental and vision; Benefits vary by county, please refer to social services agency in county of residence GHPP: Special care center services, hospital stay, outpatient medical care, pharmaceutical services, surgeries, nutrition products and medical foods, durable medical equipment, and other services
Restricted Medi-Cal: covers emergencies, pregnancy related care (prenatal and delivery), kidney dialysis, treatment for breast and cervical cancer Family PACT: provides comprehensive family planning services Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Healthy Kids: Must be a resident of Solano, Napa, Yolo or Sonoma County. Must not be covered by an employer sponsored plan now or in the last 3 months. Children must be between the ages of 0-18. Children’s family income can be between 0-300% of the FPL. Not Eligible for no-cost full-scope Medi-Cal or Healthy Families. Undocumented children are eligible.
Medi-Cal: If you are pregnant, your income can be up to 200% FPL
CMSP: Must be between the ages of 21-64, Must not be eligible for Medi-Cal; Must reside in county where applying; In CMSP counties, income can be up to 200% FPL; In non-CMSP counties, eligibility income standards vary, please refer to social services agency in county of residence
Restricted Medi-Cal: Age < 1: Up to 200% FPL Ages 1-5: Up to 133% FPL Ages 6-18: Up to 100% FPL
KPCHP: California resident living near Kaiser or in county plan area. Must not be eligible for employer based coverage CHDP: Children and youth between birth and age of 19 whose family is at 200% FPL or less. Also children in Headstart, State Preschool programs, and Foster Care.
Healthy Families Program: Age < 1: 200%-250% FPL Ages 1-5: 133%-250% FPL Ages 6-18: 100%-250% FPL Must be ineligible for no-cost MediCal or employer-based coverage; California residents and legal immigrants
GHPP: Must be diagnosed with a genetic condition that is covered by GHPP; Applicants must be residents of California; Applicants must be 21 years of age or older (some persons younger than 21 years of age may be eligible); there is no income limit; Applicants may be required to apply for Medi-Cal.
If you are pregnant, your income can be up to 200% FPL If you are elderly or disabled, your income can be up to 133% FPL Family PACT: up to 200% FPL No insurance or ineligible for Medi-Cal Insurance does not cover family planning or birth control methods. Have not met deductible of current insurance.
GUARANTEED COVERAGE IMPACT: California resident over 18 years old, Little or no insurance, Up to 200% FPL, Abnormal DRE, PSA or diagnosed with prostate cancer BCCST: 40 years old or older, with an income of 200% of the FPL, uninsured or have medical insurance that does not cover these services; not getting these services through Medi-Cal or another government-sponsored program; Women 25 and older can receive cervical cancer screening
Eligibility
GUARANTEED COVERAGE
CaliforniaKids: Must not be eligible for other government plans such as Medi-Cal or Healthy Families Program
BCCST: women can get screening and treatment Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
AIM: 200%-300% FPL for AIM; Pregnant less than 31 weeks; Live in California; California resident for at least 6 months; legal immigration status; You cannot be receiving nocost Medi-Cal or Medicare Part A and Part B benefits as of the application date; Insurance deductibles or copayments over $500 may qualify you
IMPACT: Provides men with radical prostatectomy, external beam radiation therapy, hormone therapy, watchful waiting, brachytherapy, chemotherapy, counseling and more
Coverage
CHDP: Only covers general check ups required for school, sports, etc. (Does not cover hospital, medicines, or any emergencies)
Medi-Cal: pregnancy related care (prenatal and delivery) is covered. Mothers are covered up to 60 days after delivery
Have Medi-Cal with share of cost but you have not met your share of cost.
Medi-Cal: $0 or minimal share of cost AIM: 1.5% of family annual income for AIM
Healthy Families : $4-$24 per child depending on income and choice of plan, with a $72 family maximum; $5 copay for doctor visits and prescriptions; some check-ups are no-cost
CMSP: $0 or minimal share of cost
$0 or minimal share of cost
$0 or minimal share of cost
GHPP: Some clients may also be required to pay an annual enrollment fee to GHPP. The amount of enrollment fee is based on income and family size.
www.coverageforall.org California
Monthly Cost
Healthy Kids: Monthly premiums are $0-6; $5 co-pay for most outpatient services. CaliforniaKids: $10-20 per month per child; $5-50 co-pays for services KPCHP: $8-15 per child per month ($45 max per family), co-pays range from $5-$35 for some services with a $250/child or $500 for two or more children maximum CHDP: $0 or minimal share of cost
10
Demographic
Private Health Insurance Small businesses (1-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
Low Income Families and Medically Needy
U.S. Uninsured Help Line
COBRA/ Mini-COBRA
U.S. Uninsured Help Line
CoverColorado
Colorado Health Plan
HIPAA
Individual Plans
Program
800-234-1317
Group Health
Colorado State Association of Health Underwriters 703-276-0220 www.nahu.org
Then convert to
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov
800-234-1317
800-930-3745 303-894-7490 www.dora.state.co.us/ insurance
(Colorado Medical Insurance Pool) 303-749-1111 888-770-1120 877-461-3811 (Billing) 303-863-1960 (Enrollment) www.covercolorado.org (Colorado Blue Cross Blue Shield Plan Administrator)
Waiting periods for coverage on certain conditions may apply
Coverage
Pre-Existing Health Conditions Covered
Contact your local county offices for Medicaid information in your county. List of numbers can be found here: www.cdhs.state.co.us/ servicebycounty.htm
Or
State Continuation Coverage Assorted deductibles
(Medicaid) 800-283-3221 www.chcpf.state.co.us
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
Different plans will cover different medical services
COBRA Subsidy: 15 months of partially subsidized COBRA premium
Limits on Pre-Existing Health Conditions May Apply
There may also be a lifetime maximum of benefits, for example $5M
HIPAA: Individual-plan conversion benefits are based on the program selected and there is no expiration of coverage
CoverColorado offers a statewide major medical plan, with eight deductible levels to choose from Hospitalization, physician care, diagnostic tests, x-rays, prescription drugs, and some mental health care services If you have not been insured within the past 90 days prior to applying, expenses related to any pre-existing medical condition will not be covered for the first 6 months
Diagnosis (services to find out what is wrong), Physician services, check-ups (medical and dental), family planning, maternity, prenatal, and newborn care, prescriptions, hospital services, comfort care, hospice, dental services, drug and alcohol treatment, mental health services Pre-Existing Health Conditions Covered
If you have been insured, for at least six continuous months, within 90 days of application to CoverColorado, you will not be subject to the 6-month preexisting waiting period
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 1-50
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage
Eligibility
Owner can count as an employee Proprietor-name on license must draw wages If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions- not counting birth or adoption- may apply, (1-6 months respectively)
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for CoverColorado, see next column
COBRA is for businesses with 20+ employees, Mini- COBRA is for business with under 20 employees
GUARANTEED COVERAGE
GUARANTEED COVERAGE
You must have resided in Colorado as a legal resident for at least six months prior to applying for coverage, unless you are HIPAA eligible or transferring from another state’s high risk insurance pool; Cannot be eligible for Medicaid, Medicare or any other health insurance; Must not have been terminated from CoverColorado in the 12 months prior to your application or have received $1,000,000 in benefits from the CoverColorado program; unless you are HIPAA eligible
Pregnant women and children under the age of 6 income at or below 133% of the FPL Children age 6-18 income at or below 100% of the FPL Parents income at or below 60% of the FPL SSI Disabled income at or below 74% of the FPL Some eligibility requirements change from county to county so contact your local county department
Monthly Cost
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
11
Costs depend on employer contribution and +10% or -25% of the insurance company’s index rate
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column
Colorado
Costs depend on age and county/zone If you are self-employed and buy your own insurance you are eligible to deduct 100% of the cost of the premium from your federal income tax
Premiums vary based on the plan and deductible you choose and underwriting guidelines
$0 for children and pregnant
women; $0 or small co-pays for Adults
800.234.1317
Low Income Children
Women
Native American Indians
Trade Dislocated Workers (TAA recipients)
Veterans
Child Health Plan Plus
Women’s Wellness Connection
Indian Health Services
Health Coverage Tax Credit
VA Medical Benefits Package
(WCC) 303-692-2581 866-951-WELL 866-951-9355 www.cdphe.state.co.us/ pp/cwcci
970-563-9443 www.ihs.gov/FacilitiesServices/ AreaOffices/AreaOffices_index. asp
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
Listed under "Albuquerque Area" for "Southern Colorado UTE Service Unit"
Regular checkups, Immunizations (shots), Prescriptions (medicine), Hospital services, Eye glasses, Hearing aids
Cancer treatment for some women qualified through Medicaid
Pre-Existing Health Conditions Covered
Care includes medical, nursing, dental, optometry, nutrition, health education, community health nursing, mental health, social services, substance abuse, and environmental health services, well-child, chronic diseases, allergy, women's health, and podiatry. Pharmacy, laboratory and radiology services are all provided at the centers, including in-patient and specialty care with providers in neighboring areas
Will cover 80% of COBRA if employer contributes less than 50% (or spouses’ employer)
Comprehensive preventive and primary care, outpatient and inpatient services
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Coverage
Dental services up to $600 a year including exams, cleanings, and some other services
Some diagnostic services such as ultrasound, breast biopsy, surgical consultation, colonoscopy
Program
(CHP+) 800-359-1991 www.cchp.org
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Must not be eligible for Medicaid
Age 40-64
The Southern Colorado Ute Service Unit serves the Southern Ute and the Ute Mountain Ute Tribes
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Colorado residents; U.S. citizens or permanent U.S. residents (who have had an Alien Registration number for at least 5 years)
Income below 250% FPL Must not have had pap or mammogram test in last 12 months
Must not have access to employer plan that pays 50% of coverage cost Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
20% of the insurance premium
$0 and share of cost and co-
Eligibility
Not covered by any other insurances
Under-insured or uninsured
18 and younger Household income of 200% FPL
$0 for most members
$0 or small share of cost
$0 or minimal share of cost
www.coverageforall.org Colorado
Monthly Cost
pays depending on income level
For those who have to pay, enrollment fee is $25 for one child, $35 for 2+children. Co pays are $2 - $15 per visit for routine medical care
12
Demographic
Private Health Insurance Small businesses (1-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
U.S. Uninsured Help Line
COBRA/ Mini-COBRA
U.S. Uninsured Help Line
Group Plans
HIPAA
Connecticut Health Reinsurance Association
Individual Plans
Program
800-234-1317
Connecticut Insurance Department 800-297-3900 800-203-3447 www.ct.gov/cid
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov 617-565-9600
800-234-1317
Connecticut Insurance Department 860-297-3900 800-203-3447 www.ct.gov/cid
800-842-0004 www.hract.org/hra
Low income individuals and families
Medicaid
800-842-1508 800-842-4524 (TDD/TYY) www.dss.state.ct.us
Or
State Conversion Policy
Coverage
Mostly plans with co-pays, some with deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions- not counting birth or adoption- may apply, (1-6 months respectively) Pre-Existing Health Conditions Covered
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
Different plans will cover different medical services
COBRA Subsidy: 15 months of partially subsidized COBRA premium
Limits on Pre-Existing Health Conditions May Apply
There may also be a lifetime maximum of benefits, for example $5M
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
GUARANTEED COVERAGE
Company size 1-50
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
If in business 90 days or more, can usually qualify
Eligibility
Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage Owner can count as an employee; Proprietor name on license must draw wages Twice annually, self-employed persons can join a small group health plan with guarantee issue
Choose from three conversion plans: HMO, PPO and a Special Health Care Plan (no waiting period for pre-existing conditions if you qualify) All benefits are the same except the Special plan which does not cover out patient prescriptions
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
Choose from two individual plans: PPO or a Special Health Care Plan (12 month waiting period for pre-existing conditions)
Diagnosis, physician services, check-ups (medical and dental), family planning, maternity, prenatal, and newborn care, prescriptions, hospital services, comfort care, hospice, dental services, drug and alcohol treatment, mental health services Some services may need prior approval Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
Eligibility is subject to medical underwriting
Guaranteed to all Connecticut residents
Residents with legal immigration status
If you are denied coverage for a medical condition, you may be eligible for a Connecticut Health Reinsurance Association Plan, see next column
If HIPAA-eligible then no pre-existing exclusion period
Pregnant Women, Infants, and Children up to the age 19: 185% FPL (called Husky A)
Previous coverage terminated for reasons other than nonpayment of premium or fraud Anyone under age 65
Non-Working Parents: 100% of FPL Working Parents: 107% of FPL Medically Needy Individual: 80% or 66% of FPL
COBRA is for businesses with 20+ employees, Mini- COBRA is for business with under 20 employees
Couple: 76% or 59% of the FPL Supplemental Security Income Recipients: 69% of the FPL
Monthly Cost
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
13
Costs depend on employer contribution and the Modified Community Rate
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Costs depend on age and county/zone If you are self-employed and buy your own insurance you are eligible to deduct 100% of the cost of the premium from your federal income tax
Premiums vary depending on the applicants income level, age, sex, family size,and plan chosen
$0; may share in some costs
Rates are usually capped by state law at a level between 150 and 200% of standard market rates
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column
Connecticut
800.234.1317
Publicly Sponsored Programs
SAGA
Call 211 or contact local social services office
Women
Adults
HUSKY
Connecticut Breast and Cervical Cancer Early Detection Program
Charter Oak Health Plan
(Health Care for Uninsured Kids and Youth) 877-CT-HUSKY 877-284-8759 800-656-6684 www.huskyhealth.com
860-509-7804 www.dph.state.ct.us
877-77-CTOAK 877-772-8625 www.ct.gov/coh/site/default. asp
Seniors and Disabled
Medicare
(Age 65 and up) 800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program 800-633-4227
Program
(State Administered General Assistance) 866-361-SAGA 866-361-7242 www.chnct.org
Children
Demographic
Low income persons ineligible for other public programs
Connecticut CHOICES Program (Medicare advice) 800-994-9422
Comprehensive medical care with the exception of long term care and non-emergency medical transportation
There are two plans: Husky A and Husky B Husky A is Medicaid Pre-Existing Health Conditions Covered
Screening and Diagnostic Services Include: office visits, mammograms, breast biopsies and ultrasounds, fine needle aspirations, pap tests, LEEP, Surgical consultations, clinical breast exams, and Colposcopies and Colposopydirected biopsies
Covers primary care, specialist office visits, preventive care, ambulance, emergency room visit, prescription medication, durable medical equipment, behavioral health services, inpatient and outpatient services, pre- and post-natal care, Lifetime maximum benefit of $1 million, annual maximum benefit $100,000
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Connecticut CHOICES Program is a Medicare counseling service
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Ineligible for state or federal programs such as Medicaid
Children must be under age 19 and reside in Connecticut
Be at or below 200% FPL
Connecticut adults between the ages of 19 to 64.
The income limit for an individual ranges from $502.22 monthly to $610.61, depending on what region of the state he or she lives in. The asset limit is $1,000 per household
Income level numbers, HUSKY A (Medicaid) is for children, parents and other caregivers with incomes under 185% of the federal poverty level. It also covers pregnant women with incomes under 250% of the federal poverty level.
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
$0 or minimal share of cost
HUSKY B is only for children with family incomes over 185% of poverty. There is no income limit for HUSKY B, so any child can qualify. Families with an income greater than 300% of the FPL can buy into a HUSKY plan
Have an insurance deductible of $1,000 or more Be 40 to 64 years of age for Mammograms
There are no income limits. Depending on your income, your monthly premiums may be subsidized.
19 to 64 years of age for Clinical Breast Exams & Pap tests
No co-pays or premiums
$93-$296 for monthly premiums depending on your family income
$0 and share of cost for
certain services; deductibles for certain plans
Primary Care Office Visit: $25 co-pay; Specialist Office Visit: $35 co-pay
www.coverageforall.org Connecticut
Monthly Cost
Husky A: No premiums or co-pays Husky B: Families between 185235% FPL have a max of $760 on yearly co-pays and no premiums; family between 235%-300% FPL have a $1,360 maximum combination of co-pays and premiums; Over 300% FPL buy into the plan at negotiated group price.
Uninsured or insurance plan without diagnostic coverage
Cannot be covered six months prior to apply for Charter Health Oak Plan. There are exceptions to this rule.
Eligibility
No categorical program requirements; eligibility is based on income and assets only. The income limit for an individual ranges from $476.19 monthly to $574.86, depending on what region of the state he/ she lives in; and the asset limit is $1,000 per assistance unit (household). SAGA medical is not automatically linked to SAGA cash
Women age 40 and older (35-39 if history or symptoms, age 19 and older may qualify for pap test)
Coverage
Pre-Existing Health Conditions Covered
Comprehensive care through a managed care program
14
Demographic
Private Health Insurance Small businesses (1-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
Low-income individuals & families
Parents and children
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Medicaid
Children and Families First
800-234-1317
Program
Group Health
Delaware Association of Health Underwriters 703-276-0220 www.nahu.org
Coverage
All group health insurance carriers can impose a 6-month look-back/ 12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
Eligibility Monthly Cost
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
COBRA: Coverage available for 12 to 18 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium
800-234-1317
Individual Plans
800-734-2388 www.cffde.org
Delaware Association of Health Underwriters 703-276-0220 www.nahu.org
Assorted plans depending on medical needs There are no restrictions on carriers to look at pre-existing conditions Limits on pre-existing health conditions may apply
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Doctor visits, hospital care, labs, prescription drugs, transportation, routine shots for children, mental health and substance abuse services, X-rays, home health care, hospice care, dental care (up to age 21)
Special medical foster care, resource mothers program, counseling, education and more
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 1-50 employees (including owner)
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
15
And then
302-255-9500 800-372-2022 www.dhss.delaware.gov/dhss/
Owner name on business license must draw wages from the company Most small group carriers also require 75% employee participation and accept employees who sign a waiver indicating other coverage as counting towards the 75%
Costs depend on employer contribution or health condition of self-employed and ± 35% of the insurance company’s index rate
Eligibility is subject to medical underwriting
GUARANTEED COVERAGE
Pregnant women and infants age 0-1: 200% FPL
Low income in need of services
Children (ages 1-5): 133% FPL Parents: 117% FPL Children ages 6-19 and working parents: 100% FPL (also aged, blind and disabled) SSI recipients: 133% FPL U.S. citizens or qualified legal residents
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
GUARANTEED COVERAGE
Costs for individual coverage varies
No premium no co-pay
No premium no co-pay
COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Delaware
800.234.1317
Children
Adults
Delaware Healthy Children Program
Delaware Screening for Life
800-996-9969 www.dhss.delaware.gov/dhss/
800-464-HELP 800-464-4357 www.state.de.us/dhss/dph/ dpc/sfl.html
Seniors and Disabled
Trade Dislocated Workers (TAA recipients)
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
877-222-8387 www.va.gov
Program
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
800-633-4227
ELDER Info 800-336-9500
Office visits, mammograms and clinical breast exams for breast cancer, pap tests, colorectal cancer screening tests recommended by your doctor, health education, help with coordinating associated care Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug progam called Medicare Part D
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer)
ELDER Info is a Medicare counseling service that educates and assists Medicare beneficiaries, those eligible for Medicare, and caregivers about Medicare, Medicaid, Medigap, prescription drug benefits, and other issues related to health insurance benefits.
Pre-Existing Health Conditions Covered
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Coverage
Well-baby and well-child checkups, drug/alcohol abuse treatment, speech/hearing therapy, immunizations physical therapy, eye exams ambulance services, prescription drugs, hospital care, physician services, X-rays, lab work, assistive technology, mental health counseling, limited home health and nursing care, case management and coordination, hospice care, and comprehensive dental service
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Under age 19; Family Income at or below 200% FPL; Must not have other comprehensive health insurance coverage; Must reside in the State; Must be a U.S. citizen or qualified noncitizen; and not be a dependent of a permanent State employee
You are between the ages of 18 and 64
Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with EndStage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Waiting period may apply
No insurance or private HMO; and not eligible for Medicare or Medicaid
DE Screening: 65+ if not eligible for Medicare
Not enrolled in certain state plans Age 55 and older
Certain veterans must have completed 24 continuous months of service
Eligibility
Underinsured: High, unmet deductible; or insurance that does not cover Pap tests, mammograms or colorectal screenings
Must not have access to employer plan that pays 50% of coverage cost
At or below 250% FPL Age restrictions for each service Age 18-49 - Office visit, Pap test, pelvic exam, clinical breast exam, breast exam education Age 40-49 - Mammograms, with an abnormal clinical breast exam in past 6 months Age 50-64 - ALL services + colorectal screening Age 65+ - ALL services + colorectal screening if not eligible for Medicare
$0 or share of cost
$0 and share of cost for
certain services; deductibles for certain plans
20% of the insurance premium
$0 and share of cost and
co-pays depending on income level
www.coverageforall.org Delaware
Monthly Cost
$10 to $25 monthly premium and no co-pays depending on income. For every 3 months you pay in advance, you get the 4th month free.
16
Demographic Program
Private Health Insurance Small businesses (1-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
U.S. Uninsured Help Line
COBRA and Mini-COBRA
U.S. Uninsured Help Line
Cover Florida
800-234-1317
Group Health
Florida Association of Health Underwriters www.fahu.org
Coverage
Up to $5M lifetime maximum, assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply Pre-Existing Health Conditions Covered
And then
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov COBRA or Mini-COBRA: Coverage available for 18 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 1-50 employees
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Eligibility
Owner can count as an employee Owner name on business license must draw wages from the company Groups of one have open enrollment during limited times during the year
800-234-1317
Individual Plans
Florida Association of Health Underwriters www.fahu.org
Assorted plans depending on medical needs There is a 24-month look-back and exclusionary period limit for pre-existing conditions in traditional individual market health insurance products in Florida Pre-existing conditions may not be considered for HIPAA-eligible population Limits on pre-existing health conditions may apply
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for Cover Florida, see next column
877-MY-FL-CFO 877-693-5236 850-413-3089 (out of state) www.coverfloridahealthcare. com
Six carriers have designed 27 creative health insurance products. Each carrier offers at least two benefit options – one with catastrophic and hospital coverage, and one without. Benefits include preventive services, screenings, office visits, as well as office surgery, urgent care, hospital coverage, emergency care, prescription drugs, durable medical equipment, and diabetic supplies. Pre-Existing Health Conditions Covered
Monthly Cost
17
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column
Florida
Among some of the services: ambulatory surgical center birth center services, child health check up chiropractic care, durable medical equipment and supplies, federally qualified health centers, home health hospital inpatient/outpatient care, laboratory, licensed midwives, physician, podiatry prescriptions, rural health clinics, therapy, X-rays Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
Ages 19 to 64 who have been without health insurance for at least six months – even if there are pre-existing health conditions. May also qualify if you lost your job that provided employer-sponsored health benefits, lost of benefits under COBRA; death of, or divorce from, a spouse who has provided employer-sponsored health benefits.
Pregnant Women: 185% FPL Children (Ages 0-1): 200% FPL Children (ages 1-5): 133% FPL Children (ages 6-19): 100% FPL Aged, Blind and Disabled: 90% FPL Supplemental Security Income Recipients: 74% FPL Working Parents: 62% FPL Non-Working Parents: 23% FPL Medically Needy: 25% FPL, there is an asset limit $5,000+ depending on family size
COBRA is for businesses with 20+ employees, Mini- COBRA is for business with under 20 employees
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Medicaid
850-488-3560 www.fdhc.state.fl.us/Medicaid
GUARANTEED COVERAGE
No asset or resource requirements for children or pregnant mothers
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs Costs depend on employer contribution and ± 15% of the Modified Community Rate
Low-income individuals & families
Florida resident
Costs for individual coverage varies
Premiums vary depending on the applicant’s age, gender and chosen benefit options.
$0 or $1-3 co-pays, and
coinsurance is limited to 5% up to $300 for each visit to the Emergency Room No cost for pregnant women, children and certain others
800.234.1317
Children
Women
Florida KidCare
Breast and Cervical Cancer Prevention
800-227-2345 www.doh.state.fl.us/Family/bcc
Trade Dislocated Workers (TAA recipients)
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
Program
MediKids, Healthy Kids, Children’s Medical Services and Medicaid 888-540-5437 877-316-8748 TTD www.floridakidcare.org
Seniors and Disabled
Demographic
Publicly Sponsored Programs
800-633-4227
Comprehensive health insurance coverage
Pre-Existing Health Conditions Covered
Medicare offers two standard plans, A: Hospital Insurance and B: Medical Insurance, as well as several supplemental and advantage plans Pre-Existing Health Conditions Covered
Will cover 80% of your COBRA if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Coverage
Benefits vary based on the segment of the program in which a child participates— MediKids, Healthy Kids, or the Children’s Medical Services (CMS) Network for children with special health care needs
Breast and cervical cancer screening exams (mammograms, pap smears and clinical breast exams) are provided to diagnostic exams are provided as necessary case management is provided to all clients
Pre-Existing Health Conditions Covered
Outreach, public education and professional education is provided Treatment for eligible women may be paid by Medicaid
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Under age 19 and uninsured
Uninsured and underinsured women 50 to 64 years of age, at or below 200% of FPL
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Have an income at or below 200% of the FPL Be a U.S. citizen or qualified non-citizen Cannot be eligible for Medicaid
Age 55 and older
Certain veterans must have completed 24 continuous months of service
$0 or minimal share-of-cost
$0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
$0 and share of cost and co-pays depending on income level
www.coverageforall.org Florida
Monthly Cost
Premium is based on household size and monthly income. Most families pay either $15 or $20 per family per month; some families may pay more. There may be co-payments required based on the service provided
Not enrolled in certain state plans
Eligibility
Not be the dependent of a state employee eligible for health insurance and not in a public institution
Must not have access to employer plan that pays 50% of coverage cost
18
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Low income families & medically needy
Children
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Medicaid
PeachCare for Kids
Program
800-234-1317
Group Health
Georgia Association of Health Underwriters 703-276-0220 www.gahu.org
Then convert to
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov
800-234-1317
Individual Plans
866-211-0950 770-570-3373 http://dch.georgia. gov/00/channel_
877-GA-PEACH 877-427-3224 www.peachcare.org
Women-InfantsChildren (WIC)
Georgia Association of Health Underwriters 703-276-0220 www.gahu.org
404-657-2900 800-228-9173 www.health.state.ga.us/ programs/wic/index.asp
or
State Conversion Policies Pre-existing conditions can be excluded for a limited time depending upon the type of group plan you are joining
Coverage
Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Depends on plan Plans are required by state to offer certain benefits such as mammograms, childhood immunizations and automatic coverage for newborns or adopted children
Medical, dental and vision, prescriptions, hospitalization and more depending on program Pre-Existing Health Conditions Covered
PeachCare for Kids: Doctor visits, check-ups, immunizations, preventive care specialist care, dental care, vision care, hospitalization, emergency room services, prescriptions, and mental health care WIC: Nutrition assessment, health screening, medical history, body measurement (weight and height), hemoglobin check, nutrition education, breast-feeding support and education, and vouchers for food supplements
Limits on pre-existing health conditions may apply
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Owner can count as an employee
Eligibility
Proprietor name on license must draw wages
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Eligibility is based on medical underwriting
Pregnant women at or below 200% FPL
There is a 12 month look back period during first two years of coverage. If condition is deemed preexisting there can be a 24 month exclusionary period.
Children age 0-1 up to 185% FPL
PeachCare for Kids: Low income children up to age 19 under 235% FPL; Uninsured and ineligible for Medicaid; U.S. citizens, certain qualified legal residents, refugees or asylees who reside in Georgia
Must be resident of state or documented immigrant
Children age 1-5 up to 133% FPL Children age 6-19 up to 100% FPL Working parents up to 52% FPL Non-working parents up to 29% FPL Medically needy individual up to 35% FPL
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
WIC: Pregnant or postpartum women and children up to the age of 5 years with a family income at or below 185% of the FPL. Must be a state resident; and be at nutritional or medical risk, as determined by a health professional.
Medically needy couple up to 41% FPL Georgia resident or documented immigrant
Monthly Cost
Must be a Georgia resident
19
Costs depend on employer contribution and ± 25% of the insurance company’s index rate
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Georgia
Various price ranges depending on deductible and what plan you buy.
$0 or minimal share-of-cost
PeachCare for Kids: $0 for children under age 6, $10-35 for one child, max of $70 for two or more children WIC: $0 or minimal share-ofcost
800.234.1317
Infants and children with developmental delays
Women
Babies Can’t Wait
Georgia Cancer Screening Program 404-657-6611 www.georgiacancer.org
Babies Born Healthy 404-657-3147 www.health.state.ga.us/ programs/perinatal
Trade Dislocated Workers (TAA recipients)
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
Program
404-657-2726 888-651-8224 www.babiescantwaitcentralga. org
Seniors and Disabled
Demographic
Publicly Sponsored Programs
800-633-4227
Georgia Cares
800-669-8387 (Assistance for seniors)
Comprehensive preventive and primary care, outpatient and in-patient services Pre-Existing Health Conditions Covered
Babies Born Healthy: Comprehensive, quality, prenatal services as early as possible in their pregnancy
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer)
Georgia Cares is a Medicare counseling service
Pre-Existing Health Conditions Covered
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Coverage
Georgia Cancer Screening Program: Offers clinical breast examinations, mammograms, and pelvic examinations and pap tests if you’re older than 40 years old. If screened and diagnosed for breast or cervical cancer may be eligible for complete health coverage through Medicaid
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Babies Can’t Wait: Generally children may qualify if they are very far behind in learning to move, talk or use their hands or; they are automatically eligible if they are diagnosed with certain physical and mental conditions.
Georgia Cancer Screening Program: Must be Georgia resident and have legal immigration status For mammograms must be between 40 and 64 years of age
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
$0 and share of cost for
20% of the insurance
$0 and share of cost and co-pays depending on income level
For cervical screening must be between 18 and 64 years of age Must be uninsured or underinsured, ineligible for Medicaid with income under 200% of FPL
Eligibility
Covers babies from birth up to their third birthday
Must not have access to employer plan that pays 50% of coverage cost
Babies Born Healthy: Pregnant women and newborns with a family income at or below 250% of the FPL. Cannot be eligible for Medicaid.
Georgia Cancer Screening Program:
$0
Babies Born Healthy: $0 or minimal share-of-cost
certain services; deductibles for certain plans
premium
www.coverageforall.org Georgia
Monthly Cost
$0 or share-of-cost and copays depending on income level
20
Demographic
Private Health Insurance Small businesses (1-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Low income individuals and families
Children
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Medicaid
HMSA Children's Plan
Program
800-234-1317
Group Health
National Association Of Health Underwriters 703-276-0220 www.nahu.org
Coverage
Hawaii does not have a statute that defines the size of their small group market. Most carriers define it as 1-50 however some use the definition of 1-100 Individuals who attempt to obtain coverage as a business group of one must satisfy criteria set by the carrier Pre-Existing Health Conditions Covered
Then convert to
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium
800-234-1317
Individual Plans
Options vary depending on applicant needs and plan selected Limits on pre-existing health conditions may apply
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Eligibility
All employers are required to offer coverage to most employees who work 20 hours per week
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
All individual market carriers are subject to a 6-month look-back and a 12-month exclusionary period limit on pre-existing health conditions
Monthly Cost
21
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
HI resident and legal citizen or qualified immigrant
Age 0 to 19 years old; must live in Hawaii; income up to 300% FPL; and be a U.S. citizen, U.S. national, lawful permanent resident (have a “green card”), refugee, or citizen of the Marshall Islands, Federated States of Micronesia, or Palau
Children (ages 0-19): 300% FPL Pregnant Women: 185% FPL
Family: At or below 250% qualify for free health insurance
Must be ineligble for Medicaid
Family: between 250-300% FPL qualify for low cost. Medically needy: 51% FPL Asset limits of $2,000 for a household of one, $3,000 for a household of two $250 per additional person Asset limits do not apply to individuals under age 19, or to pregnant women for the duration of the pregnancy plus 60 days
Must be a Hawaii resident
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Basic care, preventive care, immunizations, doctor visits
GUARANTEED COVERAGE
Parents or the blind, aged or disabled: 100% FPL
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Costs depend on employer contribution and rates must be approved by the state Department of Insurance
Depending on program, inpatient hospital services, outpatient hospital services, prenatal care, vaccines for children, physician services, nursing facility services for persons aged 21 or older, family planning services and supplies, rural health clinic services, home health care for persons eligible for skilled-nursing services, laboratory and x-ray services, pediatric and family nurse practitioner services, nursemidwife services and more Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
Owner can count as an employee, proprietor-name on license must draw wages
Hawaii's Medical Service Association 800-620-4672 www.coveringkids.com
National Association Of Health Underwriters 703-276-0220 www.nahu.org
Pre-Existing Health Conditions Covered
Company size: 1-50 employees
800-316-8005 808-524-3370 www.med-quest.us
Various price ranges depending on deductible and what plan you buy
$0, minimal share of cost or 'buy-in'; Premiums range between $15-60 per child per month
$55 per month
COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Hawaii
800.234.1317
Women
Adults with substance abuse problems
Breast and Cervical Cancer Program
Department of Health Alcohol and Drug Abuse Division 808-692-7506 www.hawaii.gov/health/ substance-abuse/
Trade Dislocated Workers (TAA recipients)
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
Program
808-692-7460 http://healthuser.hawaii.gov/ health/family-child-health/ chronic-disease/bcccp/index. html
Seniors and Disabled
Demographic
Publicly Sponsored Programs
800-633-4227
Sage Plus 888-875-9229
Clinical breast exam, mammogram, pelvic exam, pap test, follow-up diagnostic care for abnormal results
Comprehensive system of services to meet the treatment and recovery needs of individuals and families Inpatient and out-patient programs
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer)
Sage is a Medicare counseling and application service
Pre-Existing Health Conditions Covered
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Coverage
Pre-Existing Health Conditions Covered
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Woman age 50 to 64; Income at or below 250% of the federal poverty level; Uninsured or under-insured
Treatment services have, as a requirement, priority admission for pregnant women and injection drug users
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
$0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
$0 and share of cost and co-pays depending on income level
Must not have access to employer plan that pays 50% of coverage cost
Eligibility
$0
www.coverageforall.org Hawaii
Monthly Cost
$0 or share of cost; Costs vary depending on which program you choose.
22
Demographic
Private Health Insurance Small businesses (2-50 Employees)
U.S. Uninsured Help Line
Program
800-234-1317
Group Health
Idaho Association of Health Underwriters 703-276-0220 www.iahu.org
AHI
(Access to Health Insurance) 866-326-2485 www.accesstohealthinsurance. idaho.gov
Coverage
Up to $5M lifetime maximum, assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply AHI is a premium assistance program that makes health insurance more affordable for employees of qualified small businesses
Eligibility
COBRA
U.S. Uninsured Help Line
Consolidated Omnibus Budget Reconciliation Act Or
Conversion Plans Then
Individual Plans
Idaho Association of Health Underwriters 703-276-0220 www.iahu.org
COBRA: Coverage available for up to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium
Up to $5M, assorted deductibles depending on age and ZIP code Limits on Pre-Existing Health Conditions May Apply
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for HRP, see next column
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Costs depend on employer contribution and ± 50% of the insurance company’s index rate
Low-income individuals and families
HRP
Medicaid
Idaho Individual High Risk Reinsurance Pool 208-334-4250 800-721-3272 www.doi.idaho.gov
800-926-2588 866-326-2485 TDD 208-332-7205 www.healthandwelfare. idaho.gov Or contact local health or welfare agency
HIPAA
GUARANTEED COVERAGE
Owner name on business license must draw wages from the company
800-234-1317
Individuals with pre-existing, severe or chronic medical conditions
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov
Pre-Existing Health Conditions Covered
Owner can count as an employee
Monthly Cost
Individuals & families
Pre-Existing Health Conditions Covered
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
23
Individuals recently covered by an employer health plan
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
There are five HRP plans. All plans cover the same health benefits but cost sharing varies. All insurers sell the same HRP plans. This standardization of benefits will help you compare the cost of coverage from different companies. HRP plans cover hospital and physician services, preventive care, maternity care, prescription drugs, and limited mental health and substance abuse treatment.
Four plans to choose from: Medicaid Standard Plan, Medicaid Basic Plan, Medicaid Enhanced Plan, and the Medicare-Medicaid Coordinated Plan
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
First, if you applied for individual health insurance and were turned down due to your health status or claims history, that insurer must offer you the option to buy a HRP plan
Children Age 0-19 income at or below 133% of the FPL (copayments vary depending on the families qualifying income)
Second, if an individual health insurer offered to sell you a policy at a surcharged premium, that insurer must offer you the option to buy a HRP plan
Adults: 25% FPL
Offers health, dental, vision, and prescription coverage Treatment for special health problems like breast cancer, kidney problems, nursing home needs, and AIDS
Pregnant Women: 133% FPL
Supplemental Security Income Recipients: 74% FPL
Third, if you are HIPAA eligible, you are eligible to buy a HRP policy from any approved insurer in Idaho
Must be a U.S. citizen or legal non-citizen
You are also eligible to apply for HRP if there is a reasonable probability that you will exceed your lifetime benefit maximum under your existing coverage within 90 days and if the lifetime benefit maximum of your existing plan is at least $500,000
Costs for individual coverage varies
Costs vary depending on age, region and program.
$0 or minimal share of cost
COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Idaho
800.234.1317
Children
Women
Immigrants awaiting legal status
Children’s Access Card
Women’s Health Check
Emergency Medicaid
800-926-2588 www.idahohealth.org
800-926-2588 TDD 208-332-7205 866-326-2485 (Emergency Processing Center) Or contact local health or welfare agency
Annual clinical breast examination (CBE)
Pre-Existing Health Conditions Covered
Annual pelvic examination; Annual Pap test — After three consecutive normal Pap tests, Women’s Health Check will cover one Pap test every three years
Annual mammogram
Emergency Medicaid covers emergencies, pregnancyrelated care (prenatal and delivery), kidney dialysis, treatment for breast and cervical cancer Pre-Existing Health Conditions Covered
Medicare
Health Coverage Tax Credit
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
800-633-4227
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer)
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
$0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Diagnostic Services, if needed
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Between 133-185% FPL
Women without health insurance that covers mammograms or Pap tests;
Children ages 0-19, up to 150% FPL
Age 30-49 and have not had a Pap test in 5 years or longer or have never had a Pap test;
Non-Working Parents: 24% FPL
Must be ineligible for no-cost Medicaid or employer-based coverage Residents and legal immigrants
Age 65 or older and is NOT eligible for Medicare, or does not have Medicare Part B
Working Parents: 31% FPL Supplemental Security Income Recipients: 74% FPL U.S. citizenship not required
$0 or minimal share of cost
$0 or minimal share of cost
Not enrolled in certain state plans
www.coverageforall.org Idaho
Monthly Cost
Income below 200% FPL
Must not have access to employer plan that pays 50% of coverage cost
Eligibility
$0 or share of cost
Pregnant Women: 133% FPL
Coverage
Medical services, Dental, Mental health services, Vision, Pharmacy, Hearing, Hospitalization, and more
Trade Dislocated Workers (TAA recipients)
Program
800-926-2588 www.healthandwelfare. idaho.gov
Seniors and Disabled
Demographic
Publicly Sponsored Programs
24
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Program
800-234-1317
Group Health www.dol.gov/ebsa 866-444-3272
Illinois Association of Health Underwriters
Then convert to
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov
Coverage
Individual Plans
www.healthinsuranceinfo.net
Illinois Association of Health Underwriters
Low income families and individuals
CHIP
Medicaid
(Illinois Comprehensive Health Insurance Plan) Main Number: 217-782-6333 Illinois Residents Only General Information: 800-9628384 Eligibility Information: 866851-2751 800-545-2455 (TTY) www.chip.state.il.us
If uninsured for previous 6-12 months, a waiting period for coverage of pre-existing conditions, (6-12 months respectively) will apply
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
Benefits will vary depending on the chosen plan
COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Covers certain state mandated items, however Illinois does not require standardization. Coverage options vary by carrier, but most offer plans that are HSA (Health Savings Account) compatible Limits on Pre-Existing Health Conditions May Apply
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Eligibility
Owner can count as an employee Proprietor name on license must draw wages
FamilyCare
866-255-5437 www.familycareillinois.com
Inpatient and outpatient care, doctor visits, surgery, preventive care, diagnostic care and x-rays, home health care, skilled nursing care, hospice, transplant coverage, speech, physical and occupational therapy, mental health and chemical dependency, separate prescription drug card
Medicaid: Different program variations covering medical, dental and vision, prescriptions, hospitalization and more depending on program. Programs for people with either MS, nursing home needs, kidney dialysis, breast and cervical cancer, AIDS, TB, hyper alimentation, pregnancy
You can now choose High Deductible Health Plans starting in 2008. Call the main number to find out more information on how to change to a HDHP.
FamilyCare: Covers doctor visits, dental care, specialty medical services, hospital care, emergency services, prescription drugs and more
Pre-Existing Health Conditions Covered with Some Limitations
Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage
800-843-6154 www.health.illinois.gov www.dhs.state.il.us
703-276-0220 www.nahu.org www.isahu.com
703-276-0220 www.nahu.org www.isahu.com
Pre-Existing Health Conditions Covered with Some Limitations
800-234-1317
Individuals with pre-existing, severe or chronic medical conditions
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Eligibility is based on medical underwriting There is a 12 month look back period during first two years of coverage. If condition is deemed preexisting there can be a 24 month exclusionary period. Must be resident of state or documented immigrant If you are denied coverage for a medical condition, you may be eligible for CHIP, see next column
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Previous coverage terminated for reasons other than nonpayment of premium or fraud
Medicaid: Children ages 1-19: 133% FPL. Pregnant Women and Infants: 200% of the FPL if the mother is enrolled in Medicaid at the time of birth. If not, infants with family incomes of 133% FPL
Cannot be eligible for COBRA, or government programs (must have exhausted this option) Must prove denial of coverage or offer of higher premium than CHIP Illinois resident
Working Parents: 140% FPL Aged, blind or disabled: 85% FPL SSI recipients: 40% FPL Medically Needy Individual: 40% FPL, Couple: 39% FamilyCare: Offers healthcare coverage to parents living with their children 18 years old or younger. FamilyCare also covers relatives who are caring for children in place of their parents. Must live in Illinois and have income up to 200% FPL, Must be U.S. citizens or meet immigration requirements
Monthly Cost
Must be an Illinois resident
25
Costs depend on employer contribution and ± 25% of the insurance company’s index rate
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Illinois
Various price ranges depending on deductible and what you buy.
Can be 125-150% of the average rates charged individuals for comparable major medical coverage by 5 or more of the largest insurance companies in the individual health insurance market.
Medicaid: $0 or minimal share of cost FamilyCare: Small co-pays from $2 to $3 for doctor visits and prescriptions. Parents in FamilyCare Premium pay a monthly premium from $15 to $40 depending on the number of family members covered
800.234.1317
Children
Women
ALL Kids
Breast and Cervical Cancer Program
866-ALL-KIDS 866-255-5437 www.allkids.com
Healthy Women
800-226-0768 www.illinoishealthywomen. com
Pre-Existing Health Conditions Covered
BCCP: Offers free mammograms, breast exams, pelvic exams and Pap tests to eligible women Healthy Women: Covers family planning (birth control) and certain services provided at the family planning visit, such as the physical exam, pap tests, lab tests for family planning, testing and medicine for sexually transmitted infections found during a family planning visit, and sterilization. Illinois Healthy Women also covers mammograms, multivitamins and folic acid if they are ordered by the doctor during the family planning visit
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
800-633-4227
Illinois Cares Rx
800-633-4227 www.illinoiscaresrx.com
Medicare: Offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug coverage program called Medicare Part D
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer)
Illinois Cares Rx: Provides state prescription drug assistance to people with and without Medicare
Pre-Existing Health Conditions Covered
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Coverage
Doctor visits, hospital stays, prescription drugs, vision care, dental care and eyeglasses, covers regular checkups and immunization shots, special services like medical equipment, speech therapy and physical therapy for children who need them
Trade Dislocated Workers (TAA recipients)
Program
IL Department of Public Health’s Health-Line 888-522-1282 www.cancerscreening.illinois. gov
Seniors and Disabled
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Illinois resident, 18 and under, uninsured for 12 months to be eligible regardless of income
BCCP: Illinois resident and documented immigrant For mammograms must be between 40 and 64 years of age
Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
If already insured, income limit is approximately 250% of the FPL.
For pelvic and pap test must be between 35 and 64 years of age
If Medicaid eligible you are not IBCCP eligible Healthy Women: If you have lost regular medical benefits from the Illinois Department of Healthcare and Family Services (HFS), if you are between 19-44, if you are a U.S. citizen or legal permanent resident with a Social Security number and if you live in Illinois, and are at 200% FPL
$0
Medicare: $0 and share of cost for certain services; deductibles for certain plans
Certain veterans must have completed 24 continuous months of service
20% of the insurance premium
$0 and share of cost and
co-pays depending on income level
Illinois Cares Rx: Costs vary depending on whether applicant has Medicare or not
www.coverageforall.org Illinois
Monthly Cost
Monthly premium based on number of children in family, plus co-pay for each service with $100 limit
Illinois Cares Rx: Individuals with Medicare, people age 65 and older or people under age 65 with certain disabilities are eligible for Illinois Cares Rx. Income limits apply for certain groups
Not enrolled in certain state plans
Eligibility
May not have other health insurance and income under 200% of FPL
Must not have access to employer plan that pays 50% of coverage cost
26
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Program
800-234-1317
Group Health
Indiana Association of Health Underwriters 703-276-0220 www.nahu.org www.inahu.org
Different plans cover different medical services
Coverage
Sometimes coverage is limited to $1M in a lifetime; often $5M and some plans have no limit These factors affect the monthly premium and deductible If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply Pre-Existing Health Conditions Covered
Then convert to
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage
800-234-1317
Individual Plans Indiana Association of Health Underwriters 703-276-0220 www.nahu.org www.inahu.org
Covers certain state mandated items, however Indiana does not require standardization
Individuals with pre-existing, severe or chronic medical conditions ICHIA
Indiana Comprehensive Health Insurance Association 800-552-7921 317-614-2133 www.ichia.org
Coverage options vary by carrier, but most offer plans that are HSA (Health Savings Account) compatible
Covered services include inpatient hospital services, mental illness /substance abuse, prescription drugs, professional services, skilled home health care, skilled nursing facility, surgical expenses, transplant services
Pre-Existing Health Conditions Covered with Some Limitations
Four annual deductible options $500, $100, $1500, or $2500
Medicaid
(Indiana Family and Social Services Administration) 800-889-9949 www.in.gov/fssa
Different program variations covering medical, dental and vision, prescriptions, hospitalization and more depending on program
20% co-pay Preferred Provider Network; 40% co-pay non preferred provider network
Pre-Existing Health Conditions Covered
Low-income individuals & families
Programs for people with either MS, nursing home needs, kidney dialysis, breast and cervical cancer, AIDS, TB, hyper alimentation, pregnancy Pre-Existing Health Conditions Covered
Ineligible for Medicaid Coverage for spouse and dependents also available Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Owner can count as an employee
Eligibility
Proprietor-name on license must draw wages
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Eligibility is based on medical underwriting
Must be considered “uninsurable”
There is a 12 month look back period during first two years of coverage. If condition is deemed preexisting there can be a 24 month exclusionary period.
Cannot be eligible for COBRA, or government programs (must have exhausted this option)
Under 100% FPL with assets less than $3K for one person (after car, house, clothing), AND...
Must be resident of state or documented immigrant
Must prove denial of coverage or offer of higher premium than ICHIA Must be an Indiana resident
If you are denied coverage for a medical condition, you may be eligible for an ICHIA plan, see next column
Parents of children living in household OR... Adults with certain diseases see above, OR... On Cash Assistance, Welfare or children leaving Foster Care at age 18 No job-based coverage within three months (certain exceptions apply) Indiana resident or documented immigrant
Monthly Cost
Must be an Indiana resident
27
Costs depend on employer contribution and ± 35% of the insurance company’s index rate
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Various price ranges depending on deductible and what plan you buy.
Based on the plan you choose, age, gender, and geographic area you live in. Can not be more than 150% of amount healthy person would pay
$0 or minimal share-of-cost
COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Indiana
800.234.1317
Children with chronic medical conditions
Pregnant women, children
Children’s Special Health Care Services
Hoosier Healthwise
Hoosier Healthwise is a health insurance program for Indiana children, pregnant women, and low-income families
Diagnostic evaluations, comprehensive well child and sick child care, specialty care and other services related to the eligible medical conditions, immunizations, prescription drugs, routine dental care, community referrals and information
After birth, care for infant only up to age 1, care for mother up to 60 days
Pre-Existing Health Conditions Covered
Comprehensive care for mother, not just maternity
Families get check-ups, doctor visits, hospital care, dental and more
Indiana Breast and Healthy Indiana Plan 877-GET-HIP-9 Cervical Cancer Early 877-438-4479 Detection Program 800-433-0746 317-233-7405 www.in.gov/isdh/19851.htm
BCCP provides clinical breast examinations, mammograms, and pap tests for eligible women, as well as diagnostic testing for women whose screening outcome is abnormal Screening, diagnostics, consultations and treatment Pre-Existing Health Conditions Covered
800-403-0864 www.in.gov/fssa/hip/
(Healthy Indiana Plan still has room for adults who have children in their homes, but it has started putting “noncaretaker’’ adults on a waiting list for the program)
Services include: physician services, prescriptions, diagnostic exams, home health services, outpatient hospital, inpatient hospital, hospice, preventive services, family planning, and case and disease management; mental health coverage, substance abuse treatment, inpatient, outpatient, and drugs
Seniors and Disabled Medicare
(Age 65 and up) 800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program 800-633-4227
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug coverage program called Medicare Part D Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Ages newborn to 21 years
Income at or below 250% FPL
Family income at or below 250% FPL
Children and ages 18-20 if living with a caretaker
Adults between the age of 19-64
Severe chronic illnesses that have lasted or will last two years or conditions that require special devices or would produce disabling physical conditions if untreated
No residency requirements for Medicaid
Must be Indiana resident and have legal immigration status For mammograms must be between 40 and 64 years of age For pelvic and pap test must be between 35 and 64 years of age
Individuals must not have access to employer sponsored health insurance coverage.
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)
Must have a family income at or below 200% of the FPL
Individuals must be uinsured for the previous six months.
Eligibility
May not have other health insurance and income under 200% of FPL
Each participant's family must also apply for Medicaid
65 and older not enrolled in Medicare
$0-$50 a month depending on family income and the number of family members covered
$0
2-5% of the families gross income depending on the applicants income.
$0 and share of cost for
certain services; deductibles for certain plans
No co-pays except for ER use.
www.coverageforall.org Indiana
Monthly Cost
$0 or minimal share-of-cost
Coverage
Treatment for chronic medical conditions such as severe asthma, autism, cerebral palsy, arthritis, congenital heart disease, cystic fibrosis, chromosomal disorders, renal disease seizures and more
Adults
Program
(CSHCS) 800-475-1355 www.in.gov/isdh/19613.htm
800-889-9949 www.in.gov/fssa/ompp/2544. htm
Women
Demographic
Publicly Sponsored Programs
28
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA or Mini-COBRA/ Conversion
U.S. Uninsured Help Line
Program
800-234-1317
Group Health
Iowa Association of Health Underwriters 703-276-0220 www.eiahu.org
Or
HIPP
(Health Insurance Premium Payment) 888-346-9562 Then convert to
800-234-1317
Individual Plans
Individuals with pre-existing, severe or chronic medical conditions HIPIOWA
Low income families and individuals Medicaid
(Health Insurance Plan of Iowa) 877-793-6880 www.hipiowa.com
800-338-8366 800-972-2017 www.ime.state.ia.us/Members Or contact local county Department of Human Services
Iowa Association of Health Underwriters 703-276-0220 www.eiahu.org
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov Up to $5M lifetime maximum, assorted deductibles
Coverage
If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply Pre-Existing Health Conditions Covered
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as previous employer’s plan COBRA Subsidy: 15 months of partially subsidized COBRA premium
Up to $5M, assorted deductibles depending on age and ZIP code Limits on Pre-Existing Health Conditions May Apply
HIPIOWA offers five comprehensive preferred provider plans each with a pharmacy benefit to choose from and a medicare carveout plan Pre-Existing Health Conditions Covered with Some Limitations
HIPP: Benefits are the same as what you had with your previous employer, HIPP is a premium assistance program HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage
Eligibility
Owner can count as an employee Proprietor name on license must draw wages
Mini-COBRA: Applies to businesses with less than 20 employees HIPAA: After exhausting your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even with pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Inpatient and outpatient hospital services, physician services, medical and surgical dental services, nursing facility services for persons aged 21+, family planning services, nurse/midwife services, chiropractors, podiatrists, optometrists, psychologists, dental services, physical therapy, therapies for speech hearing and language disorders, occupational therapy, prescribed drugs, prosthetic devices, vision, mental health, hospice care and more
Eligibility is based on medical underwriting There is a 12 month look back period during first two years of coverage. If condition is deemed preexisting there can be a 24 month exclusionary period. Must be resident of state or documented immigrant If you are denied coverage for a medical condition, you may be eligible for HIPIOWA, see next column
GUARANTEED COVERAGE
GUARANTEED COVERAGE
A notice of rejection of health insurance coverage within the last nine months or reduction of limitation which substantially reduces benefits compared to benefits available to others
Children (ages 1-19): 133% FPL
A notice of refusal to issue insurance except at a rate exceeding the plan rate of a comparable HIPIOWA plan. Other involuntary termination (other than nonpayment)
Supplemental Security Income Recipients: 74% FPL
Ineligible for public programs
Pregnant Women and Infants (ages 0-1): 200% FPL Working Parents: 82% FPL Non-Working Parents: 33% FPL
Medically Needy Individual: 67% FPL Medically Needy Couple: 50% FPL U.S. citizen and Iowa resident
Can get if eligible for HIPAA Iowa residency required
Monthly Cost
HIPP: You may be eligible for HIPP if you have a high-cost health condition Costs depend on employer contribution and ± 25% of the insurance company’s index rate
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Costs for individual coverage varies
Can be 125-150% of the average rates charged individuals for comparable major medical coverage by 5 or more of the largest insurance companies in the individual health insurance market.
$0 or minimal share of cost
HIPP: $0 or minimal share of cost
29
Iowa
800.234.1317
Individuals and families with moderate income IowaCare
Or contact local county Department of Human Services
Inpatient and outpatient hospital, physician or advanced registered nurse practitioner, and dental
Unlike Medicaid, IowaCare is not an entitlement, meaning that it depends on specific appropriations
Native American Indians
Trade Dislocated Workers (TAA recipients)
Hawk-i
Emergency Medicaid
Indian Health Services
Health Coverage Tax Credit
(Healthy and Well Kids in Iowa) 800-257-8563 888-422-2319 TDD www.hawk-i.org/index.html
A child who qualifies will get all of his or her health care services through a health plan that has agreed to participate in the program: doctor visits, outpatient hospital services, vaccines and shots (immunizations) emergency care, inpatient hospital services, prescriptions, vision, dental, hospice, speech and physical therapy, nursing care services, chiropractic care mental health/substance abuse
800-338-8366 www.ime.state.ia.us/Members
Up to 3 days of Medicaid is available to pay for the cost of emergency services for aliens who do not meet citizenship, alien status, or social security number requirements. The emergency services must be provided in a facility such as a hospital, clinic, or office that can provide the required care after the emergency medical condition has occurred.
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Eligible people are adults aged 19-64 in households with adjusted income of up to 200 percent of the federal poverty level (about $1,600/month for a family of two), who are not eligible for Medicaid, who do not have other health insurance, and who agree to pay a small premium
Be under 19 years old
Children (ages 1-19): 133% FPL
Have no other health insurance
Pregnant Women and Infants (ages 0-1): 200% FPL
Treatment for special health problems like breast cancer, kidney problems, nursing home needs, and AIDS Pre-Existing Health Conditions Covered
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Can use credit to purchase plan through HIPIOWA Pre-Existing Health Conditions Covered
Be a citizen of the United States or a qualified alien Family income must be at or below 200% of the FPL Cannot be the dependent of a State of Iowa employee Children who qualify for Medicaid cannot get Hawk-i
$0 or minimal share of cost
Non-Working Parents: 33% FPL Supplemental Security Income Recipients: 74% FPL Medically Needy Individual: 67% FPL
Must be receiving TAA (Trade Adjustment Assistance)
$0 or minimal share of cost
20% of the insurance premium
Must not have access to employer plan that pays 50% of coverage cost Not enrolled in certain state plans
Medically Needy Couple: 50% FPL
$0 or minimal share of cost
www.coverageforall.org Iowa
Monthly Cost
depending on your income. No one pays more than $40
Working Parents: 82% FPL
GUARANTEED COVERAGE The Aberdeen Area Office in Aberdeen, South Dakota, works in conjunction with its 13 Service Units to provide health care to approximately 94,000 Indians on reservations located in North Dakota, South Dakota, Nebraska, and Iowa. The Area Office’s service units include nine hospitals, eight health centers, two school health stations, and several smaller health stations and satellite clinics
Eligibility
premium
Offers health, dental, vision, and prescription coverage
Each county has one or more health plans Pre-Existing Health Conditions Covered
$1-$3 co-pays and monthly
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
Or contact local county Department of Human Services
Pre-Existing Health Conditions Covered
Pregnant women at or below 300% of the FPL (if their medicial costs can bring their monthly income to 200% of the FPL)
605-226-7531 www.ihs.gov
Coverage
Services do not include checkups or pharmaceuticals, with the exception of those needed during and immediately following hospital stays. Emergency services are provided at local hospitals, not via IowaCare
Immigrants awaiting legal status
Program
800-338-8366 515-725-1003 www.ime.state.ia.us/IowaCare/ index.html
Children in moderate income families
Demographic
Publicly Sponsored Programs
30
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA/ Mini-COBRA
U.S. Uninsured Help Line
Group Health
Then
Program
800-234-1317
Kansas Association of Health Underwriters 703-276-0220 www.nahu.org
Coverage
Up to $5M lifetime maximum, assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply There is a 6-month look-back/ 3-month exclusionary period for preexisting conditions on enrollees that do not have prior creditable coverage
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
800-234-1317
Individual Plans
Individuals with pre-existing, severe or chronic medical conditions
Low income families and children
KHIA
Medicaid
Kansas Health Insurance Association 800-362-9290 www.khiastatepool.com
Kansas Association of Health Underwriters 703-276-0220 www.nahu.org
Up to $5M, assorted deductibles depending on age and ZIP code
COBRA Subsidy: 15 months of partially subsidized COBRA premium
There is a 12-month look-back and 24-month exclusionary period limit for pre-existing conditions
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Pre-Existing Health Conditions Covered with Some Limitations
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
(KMAP) 800-766-9012 785-291- 4414 https://www.kmap-state-ks.us/
Women-InfantChildren (WIC)
800-332-6262 785-296-1320 www.kdheks.gov/nws-wic
Comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, transplants, rehabilitation, durable medical equipment, mental health and substance abuse, physical, speech and occupational therapy, among other services
Medicaid: Physical health services: office visits, regular checkups, immunizations, hospital services, inpatient and outpatient hospital, lab and x-ray, prescription drugs, eye doctor exams and glasses, hearing services and speech, and physical and occupational therapy; Dental health services for children: checkups, cleanings, sealants, x-rays and fillings; Mental Health Services (Inpatient and outpatient): mental, behavioral and substance abuse services
Pre-Existing Health Conditions Covered
WIC: Provides nutrition education and supplemental foods to infants, children and women who are pregnant, postpartum or are breastfeeding Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Monthly Cost
Eligibility
Owner can count as an employee
31
Owner name on business license must draw wages from the company
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for KHIA, see next column
Mini-COBRA: Applies to small businesses with less than 20 employees
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
GUARANTEED COVERAGE
You are eligible if your previous coverage was terminated for reasons other than non-payment of premium or fraud (such as a pre-existing condition)
Medicaid: Children ages 1-5: 133% FPL; Ages 6-19: 100% FPL; Pregnant Women and Infants ages 0-1:150% FPL; Supplemental Security Income Recipients: 74% FPL; Medically Needy Individual: 66% FPL; Medically needy couple: 49%; Working Parents: 34%; Nonworking Parents: 27%; U.S. citizen, Kansas resident
Cannot be eligible for COBRA or government programs (except “end stage renal disease” covered under Medicare) Applicants must have applied for health insurance and been declined by two carriers because of a health condition
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Costs depend on employer contribution and ± 25% of the insurance company’s index rate
GUARANTEED COVERAGE
Must prove denial of coverage or offer of higher premium than KHIA rate
WIC: Women who are pregnant, Breastfeeding, up to baby’s first birthday, Non-breastfeeding mothers, up to six months after baby’s birth, Children under five years old, Family income up to 185%. Automatically eligible if enrolled in Food Stamp Program, Temporary Assistance for Families, and Medicaid Program
Live in KS and had 12 months of continuous coverage
Costs for individual coverage varies
Premium rates are determined according to the KHIA plan you select, your age, gender, and tobacco use.
Medicaid & WIC: $0 or minimal share-of-cost
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Kansas
800.234.1317
Moderate income families
Children with special needs
Women
Low income individuals
Health Wave
Children with Special Health Care Needs
Women’s Health Care and Family Planning Services
800-766-9012 785-296-3959 www.srskansas.org
800-792-4884 800-792-4292 TTY www.kansashealthwave.org
800-332-6262 785-296-1307 www.kdheks.gov/c-f/womens. html
Or contact local social services agency
Early Detection Works
SHICK
Pre-Existing Health Conditions Covered
Outreach clinics bring specialty diagnosis, consultation, and follow-along care as close to the child's home as possible. Clinics are conducted for hearing loss, orthopedic conditions, neurological impairment, cardiac diseases, and genetic diseases, counseling and planning services Pre-Existing Health Conditions Covered
Senior Health Insurance Counseling of Kansas 800-860-5260 www.agingkansas.org/SHICK/ shick_index.html
Women’s Health Care and Planning Services: Services are provided by a physician or mid-level practitioner with assistance from public health nurses. In larger health departments social workers, health educators and nutritionists are available for consultation. If problems are discovered which are beyond the scope of the clinics, appropriate referrals will be made by the health care provider. Clients are seen on by appointments
Prescription drugs, mental health services and medical (doctor) coverage. We also cover inpatient hospital, hearing, dental, and eye-wear coverage for most persons. A managed care network serves many families and children. Program pays enrolled providers directly for the medically necessary services they perform
Early Detection Works: Services include breast and cervical cancer screenings, treatment and possibly other services
Pre-Existing Health Conditions Covered
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also includes a prescription drug program called Medicare Part D SCHICK is a Medicare counseling service Pre-Existing Health Conditions Covered
Cash General Assistance also available
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
All applications will be screened for HealthWave 19 (Medicaid) first
Under age 22 living in Kansas
Women’s Health Care and Planning Services: Depends on facility
Children up to age 19; pregnant Women, persons who are blind or disabled by Social Security rules, persons age 65 or older, persons receiving inpatient treatment for tuberculosis, low income families with children (people who qualify TAF cash assistance), Persons screened and diagnosed with breast or cervical cancer apply to all medical plans
Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with EndStage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)
At or below 200% FPL Live in Kansas Complete the application and list all household members, sign and date the application and provide all household income verification for 3 months (2 months for renewals)
Up to 185% for SHS Program Up to 300% for PKU Food Kansas residents of any age with covered genetic and/or metabolic conditions
Early Detection Works: Age 40 -64 years Do not have insurance or have insurance that does not pay for these services or has insurance with a high deductible Ineligible for Medicare Part B or Medicaid/MediKan Income up to 250% FPL
If self-employed, provide your most recent tax return, including all schedules and attachments, or 3 months of business ledgers
$0 or some people must pay a premium
$0 or minimal share-of-cost
Kansas Residency citizenship and Immigrant Status- persons must be citizens or immigrants with a certain status. Some immigrants must wait 5 years before they can get coverage
$0 or minimal share-of-cost
$0 and share of cost for
certain services; deductibles for certain plans
www.coverageforall.org Kansas
Monthly Cost
HealthWave 21: $0 for most families; $20-$30 for others (premiums are subject to change at anytime); no co-pays, deductibles, or exclusions for pre-existing health conditions. HealthWave19: $0 or small share of cost (There are minor copays for adults)
Eligibility
GUARANTEED COVERAGE
Youth with a medical condition covered by the program.
Coverage
Some of the services covered are Physical health services: office visits, regular checkups, immunizations, hospital services, inpatient and outpatient hospital, lab and x-ray, prescription drugs, eye doctor exams and glasses, hearing services and speech, and physical and occupational therapy, dental health services for children (checkups, cleanings, sealants, x-rays and fillings), mental health services - inpatient and outpatient
Diagnostic services and treatment services include medical specialists, outpatient care, hospitalization, surgery, durable medical equipment, reimbursement for transportation to medical specialty care, and interpreter services. A limited amount of therapy (speech, PT, OT) is provided for eligible conditions
Medicare Prescription Drug Program 800-633-4227
877-277-1368 785-296-1207 http://www.kdheks.gov/edw/
All applications will be screened for HealthWave 19 (Medicaid) first.
Medicare
(Age 65 and up) 800-MEDICARE 800-633-4227 www.medicare.gov
Program
(CSHCN) 800-332-6262 785-296-1313 www.kdheks.gov/cyshcn
MediKan
Seniors and Disabled
Demographic
Publicly Sponsored Programs
32
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
Low income families & medically needy
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Kentucky Access
Medicaid
Program
800-234-1317
Group Health
Kentucky Office of Insurance 502-564-3630 800-595-6053 800-462-2081 TDD http://www.doi.state.ky.us/
Then
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov or
800-234-1317
866-405-6145 www.kentuckyaccess.com
Individual Plans
800-635-2570 502-564-4321 www.chfs.ky.gov/dms
Kentucky Office of Insurance 502-564-3630 800-595-6053 800-462-2081 TDD http://www.doi.state.ky.us/
Kentucky Continuation Coverage Pre-existing conditions can be excluded for a limited time depending upon the type of group plan you are joining
Coverage
Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
In Kentucky all insurers are required to offer a “standard plan” which offers the same benefits regardless of the insurer
COBRA Subsidy: 15 months of partially subsidized COBRA premium
Insurers are required to offer certain benefits such as maternity stay and mammograms
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Kentucky Access offers 3 health benefit plans: Traditional Access (indemnity type plan), Premier Access (PPO type plan), Preferred Access (PPO type plan). Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered with Some Limitations
In Kentucky all insurers are required to offer a “standard plan” which offers the same benefits regardless of the insurer Insurers are required to offer certain benefits such as maternity stay and mammograms Pre-Existing Health Conditions Covered
State conversion plans offered through private health insurance market will vary Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Owner can count as an employee
Eligibility
Proprietor name on license must draw wages
Medical underwriting will determine eligibility If you are denied coverage for a medical condition, you may be eligible for Kentucky Access, see next column
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Anyone who is eligible for HIPAA; Federally eligible Individuals coming off of group, governmental, church plan, COBRA or state continuation; If you are rejected for private medical coverage; If you can prove higher premium rates than KY Access; If you have a high cost condition
Ages 1-19 up to 200% FPL
If one family member is eligible other family members are eligible
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Kentucky resident
Pregnant women and infants up to 185% FPL Working parents up to 62% FPL Non-working parents up to 36% FPL Medically needy individuals up to 30%, couples 28% Limits on family resources such as savings accounts, cash, etc. for all but children and pregnant women
Monthly Cost
Must be a Kentucky resident
33
Costs depend on employer contribution and ± 35% of the insurance company’s index rate
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Depends on plan selected
Each individual plan is priced differently depending on age and gender, no family rates
$0 or nominal co-payment
COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Kentucky
800.234.1317
Children
KCHIP
Women-InfantChildren
Women
Commission for Children with Special Health Care Needs
Kentucky Women’s Cancer Screening Program
(CCSHCN) 800-232-1160 http://chfs.ky.gov/ccshcn/ About.htm
502-564-2154 800-4CANCER http://chfs.ky.gov/dph/info/ wpmh/cancerscreening.htm
Veterans
Medicare
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
877-222-8387 www.va.gov
Medicare Prescription Drug Program 800-633-4227
800-462-6122 502-564-3827 800-648-6056 TTY http://chfs.ky.gov/dph/mch/ns/ wic.htm
State Health Insurance Assistance Program 877-293-7447 http://chfs.ky.gov/dail/ship.htm
Services are provided through a variety of specialty clinics held across the commonwealth (Primary medical care is not covered)
If screened and diagnosed for breast or cervical cancer, may be eligible for complete health coverage through Medicaid, including dental, prescriptions etc.
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Coverage
KCHIP: Covers doctor visits, dental care, hospitalization, outpatient hospital services, emergency services, primary care services, psychiatrists, laboratory tests and X-rays, vision exams, hearing services, mental health services, prescription medicines, glasses, immunizations, well-child checkups, physical therapy, speech therapy, transportation, and many other services
Seniors and Disabled
Program
(Children’s Health Insurance Program) 877-524-4718 877-524-4719 TTY www.kidshealth.ky.gov
Children with chronic illnesses
Demographic
Publicly Sponsored Programs
SHIP is a Medicare counseling and application service Pre-Existing Health Conditions Covered
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Kentucky resident less than 21 years old
Must be Kentucky resident Under 64 years of age
Disabled or age 65 and older and people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
$0 and share of cost for
$0 or share of cost and co-pays depending on income level
A medical condition that usually responds to treatment provided by the program Must meet financial guidelines
WIC: Are pregnant or have a pregnant woman or infant in the family who receives Medicaid, or have a member of your family who receives KTAP, or have a household income at or below 185 FPL%.
KCHIP: $0 or $20 monthly premium depending on income $1 to $3 for Prescription Co-Pays, $6 for ER Copays, Max of $450 annually for premiums
Must be uninsured or underinsured, ineligible for Medicaid At or below 250% FPL Women younger than 40 are eligible to receive screening services only if they have a family history of breast cancer
$0 or minimal share-of-cost
$0 or nominal co-payment
certain services; deductibles for certain plans
Certain veterans must have completed 24 continuous months of service
WIC: $0 to minimal share of cost
www.coverageforall.org Kentucky
Monthly Cost
GUARANTEED COVERAGE
KCHIP: Must not be eligible for any other insurance, including individual, group or public; Children under age 19; Kentucky resident and family income at or below 200% FPL; Possible waiting periods for some children at certain income levels
Eligibility
GUARANTEED COVERAGE
34
Demographic
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA/ Mini-COBRA
U.S. Uninsured Help Line
Program
800-234-1317
Group Plans
Louisiana Association of Health Underwriters 703-276-0220 www.la-ahu.org
and then
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
LaHIPP
800-234-1317
Individual Plans
Individuals with pre-existing, severe or chronic medical conditions
Low-income individuals & families
LHP
Medicaid
Louisiana Health Plan 800-736-0947 225-926-6245 (Baton Rouge) www.lahealthplan.org
888-342-6207 www.dhh.state.la.us/ offices/?ID=92
Four plans offering comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, ambulance, labs and x-rays, skilled nursing care, home health visits, transplants, rehabilitation, durable medical equipment, physical, speech and occupational therapy, vision care, and preventive care, among other services
Physician, hospital, laboratory, x-ray, and nursing home services. Optional programs cover services such as pharmacy and intermediate care facilities for the mentally retarded
Louisiana Association of Health Underwriters 703-276-0220 www.la-ahu.org
Coverage
888-695-2447 www.lahipp.dhh.louisiana.gov Carriers can impose a 6-month look-back/12-month exclusionary period for preexisting conditions on enrollees that do not have prior creditable coverage
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
Benefits will vary depending on the chosen plan
COBRA Subsidy: 15 months of partially subsidized COBRA premium
Pre-Existing Health Conditions Covered
HIPAA: Benefits are based on the program selected and there is no expiration of coverage (see LHIA for plan details)
Assorted plans depending on medical needs There is a 12-month look-back and exclusionary period limit for pre-existing conditions in traditional individual market health insurance products in Louisiana Limits on Pre-Existing Health Conditions May Apply
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
LaHIPP: Benefits are the same as what you had with your previous employer, LaHIPP is a premium assistance program Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Eligibility
Owner can count as an employee Owner name on business license must draw wages from the company
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for LHP, see next column
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Monthly Cost
Pregnant women & Children 0-19 Income up to 200% FPL Supplemental Security Income Recipients: 74% FPL Non-Working Parents: 12% FPL Medically Needy Couples and Working Parents: 26% FPL Medically Needy Individual: 14% FPL Legal Louisiana residents Asset limits for some people
Must be declined by two separate insurance carriers There is a 6-month waiting period for pre-existing conditions Eligible with HIPAA
LaHIPP: You may be eligible for HIPP if you have a high-cost health condition and have Medicaid COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
GUARANTEED COVERAGE
Have an automatically rejectable health condition, or during the 12 months prior to applying for coverage from the Association have been rejected by a licensed insurance company, nonprofit health care services plan or HMO for coverage substantially similar to the Association coverage without material underwriting restriction at a rate equal to or less than the Association plan Not be eligible or receiving health benefits under any federal or state program and not have received $500k in benefits from the Association or any organization similar to the Association
Mini-COBRA: Applies to small businesses with less than 20 employees
Costs depend on employer contribution and ± 35% of the insurance company’s index rate
GUARANTEED COVERAGE
Costs for individual coverage varies
Four plan options with deductible choices of $1000, $2000, $3500 and $5000
$0
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column LaHIPP: $0 or minimal share of cost
35
Louisiana
800.234.1317
Children in moderate income families LaCHIP
Women-InfantChildren (WIC)
Women
CSHS
Breast and Cervical Cancer Prevention
Louisiana Children’s Special Health Services 504-896-1340 www.dhh.louisiana.gov/ offices/?ID=256
LaMOMS
800-251-BABY 800-251-2229 www.dhh.louisiana.gov/ offices/?ID=320
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
888-342-6207 TTD: 800-220-5404 www.dhh.louisiana.gov/ offices/?id=137 Health care services, medical tests and procedures, hospitalization, therapies, home health services, medical equipment and supplies, parent/family support services (parent liaisons), medications and special diets, nursing, nutrition and social services follow-up, care coordination, case management, and resource development, or over 21 years of age for the Cystic Fibrosis program
BCCP: Screening and/or diagnostic mammograms annually for women 50 years+, ultrasound. Fine needle aspiration of the breast and breast biopsy, if indicated, Annual Pap exams for women 18 years of age and older not already enrolled in a program that provides this service, Colonoscopy and biopsy, if indicated, follow-up and referral for abnormal Pap exams and/or Mammograms
Veterans
Medicare
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
877-222-8387 www.va.gov
Medicare Prescription Drug Program 800-633-4227
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Coverage
LaCHIP: provides Medicaid coverage for doctor visits for primary care as well as preventive and emergency care, immunizations, prescription medications, hospitalization, home health care and many other health services
888-342-6207 504-218-2322 www.dhh.state.la.us/offices/ page.asp?id=92&detail=3879 or http://labchp.lsuhsc.edu/ default.htm
Seniors and Disabled
Pre-Existing Health Conditions Covered
LaMOMS: Pregnancy-related services, delivery and care up to 60 days after the pregnancy ends including doctor visits, lab work/tests, prescription medicines and hospital care
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
LACHIP: Children must be under age 19 and not covered by health insurance.
Children under age 21, who live in Louisiana, have a condition covered by CSHS, would benefit from rehabilitation services, have a long-term condition that requires specialty care and a multi-disciplinary treatment team, and meet financial requirements may qualify for services
BCCP: U.S. citizens or qualified aliens under 65 years old; uninsured and screened for breast or cervical cancer under the CDC
Disabled or age 65 and older and people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
$0 and share of cost for
$0 and share of cost and
Family income cannot be more than 250% of the FPL Louisiana residents and able to document either U.S. citizenship or meet residency requirements
Program
Children’s Health Insurance Plan 877-2 LACHIP 877-252-2447 www.lachip.org
Children with special health care needs
Demographic
Publicly Sponsored Programs
Eligibility continues until the course of treatment ends or the criteria for the program are no longer met and may begin up to three months before the month a woman applies for Medicaid. A woman may be eligible to be paid back for services received up to three months before she applied if she used a Medicaid provider and if the service is covered by Medicaid
Certain veterans must have completed 24 continuous months of service
Eligibility
WIC: Live in Louisiana, Pregnant and postpartum women, infants, and children under age 5; Income must be: Family of 1 $1,670, Family of 2 $2,247, Family of 3 $2,823, Family of 4 $3,400, $577 for each additional family member
Income up to 250% FPL
LaMOMS: Income up to 200% FPL
$0 or minimal share-of-cost
$0 or minimal share-of-cost
certain services; deductibles for certain plans
co-pays depending on income level
WIC: $0 or minimal share-ofcost
www.coverageforall.org Louisiana
Monthly Cost
LACHIP: $0-50 monthly premium depending on income
36
Demographic
Private Health Insurance Small businesses (1-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Low income families & medically needy
U.S. Uninsured Help Line
COBRA/ Mini-COBRA
U.S. Uninsured Help Line
MaineCare
Program
800-234-1317
Group Health
207-624-8475 800-300-5000 TTY 888-577-6690 Maine Bureau of Insurance www.maine.gov/pfr/insurance
Then convert to
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov or
800-234-1317
Individual Plans
207-624-8475 800-300-5000 TTY 888-577-6690 Maine Bureau of Insurance www.maine.gov/pfr/insurance
Moderate income individuals, families employees Dirigo Choice
(Medicaid) 800-321-5557 207-624-7539 207-287-3707 TTY www.maine.gov/bms
(State-sponsored plan) 877-892-8391 207-287-9900 www.dirigohealth.maine.gov (DirigoChoice individual coverage is currently closed. Enrollment will reopen as the program expands in 2010. Financial Assistance is no longer available to new enrollees)
State Conversion Plans
Coverage
Pre-existing conditions can be excluded for a limited time depending upon the type of group plan you are joining (6-12 month look back) Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Depends on plan chosen Plans are required by state to offer certain benefits such as mammograms, childhood immunizations and automatic coverage for newborns or adopted children
Medical, dental and vision, prescriptions, hospitalization and more depending on program
Three plans to choose from. Plans offer doctor visits, hospital care and other preventative care
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
There is a 6-12 month look-back for pre-existing conditions, possible waiting periods Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 1-50 employees
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
In Maine, no medical underwriting is allowed
Pregnant women at or below 200% FPL; Infants at or below 185% FPL; Working or nonworking parents with children under the age of 18 at or below 200% FPL; Children age 1-20 at or below 150% FPL; Working Disabled at or below 250%; Medically needy individuals qualify for spend down coverage. There is no income limit. Spend down figures out what the medically needy person can afford by seeing how high their income is. The person pays a deductible and then begins their coverage. As the income grows, the deductible gets higher; A waitlist for healthy, childless adults 21 to 64 is still in effect, and individuals could be on the waitlist anywhere from 3 months to a year
Individuals and employees under 300% of the FPL are eligible for DirigoChoice. Currently there is a waitlist for the Individual Category. Business Categories are still available; however, discounted premiums and deductibles are not available to new enrollees
$0 or minimal share of cost
Costs depend on age, region of Maine, and coverage plan selected. Discounted premiums and deductibles are no longer available to new enrollees.
Owner can count as an employee
Eligibility
Proprietor-name on license must draw wages
Mini-COBRA: Applies to businesses with less than 20 employees HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Currently there is an enrollment freeze for the Individual Category. Business Categories are still available; however, discounted premiums and deductibles are not available to new enrollees Resident of Maine
Monthly Cost
Must be a Maine resident
37
Costs depend on employer contribution and ± 20% of the Modified Community Rate
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Premiums vary by 20% above and below community rating Annual deductibles range from $250-$1,500
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column
Maine
800.234.1317
Children with special needs
Pregnant women and children
Maine Children with Special Needs Program
CubCare/MaineCare
(As of March 1, 2008, CSHN has capped program enrollment and will no longer be accepting applications for payment of services)
Women-InfantChildren (WIC)
Maine Breast and Cervical Health Program 800-350-5180 207-287-8068 800-438-5514 (TTY) www.maine.gov/dhhs/ bohdcfh/bcp
800-437-9300 207-287-3991 800-438-5514 (TTY) www.maine.gov/dhhs/wic/
Veterans
Medicare
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
877-222-8387 www.va.gov
Medicare Prescription Drug Program 800-633-4227
Cubcare/MaineCare: Doctor visits, check-ups, immunizations, preventive care, dental, mental, hospitalization
If screened and diagnosed for breast or cervical cancer may be eligible for complete health coverage through Medicaid
Blood disorders, cardiac defects, childhood oncology craniofacial anomalies, gastrointestinal, metabolic ophthalmologic, orthopedic, neurological, neurosensory neuromuscular, respiratory
WIC: Screening for growth and anemia, Healthy advice for families, Nutrition & Healthy Foods, Breastfeeding support, other referrals to other services
Pre-Existing Health Conditions Covered
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Coverage
Medical treatment, including diagnostic, medical, surgical, corrective and other therapeutic interventions for:
Assistance with coordination of care and referral services to families of infants, children, and adolescents with special health needs regardless of income.
Seniors and Disabled
Program
207-287-5139 800-698-3624 TTD: 800-438-5514 www.maine.gov/dhhs/boh/ cshn
800-442-6382 877-KIDS-NOW 877-543-7669 www.maine.gov/bms
Women
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Must be Maine resident Infants, children, and adolescents who are at or below 225% of FPL
Cubcare/MaineCare: Low income children under age 18
Must be Maine resident Ages 50 and older
Ages 21 and under
Maine residents
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
$0 and share of cost for
$0 and share of cost and
No citizenship requirements for pregnant women and children
Income must be equal to or less than 200% of the FPL
Must be uninsured or underinsured, ineligible for Medicaid, MaineCare, and Medicare Part B Limited openings for women age 35-39 who have seen a doctor and need additional tests for a possible breast or cervical cancer or if they have not had a Pap in 5 or more years
Cubcare/MaineCare & WIC: $0 or small monthly premium
$0 or nominal co-payment
certain services; deductibles for certain plans
co-pays depending on income level
www.coverageforall.org Maine
Monthly Cost
WIC: Pregnant or postpartum women and children up to the age of 5 years with a family income at or below 185% of the FPL. Must be a state resident; and be at nutritional or medical risk, as determined by a health professional.
Certain veterans must have completed 24 continuous months of service
Eligibility
$0 or nominal co-payment
Under 250% FPL
38
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Program
800-234-1317
Group Health
Maryland Association of Health Underwriters 703-276-0220 www.marylandahu.com
and then
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
800-234-1317
Individual Plans Maryland Association of Health Underwriters 703-276-0220 www.marylandahu.com
Individuals with Low Income pre-existing, Families & severe or chronic Medically Needy medical conditions Maryland Health Insurance Plan
MHIP 888-444-9016 www marylandhealthinsuranceplan. net
Medicaid
410-767-5800 800-492-5231 800-735-2258 TDD www.dhmh.state.md.us/ mma/mmahome.html
Medical Assistance for Families
Coverage
800-456-8900 http://dhmh.state.md.us/ ma4families/
If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
Benefits will vary depending on the chosen plan
COBRA Subsidy: 15 months of partially subsidized COBRA premium
Pre-Existing Health Conditions Covered
HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered
Assorted plans depending on medical needs There is a 6-month look-back and 12-month exclusionary period limit for pre-existing conditions in traditional individual market health insurance products in Maryland Limits on pre-existing health conditions may apply
Four plans offering comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, transplants, rehabilitation, durable medical equipment, mental health and substance abuse, physical, speech and occupational therapy, and preventive care, and more Choice of one of four plan benefit options Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Monthly Cost
Eligibility
Owner can count as an employee
39
Owner name on business license must draw wages from the company
Costs depend on employer contribution and ± 40% of the Modified Community Rate
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for MHIP, see next column
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Previous coverage terminated for reasons other than nonpayment of premium or fraud
Medicaid: Pregnant Women up to 250% FPL; Infants and children (ages 0-19): 200% FPL; Medically Needy Individual: 49% FPL; Medically Needy Couple: 41% FPL; Working Parents: 40% FPL; Non-Working Parents: 33% FPL; SSI Disabled (nonelderly) at or below 74% of FPL; Working Disabled at or below 300% of FPL
Cannot be eligible for group plan, COBRA, or government programs
Or, have/been offered, health insurance that provides limited coverage, or excludes coverage for a specific medical condition or conditions
Costs for individual coverage varies
Medical Assistance for Families: Low-cost or free prescriptions, doctor visits, emergency room visits, hospital stays, x-ray and lab services, and many other services Pre-Existing Health Conditions Covered
Denied coverage due to a medical condition
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs
Medicaid: Doctor visits, prescriptions, hospital care (including emergency care), tests, x-rays, family planning, mental health services, substance abuse services, home health care, dental care, eye care, occupational therapy, physical and speech therapy, and more
Resource requirements for everyone but children or pregnant mothers
Families with an income at or below 300% of the FPL can qualify for discounted premiums also known as MHIP+
Maryland resident and qualified immigrant
Rates shall not exceed 150% of the standard premium rate charged by commercial carriers.
$0 or minimal share of cost,
Medical Assistance for Families: Eligibility is set at or below 121% FPL
no co-pays for emergency services and family planning services
COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Maryland
800.234.1317
Children and Pregnant Women
Women
MCHP
Breast Cancer Screening Program
MCHP Premium 410-767-6883 800-456-9800 800-735-2258 (TDD)
Women-InfantChildren (WIC)
800-242-4WIC 800-242-4942 www.fha.state.md.us/wic/
MCHP Premium: Access to health coverage through Healthchoice, the Maryland Managed Care Program WIC: Screening for growth and anemia, Healthy advice for families, Nutrition & Healthy Foods, Breastfeeding support, other referrals to other services
Breast and Cervical Cancer Diagnosis and Treatment Program
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
800-633-4227
410-767-6787 800-477-9774 www.fha.maryland.gov/ cancer/bccdt_home.cfm
Screening mammogram, clinical breast exam, Pap test and pelvic exam cervical biopsy, diagnostic mammogram, colonoscopies, surgical consultation, breast ultrasound, breast biopsy, colposcopy surgery, adjuvant therapy (chemotherapy, radiation therapy), home health, pharmacy, DME (including prosthesis and bras), physical therapy, occupational therapy, wigs and breast reconstruction
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D Pre-Existing Health Conditions Covered
Will cover COBRA if employer contributes less than 50% (or spouses’ employer)
Comprehensive preventive and primary care, outpatient and inpatient services
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Coverage
MCHP: Prenatal and post-partum doctor visits, hospital delivery bill, immunizations, lab work and tests, dental and vision care, prescription medicines (including vitamins), transportation to medical appointments, mental health services, substance abuse treatment, after delivery, family planning services
800-477-9774 http://fha.maryland.gov/ cancer/bccp_home.cfm
Trade Dislocated Workers (TAA recipients)
Program
Maryland Children’s Health Program 800-456-8900 800-735-2258 TTD www.dhmh.state.md.us/ mma/mchp
Seniors and Disabled
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
MCHP: Children 0-19; Household income up to 200% FPL; Must not be eligible for Medicaid; Pregnant women any age with income up to 250% FPL
A woman must be a Maryland resident aged 50
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
WIC: Live in Maryland, Pregnant and postpartum women, infants, and children under age 5; Income must be at or below 185% FPL
Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
20% of the insurance premium
$0 and share of cost and co-pays depending on income level
Insurance: Uninsured or have health insurance which does not cover the screening procedures. Income: Women with household incomes at or below 250% FPL
$0
$0 and share of cost for
certain services; deductibles for certain plans
MCHP Premium: Monthly fee of
$46 or $58 depending on
family income.
WIC: $0 to minimal share of cost
www.coverageforall.org Maryland
Monthly Cost
MCHP: $0 or monthly premium payment depending on family income.
Must not have access to employer plan that pays 50% of coverage cost
Eligibility
MCHP Premium: Children 0-19; Household income between 200-300%; Must not be eligible for Medicaid or MCHP; Must currently be without health insurance coverage
Women aged 40- 49 who have symptoms of breast cancer, who have a personal history of breast cancer, or who have a mother or sister who developed breast cancer before menopause
40
Demographic Program
Private Health Insurance Small businesses (1-50 Employees)
Individuals recently covered by an employer health plan
U.S. Uninsured Help Line 800-234-1317
COBRA/ Mini-COBRA
Group Plans
Or
For help learning about plans contact: MA Association of Health Underwriters 508-634-7373 www.massahu.org MA Division of Insurance 617-521-7794 www.mass.gov/doi Commonwealth Connector 877-MAENROLL 877-623-6765 www.mahealthconnector.org
Coverage
Many private insurers and HMOs offer health plans to employer groups. Employer groups can purchase health plans either directly from the insurance carrier or can access a select group of health plans that are offered through the Commonwealth Connector Employers may choose one or more employer-sponsored plans for their eligible full-time employees among several carriers and plan designs including Health Savings Accounts plans. Employers may also facilitate the offering of non-employer sponsored plans through the Connector for their part-time and ineligible employees and establish a Section 125 plan enabling employees to use pre-tax dollars to pay health insurance premiums. Each employee can then choose among any of the carriers and plans offered through the Connector Pre-Existing Health Conditions Covered
State Conversion Plans Then
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov
Medical Security Program Premium Assistance Plan 800-908-8801
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage These programs allow employees to maintain their same health plan and transition to a new plan without a break in health coverage if they meet certain eligibility criteria
Monthly Cost
Eligibility
Pre-Existing Health Conditions Covered
41
Private/Public Programs
Individuals and Families Above 300% of the FPL Individual Plans
For help learning about plans contact: MA Association of Health Underwriters 508-634-7373 www.massahu.org Or MA Division of Insurance 617-521-7794 www.mass.gov/doi Or Commonwealth Connector 877-MAENROLL 877-623-6765 www.mahealthconnector.org Many private insurers and HMOs offer health plans to employer groups. Employer groups can purchase health plans either directly from the insurance carrier or can access a select group of health plans that are offered through the Commonwealth Connector
Commonwealth Choice plans (Gold, Silver, or Bronze) are lower cost private plans that are available through the Commonwealth Connector and directly through the different insurance carriers. The companies that are offering the plans include: Blue Cross Blue Shield of Massachusetts, Fallon Community Health Plan, Harvard Pilgrim Health Care, Health New England, Neighborhood Health Plan, and Tufts Health Plan Young Adults Plans (YAP) are available to people between 18-26 to years of age and can only be purchased through the Commonwealth Connector Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Employers with one or more full-time employees may establish a group plan with employer contributions so long as the premium contribution towards full-time non-bargaining employees (defined by the state as working 35 hours or more) is not discriminatory. An employer may also establish a Section 125 plan for employees who are not eligible for their group plan and allow them to purchase insurance through the Commonwealth Connector.
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Anyone can qualify for these plans
A full-time employee is someone who works 35 hours or more per week at a Massachusetts location (even if they live in another state). Individuals who are not considered full-time employees include: 1) Independent contractors; 2) Seasonal employees; 3) Temporary employees; 4) Workers from temp agencies (they are the temp agency’s employees. Employers with 11 or more full-time equivalent employees have four requirements: 1) You must offer a Section 125 cafeteria plan that meets Commonwealth Connector regulations. If you don’t offer a Section 125 cafeteria plan, you will pay the Free Rider Surcharge if your employees or their dependents get medical care that is paid by the state’s Free Care Pool- now called the Health Safety Net -for the uninsured; 2) You must make a “fair and reasonable” contribution to your employees’ health insurance or pay a Fair Share Contribution or fine of up to $295 per employee per year (see below); 3) Employers must complete an Employer Health Insurance Responsibility Disclosure (HIRD) Form/ Report which must be filed on-line, to report if you offer a Section 125 Plan that complies with Commonwealth Connector regulations; 4) Employers must collect an HIRD Employee Form from employees who decline your employer sponsored health insurance and/or your employer sponsored Section 125 Plan.
Employers must make a “fair and reasonable” contribution to your employees’ health insurance or pay a Fair Share Contribution or fine of up to $295 per employee per year. A “fair and reasonable” contribution by an employer is: (i) 25% of an employer’s full-time employees* are participating in the employer’s group health plan or (ii) an employer’s contribution of at least 33% toward a health plan premium for all full-time employees* who are employed more than 90 days. An employer who meets either (i) OR (ii) will not be subject to the Fair Share Contribution of up to $295 per employee
Massachusetts
Mini-COBRA: Applies to small businesses with less than 20 employees HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
There is no medical underwriting Commonwealth Choice plans (Gold, Silver, or Bronze) may be right for you if: you are a resident of Massachusetts or are employed by a Massachusettsbased employer, you are age 18 or older, you are not eligible for Commonwealth Care products because family’s income before taxes is above 300% of the federal poverty level Young Adults Plan (YAP) is available to people between 18-26 to years of age.
Medical Security Program: If you have COBRA, your former employer’s group plan, or an individual plan, you may be eligible for monthly reimbursement of your premium payments. To be eligible, you must be responsible for 100% of your monthly premium. If eligible, you will be enrolled in the Premium Assistance plan with the same type of coverage you have on your existing plan. You must continue to pay your monthly health insurance premium. The Medical Security Program will reimburse you upon receipt of a claim form with proof of payment
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%-150% of group health rates Medical Security Program: You may receive 80% of the actual premium paid, or up to $1,110 per month for a family plan and up to $450 per month for an individual plan
Costs on the Commonwealth Choice Plans Members must pay a monthly premium. The premium the members pay will depend on the health plan and benefit package they choose, and must be paid every month, even if no services are used. Members must pay a fee co-payment each time they use benefits. In addition, there may be a deductible an amount that the member must pay out-ofpocket for services before the health plan begins paying. This amount will vary by health plan and there will be different family and individual out-of-pocket maximum amounts.
800.234.1317
Individuals and Groups Below 300% of the FPL Individual and Group Plans
Children
Breast Cervical Cancer Treatment Program (BCCTP)
Children’s Medical Security Plan (CMSP)
877-414-4447 617-624-5992 TTY www.massresources.org
Healthy Start Program
888-665-9993 (Eligibility) 888-488-9161 (Customer Service)
888-665-9993 800-909-2677 www.cmspkids.com
Women-InfantChildren (WIC) 800-WIC-1007 800-942-1007 www.mass.gov search “WIC”
Seniors
Medicare
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program 800-633-4227
Program
For help learning about plans contact: MassHealth Families & Children: MassHealth Standard, MassHealth Family Assistance, Children’s Medical Security Plan Unemployed Adults: MassHealth Essential, Medical Security Plan, MassHealth Basic Pregnant Women: MassHealth Prenatal, Healthy Start Disabled: MassHealth, CommonHealth 888-665-9993 (Enrollment Center) 888-665-9997 TTY (Enrollment Center) 800-841-2900 (Customer Service) 800-497-4648 TTY (Customer Service) www.ma.gov/masshealth
Women
Demographic
Publicly Sponsored Programs
Commonwealth Care 877-MA-ENROLL (877-623-6765) www.mahealthconnector.org The Insurance Partnership 800-399-8285 508-698-2070 www.insurancepartnership.org MassHealth members get similar benefits depending on the MassHealth plan they qualify for. There are similar plans with different names for children, adults, families, pregnant women, undocumented immigrants, the disabled and other groups
CMSP: covers doctor visits with your child’s regular doctor and specialists (like a heart doctor); immunizations (shots); eye exams and hearing tests; X-rays and labs; some mental health care; and dental care. Children with pre-existing health conditions are covered for visits
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D Pre-Existing Health Conditions Covered
Healthy Start: Offers early, complete prenatal care to pregnant women and children
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Note: Those who are self employed, are seasonal workers and/or have income is not solely from W-2 income sources with regular pay stubs, should contact an enrollment specialist to determine what their gross income is and to determine what programs they are eligible for.
BCCTP: You are under 65. You have been screened for breast or cervical cancer at a Women’s Health Network site and found in need of treatment. Your income is no greater than 250% of the FPL. Your insurance coverage does not cover the treatment you need. You meet the other eligibility requirements for MassHealth
CMSP: Children under 19 who do not have other insurance. Children can get this insurance even if their family makes too much money for other programs.
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)
Pre-Existing Health Conditions Covered
CommonWealth Care you must be 19 or older and have a gross income below 300% of the FPL; must be uninsured and eligible as defined by the Commonwealth Connector¹s regulations; and must be a U.S. citizen/ national, qualified alien, or alien with special status. You are considered uninsured if: you are currently insured under COBRA; are paying a full premium for you health insurance in the non group insurance commercial market; are in a waiting period prior to becoming eligible under an employer-provided health plan (where employer covers at least 20% of the cost of the premium of a family health plan or 33% of an individual plan) The Insurance Partnership offers employers with 50 or fewer full time employees assistance with their premiums or their business and income eligible employees. To be eligible, employers must offer (or plan to offer) comprehensive health insurance to its employees and must contribute (or be willing to contribute) at least 50% of the cost of the insurance purchased by the employee. Eligible employees must have family gross income below 300% of the FPL, be between the ages of 19 and 64 (inclusive) and must not have been offered health insurance by their current employer in the past six months, and not have been eligible for health insurance through their spouse’s employer in the past six months
The Insurance Partnership will pay small businesses up to $1,000 a year toward health insurance costs for each qualified employee. The amount depends on the tier of coverage chosen by the employee.
Note: Massachusetts residents age 18 and older under the Individual Mandate law are required to have health insurance that is deemed by the state to be affordable to them at their income level or they risk being fiscally penalized on their personal state income taxes. There is also a waiver/appeals process from the Individual Mandate. On January 1, 2009, individuals, who are NOT exempt from the Individual Mandate, will have to have health insurance that is deemed affordable to them at their income level AND meets "Minimal Creditable Coverage" (MCC) standards set by the Connector. For help contact the local organizations on the back of this Matrix.
No monthly premium for participants with an income below 133%. Participants with an income between 133-250% of the FPL will pay a monthly premium.
CMSP: Depending on your income costs will vary (Premiums between $0-64 per child; Co-pays $2-8, Pharmacy $3-4).
$0 and share of cost for certain services; deductibles for certain plans
WIC: $0 to minimal share of cost
www.coverageforall.org Massachusetts
Monthly Cost
MassHealth and CommonWealth Care costs vary depending on which program suites you best. The costs of each plan are based on a sliding scale.
Healthy Start: Must be pregnant, be a resident of Massachusetts, have little or no health coverage for pregnancy, be ineligible for MassHealth (except MassHealth Limited), Income must be no greater than 200% FPL
WIC: Live in Massachusetts, have a nutritional need (WIC staff can help you determine this), are a child under 5, a new mom, or a pregnant or breastfeeding woman, Income must be at or below 185% FPL
Eligibility
MassHealth you must be one of the following: a parent living with your children under age 19, an adult caretaker relative living with children under age 19 to whom you are related by blood, adoption, or marriage, or are a spouse or former spouse of one of those relatives, and you are the primary caretaker of these children when neither parent is living in the home; or you are under age 19, whether or not you live with your family; you are pregnant, with or without children; or you have been out of work for a long time; or disabled or HIV positive, or you are a woman under 65 with breast cancer or cervical cancer
Coverage
CommonWealth Care benefits include: your own health care provider; preventative care checkups, care when you are sick or injured; prescriptions at your local pharmacy; treatment for alcohol, drug abuse, and mental health problems; vision care; dental care (available to some members only). CommonWealth Care offers four types of plans. Plan Type 1, 2, 3 or 4. A Plan Type is a certain list of health benefits and copayments that is available to members based on their income
BCCTP: Screening will be done through the Women’s Health Network. Insurance coverage will be issued through MassHealth Standard. This coverage includes cancer treatment and comprehensive medical care. You will get your benefits through the Primary Care Clinician (PCC) plan (cannot get coverage through HMO)
42
Demographic
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
U.S. Uninsured Help Line
COBRA
Group Health
HIPAA
Program
800-234-1317
Michigan Association of Health Underwriters 703-276-0220 www.mahu.org
If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply
Coverage
Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
Eligibility
COBRA: Coverage available for up to 18 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Owner can count as an employee
Monthly Cost
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
Low income individuals and families
U.S. Uninsured Help Line
Blue Cross/ Blue Shield of Michigan
Medicaid and Healthy Kids
800-234-1317
Individual Plans
Michigan Association of Health Underwriters 703-276-0220 www.mahu.org
800-642-3195 www.michigan.gov/mdch
888-MI-BCBSM 888-642-2276 www.bcbsm.org
Assorted plans depending on medical needs
Plans vary depending on applicant needs
There is a 6-month look-back and 12-month exclusionary period limit for pre-existing conditions in traditional individual market health insurance products in Michigan
Pre-Existing Health Conditions Covered
Ambulance, dental, doctor visits, family planning, health checkups, hearing and speech, home health care, hospice, hospitalization, lab and X-rays, immunizations, medical supplies, nursing home care, medicine, mental health care, personal care services, prenatal care, surgery, vision, substance abuse treatment, physical therapy
Limits on pre-existing health conditions may apply
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
43
and then
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
Owner name on business license must draw wages from the company
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for BCBSM, see next column
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Cannot be eligible for COBRA, or government programs (must have exhausted this option)
Limited assets such as cash, savings, stocks and bonds (except for pregnant women and children)
HMOs in the state must offer guarantee issue coverage to residents during annual open enrollment periods Must be Michigan resident
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Children 1-19 income at or below 150% Non-Working Parents: 39% FPL Working Parents: 66% FPL Medically Needy Individual: 57% FPL Medically Needy Couple: 56% FPL
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for any other insurance programs
Costs depend on employer contribution and ± 45% of the insurance company’s index rate
Pregnant women and infants up to 185% FPL;
SSI Recipients: 74% FPL
Costs for individual coverage varies
Rates are not restricted and will depend on plan (BCBSM does community rating)
$0 or minimal share-of-cost and no co-pays
$5 monthly payment per family for children
COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Michigan
800.234.1317
Children in moderate income families MIChild
Healthy Kids
888-988-6300 www.michigan.gov/mdch
MIChild: Regular checkups, shots, emergency care, dental care, hospital, pharmacy, hospital care, prenatal care and delivery, vision and hearing, mental health and substance abuse services
Breast and Cervical Cancer Control Program
Adult Medical Program
800-922-MAMM 800-922-6266 www.michigan.gov/mdch (Click on “Prevention”)
Adult Benefits Waiver www.michigan.gov/mdch Contact local Department of Human Services
Medicare
Health Coverage Tax Credit
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
Medicare/Medicaid Assistance Program
800-26-BIRTH 800-262-4784 www.michigan.gov/mdch (Listed under “Pregnant Women, Children & Families”)
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Trade Dislocated Workers (TAA recipients)
800-633-4227
Women-InfantChildren (WIC)
BCCP: Cancer screening services and follow-up care, including cancer treatment if that should be needed
Seniors and Disabled
800-803-7174
Basic medical care, pharmacy, no-inpatient Pre-Existing Health Conditions Covered
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and ‘advantage’ plans. It also offers a prescription drug program called Medicare Part D Medicare/Medicaid Assistance Program is a counseling service for Seniors and Disabled Pre-Existing Health Conditions Covered
Will cover COBRA if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Under BCBS of MI options are: Health Coverage Community Blue Option with RX Plan 1 or the Blue Value Option 9 with RX Plan 2 Pre-Existing Health Conditions Covered
Coverage
Healthy Kids: Ambulance, dental, doctor visits, family planning, health checkups, hearing and speech, home health care, hospice, hospitalization, lab and x-rays, immunizations, medical supplies, nursing home care, medicine, mental health care, personal care services, prenatal care, surgery, vision, substance abuse treatment, physical therapy. Also offers prenatal care for pregnant women
Adults with no Children
Program
800-843-6447 888-988-6300 www.michigan.gov/mdch (Listed under “health care coverage” and “children & teens”)
Women
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
MIChild: Income must be above 150% but below 200% of the FPL; Must be uninsured; Must be ineligible for Medicaid; Residents and U.S. citizens; Families who voluntarily drop employer-based comprehensive insurance must wait six months to enroll; If families drop private insurance, they may immediately enroll in MIChild
BCCP: Have an income 250% FPL or lower
Uninsured, ineligible for Medicaid, meet income and assets test
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
Be age 40 - 64 for breast/ cervical cancer screening and for diagnostic follow-up of breast/cervical abnormalities or
Countable income at or below 35% of the FPL
Must not have access to employer plan that pays 50% of coverage cost. Not enrolled in certain state plans Also see BCBSM
Be age 18 - 39 and have been identified with a cervical abnormality through the Family Planning program (Title X) Note: Women who are enrolled in a managed care program, a health maintenance organization, or Medicare Part B are not eligible for the BCCC
Eligibility
Healthy Kids: Pregnant women, babies and children under age 19 are eligible, Income must be at or below 150% FPL
Be uninsured or underinsured for these tests and
WIC: Live in Michigan, have a nutritional need (WIC staff can help you determine this), are a child under 5, a new mom, or a pregnant or breastfeeding woman, Income must be at or below 185% FPL
Healthy Kids: $0 to minimal share of cost
BCCP: $0 WIC: $0 to minimal share of cost
$0 or small share of cost
$0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
www.coverageforall.org Michigan
Monthly Cost
MIChild: $10 monthly premium and no co-pays
44
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
U.S. Uninsured Help Line
COBRA & Mini-COBRA
U.S. Uninsured Help Line
Minnesota Comprehensive Health Association
Program
800-234-1317
Group Health
Minnesota Association of Health Underwriters 651-917-6253 www.emahu.org
Then convert to
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
800-234-1317
Individual Plans
Minnesota Association of Health Underwriters 651-917-6253 www.emahu.org
Low income individuals and families
(MCHA) 952-593-9609 866-894-8053 www.mchamn.com
Medicaid
(Medical Assistance) Twin-Cities Metro Area 651-431-2670 Outside Twin-Cities Metro Area 800-657-3739 www.dhs.state.mn.us www.bridgetobenefits.org
Or
State Conversion Plans Pre-existing conditions can be excluded for a limited time depending upon the type of group plan you are joining
Coverage
Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium
Options vary depending on applicant needs and plan selected Pre-Existing Health Conditions Covered with Some Limitations
HIPAA: Benefits are based on the program selected and there is no expiration of coverage State conversion plans offered through private health insurance market will vary
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Eligibility
Owner can count as an employee, proprietor-name on license must draw wages
All individual market carriers are subject to a 6-month look-back and a 12-month exclusionary period limit on pre-existing health conditions If you are denied coverage for a medical condition, you may be eligible for an MCHA plan, see next column
Monthly Cost
45
Minnesota
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive
GUARANTEED COVERAGE
GUARANTEED COVERAGE
State resident for the six months immediately preceding the completion of your application
Limited assets such as cash, savings, stocks and bonds (except for pregnant women and children)
Have been rejected for individual health coverage within six months of the application either by a health insurance carrier of a licensed insurance agent; or
Various price ranges depending on deductible and what plan you buy
Infants (ages 0-2): 280% FPL Pregnant Women: 275% FPL Children (ages 2-18): 150% FPL Elderly, blind and people with disabilities, Parents (and adults ages 19 and 20): 100% FPL SSI Recipients: 70% FPL Medically Needy Individual: 67% FPL, Couple-62%
Have been treated with the last three years for one of the special “Presumptive Conditions” listed on the MCHA application form
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Clinic and physician, immunizations, ambulance, emergency room services when used for emergency care, inpatient and outpatient hospital care, lab, X-ray, family planning, pregnancy related services, nurse midwife, medical equipment and supplies, Hearing aids, physical, occupational, speech, respiratory and rehabilitative therapy, transportation, mental health services, alcohol and drug treatment, prosthetics, nursing facilities, home health services, hospice, and more Pre-Existing Health Conditions Covered
Have reached age 65 or over and are not eligible for the health insurance benefits of Medicare Program; or
Mini-COBRA: Applies to small businesses with less than 20 employees
Costs depend on employer contribution and ± 25% of the insurance company’s index rate
Professional service, prescription drugs and pharmacy services, mail service, prescription drug program, hospital ambulance, home health care, outpatient, rehabilitation, mental health substance abuse, durable medical equipment and prosthetics, organ and bone marrow transplant, dental infertility services, hospice, reconstructive and restorative surgery, skilled nursing, emergency and more
Disabled are allowed to “spend down” for eligibility
$0 or co-pays for parents
Premiums must be set between 101% - 125% of the weighted average for comparable policies Seven individual plans options, including PPO plans with deductibles of $500, $1000, $2000, $5000, and $10,000, and two different Medicare supplemental policies
800.234.1317
Women
Lower income individuals
Sage Screening Program
MinnesotaCare
Women-InfantChildren (WIC)
800-WIC-4030 800-942-4030 www.health.state.mn.us/divs/ fh/wic/index.html Sage Screening Program: Free screening and follow-up services to uninsured and underinsured women
Twin-Cities Metro Area 651-297-3862 Outside Twin-Cities Metro Area 800-657-3672 www.bridgetobenefits.org MinnesotaCare: Dental services, Doctor and health clinic visits for preventive care, Doctor and health clinic visits for nonpreventive care, Emergency room visits, Inpatient hospital coverage General Assistance: Doctor and clinic visits, routine checkups, family planning, immunizations, inpatient hospital and outpatient surgery, eye exams, prescription drugs, diabetic supplies and equipment, chiropractic care, lab and x-ray services, residential alcohol and drug treatment, and mental health services; families with children can also get dental and vision care
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
800-633-4227
MinnesotaHelp.info 800-333-2433 TTD: 800-627-3529 http://minnesotahelp.info/
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D MinnesotaHelp.info is a Medicare counseling service
Will cover COBRA if employer contributes less than 50% (or spouses’ employer)
Comprehensive preventive and primary care, outpatient and inpatient services
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Coverage
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
General Assistance
Trade Dislocated Workers (TAA recipients)
Program
888-643-2584 888-6-HEALTH www.health.state.mn.us/divs/ hpcd/ccs/mbcccp.htm
651-297-3862 Outside Twin-Cities Metro Area 800-657-3672 TTY: 800-6273529 www.bridgetobenefits.org
Seniors and Disabled
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Sage Screening Program: Income at or below 200% FPL; Age 40 or older; Have no insurance or are underinsured
MinnesotaCare: Children, families, pregnant women, and adults without children can all get MinnesotaCare. You have to live in Minnesota and have a Social Security number. Adults without Children income at or below 200%, Parents of children under 21, Pregnant women and children under 21 income at or below 275% of the FPL. You cannot get MinnesotaCare if you have had health insurance during the last four months unless the insurance was Medical Assistance. After four months without insurance, then you could get MinnesotaCare
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Not enrolled in certain state plans Also see MCHA
Certain veterans must have completed 24 continuous months of service
Eligibility
WIC: Live in Minnesota, have a nutritional need (WIC staff can help you determine this), are a child under 5, a new mom, or a pregnant or breastfeeding woman, Income must be: Family of 1: $1604 , Family of 2: $2159, Family of 3: $2714, Family of 4: $3269, $555 for each additional family member
Must not have access to employer plan that pays 50% of coverage cost.
General Assistance: Must be an adult between ages 21-64, have no dependent children under age 18, live in Minnesota and have income below the limits. For full medical benefits you must have an income at or below 75% of the FPL; If your income is between 75% and 175% you can receive hospital coverage only
WIC: $0 to minimal share of cost
MinnesotaCare: $4 or more
for children, around $22 for adults
$0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
$0 and share of cost and co-pays depending on income level
General Assistance: $0 to minimal share of cost
www.coverageforall.org Minnesota
Monthly Cost
Sage Screening Program: $0
46
Demographic
Private Health Insurance Small businesses (1-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Program
800-234-1317
Group Health
Mississippi Association of Health Underwriters 703-276-0220 www.nahu.org
Up to $5M lifetime maximum, assorted deductibles
Coverage
If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply Pre-Existing Health Conditions Covered
and then
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
COBRA: Coverage available for up to 18 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered
800-234-1317
Individual Plans
Mississippi Association of Health Underwriters 703-276-0220 www.nahu.org
Assorted plans depending on medical needs There is a 12-month lookback and exclusionary period limit for pre-existing conditions in traditional individual market health insurance products in Mississippi Pre-Existing Health Conditions Covered with Some Limitations
Individuals with pre-existing, severe or chronic medical conditions
Low income individuals and families
MCHIRPA
Medicaid
Mississippi Comprehensive Health Insurance Risk Pool Association 601-899 9967 888-820 9400 www.mississippihealthpool.org
601-359-6050 800-421-2408 www.medicaid.ms.gov
Includes hospital services, physician care, limited mental health care, prescription drugs, and other services
Among some of the services: office visits and family planning services, hospital care, outpatient services, prescription drugs eyeglasses, home health services, long term care services, inpatient psychiatric care, non-emergency transportation services, chiropractic services, dialysis services, dental extractions and related treatment, durable medical equipment and medical supplies, hospice services
Benefits for nervous and mental conditions, alcohol and drug services and certain other treatment and services are provided with substantial limitations Prescription coverage doesn’t begin until you have been enrolled in MCHIRPA for 6 months
Pre-Existing Health Conditions Covered
Lifetime Maximum Benefit of $1,000,000 Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
Eligibility
Company size 1-50 employees Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage Owner can count as an employee Owner name on business license must draw wages from the company
GUARANTEED COVERAGE COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for MCHIRPA, see next column
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA.You cannot be eligible for Medicare or other public or group insurance programs
GUARANTEED COVERAGE
GUARANTEED COVERAGE
You have been turned down for coverage by an insurance company in the last 12 months or diagnosed with a health condition that causes insurance companies to automatically reject you; or you were offered coverage by an insurance company, but the policy contained a material underwriting restriction (such as an elimination rider); or offered coverage costing more than an MCHIRPA policy and cannot be eligible for or have other, similar coverage from a private or government health plan (including Medicare and Medicaid) in order to get MCHIRPA coverage
Pregnant Women: 185% FPL Children (ages 1-5): 133% FPL Children (Ages 6-19): 100% FPL Aged, Blind and Disabled: 95% FPL Working Parents: 46% FPL Non-Working Parents: 25% FPL Asset limits for some people Legal Mississippi resident
Eligible for MCHIRPA with HIPAA
Monthly Cost
Legal Mississippi resident
47
Costs depend on employer contribution and ± 25% of the insurance company’s index rate
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Mississippi
Costs for individual coverage varies
Premiums vary based on the plan chosen as well as age and gender. Rates are limited to 175% of regular market rates. Deductible amount varies depending on plan chosen
$0 to $10 co-pays
800.234.1317
Children in moderate income families
Infants
Women
Mississippi CHIP
First Steps
Breast and Cervical Cancer Prevention
601-576-7427 800-451-3903 www.msdh.state.ms.us/ firststeps/home.htm
Women-InfantChildren (WIC)
601-576-7466 800-721-7222 www.msdh.state.ms.us/ msdhsite/_static/41,0,103. html
800-545-6747 www.msdh.state.ms.us/ msdhsite/_static/41.html
Veterans
Medicare
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
877-222-8387 www.va.gov
Program
Children’s Health Insurance Plan 877-543-7669 877-KIDS-NOW www.medicaid.ms.gov/CHIP. aspx
Seniors and Disabled
Demographic
Publicly Sponsored Programs
Medicare Prescription Drug Program 800-633-4227
Mississippi Seniorxms.org 888-948-3090 www.seniorxms.org
Comprehensive benefit package that includes coverage of doctor visits, hospitalization, prescriptions, vision, hearing and dental care, and immunizations Pre-Existing Health Conditions Covered
Screening and/or diagnostic mammograms annually for women 50 years of age and older, ultrasound, fine needle aspiration of the breast and breast biopsy, colonoscopy and biopsy, if indicated Follow-up and referral for abnormal pap exams and/or mammograms
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Mississippi Seniorxms.org offers assistance and advice to Seniors in need.
Coverage
First Steps: Provides family training and counseling, nursing care, nutritional counseling and planning, psychological services in behavior management, learning and mental health, physical therapy to help teach body movement, crawling, walking, occupational therapy to help teach self-help, playing and eating skills, speech pathologist services to help develop language skills, transportation assistance to and from appointments
Pre-Existing Health Conditions Covered
WIC: Nutrition education and services; breastfeeding promotion and education; A monthly food prescription of nutritious foods; and access to maternal, prenatal and pediatric health-care services Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Children up to age 19 with family incomes up to: 200% FPL
First Steps: Any child (under the age of 36 months) of a Mississippi resident who has a 25% or greater developmental delay in any one developmental area
MS resident, U.S. citizen or eligible immigrant
Each adult or child applying must provide his or her Social Security number on the application
Yearly costs range from $50.00 to $100.00 per child, per year up to the first 3 children (no cost for additional children); out-of-pocket maximum limits $0-950 depending on income
First Steps & WIC: $0 or minimal share of cost
GUARANTEED COVERAGE
Cannot have Medicaid, Medicare or other insurance or method of reimbursement
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
$0 and share of cost and co-pays depending on income level
$0 and share of cost and co-pays depending on income level
Women 40-49 qualify for mammograms while funds are available Must be 40-64 years of age for Pap Exam
Certain veterans must have completed 24 continuous months of service
Must be 50-64 years of age for Mammogram 18-44 years of age and have had tubal ligation, hysterectomy or post menopausal
$0 or minimal share of cost
www.coverageforall.org Mississippi
Monthly Cost
$0 to 15 co-pays
WIC: Live in Mississippi, have a nutritional need, are a child under 5, a new mom, or a pregnant or breastfeeding woman, Income must be: Family of 1: $1604 , Family of 2: $2159, Family of 3: $2714, Family of 4: $3269, $555 for each additional family member
GUARANTEED COVERAGE Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Eligibility
Proof of most recent full month's family income, (such as a paycheck stub) must accompany the application.
GUARANTEED COVERAGE
48
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
Low income individuals and families
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Missouri Health Insurance Plan
MO Healthnet
Program
800-234-1317
Group Health
Missouri Association of Health Underwriters 703-276-0220 www.nahu.org
Then convert to
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov
800-234-1317
Individual Plans
(Medicaid) 888-275-5908 www.dss.mo.gov/mhd/index. htm
800-843-6447 800-821-2231 www.mhip.org
Missouri Association of Health Underwriters 703-276-0220 www.nahu.org
or
State Conversion Plans Pre-existing conditions can be excluded for a limited time depending upon the type of group plan you are joining
Coverage
Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage State conversion plans offered through private health insurance market will vary
Covers certain state mandated services Unlimited look-back and 24-month exclusionary period limit for pre-existing conditions Coverage options vary by carrier, but most offer plans that are HSA (Health Savings Account) compatible Pre-Existing Health Conditions Covered with Some Limitations
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Owner can count as an employee
Eligibility
Proprietor-name on license must draw wages
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Medical, dental and vision, prescriptions, hospitalization and more depending on program
For most services, plan will pay for 80% of covered charges after you satisfy your annual deductible if you receive care in-network. After paying maximum amount of coinsurance charges for covered in-network services, MHIP will pay 100% of your covered charges for the rest of the calendar year
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
Hospital, physician care, maternity, prescription drugs, some limitations on alcohol and drug abuse care
Eligibility is based on medical underwriting There is a 12 month look back period during first two years of coverage. If condition is deemed preexisting there can be a 24 month exclusionary period.
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Cannot be eligible for COBRA, or government programs (must have exhausted this option)
Limited assets such as cash, savings, stocks and bonds
Must be Missouri resident
Working parents with household income up to 84% FPL Non-working parents with household income up to 77% FPL Pregnant women and children aged 0-1 up to 185% FPL
Must be resident of state or documented immigrant
Children ages 1-5 up to 133% FPL
If you are denied coverage for a medical condition, you may be eligible for MHIP, see next column
Children ages 6-18 up to 100% FPL Aged, blind, disabled up to 85% FPLL
Monthly Cost
Must be a Missouri resident
49
Costs depend on employer contribution and ± 25% of the insurance company’s index rate
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Missouri
Various price ranges depending on deductible and what plan you buy.
Deductibles: $500, $1000, $2500, and $5000. Also, MHIP charges enrollees different rates based on their age, sex, and the deductible level they choose. MHIP rates cannot be more than twice of the amount that a healthy person would pay if he or she bought a similar plan from the five largest MO insurers
$0 or minimal share of cost
800.234.1317
Children with special needs
Pregnant women and children
Women
Children with Special Health Care Needs (CSHCN)
MO HealthNet for Kids
Show Me Healthy Women
(Medicaid) 888-275-5908 www.dss.mo.gov/mhk/index. htm
573-522-2845 www.dhss.mo.gov/ BreastCervCancer/index.html
Women-InfantChildren (WIC)
573-522-2845 www.dhss.mo.gov/ WISEWOMAN
WISEWoman
573-751-6204 800-392-8209 www.dhss.mo.gov/wic/
Pre-Existing Health Conditions Covered
MO HealthNet for Kids: Comprehensive care including but not limited to doctor visits, mental, dental, prescriptions, hospitalization and more WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services Pre-Existing Health Conditions Covered
Medicare
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
877-222-8387 www.va.gov
Medicare Prescription Drug Program 800-633-4227
MO Senior Rx 800-375-1406 www.morx.mo.gov
Show Me Healthy Women: Women age 50 to 64 or older without Medicare Part B are eligible for a clinical breast examination (CBE), and mammogram, plus a pelvic exam and pap test Women age 35-39 (with no other funding source available) are eligible for a pelvic examination and pap test and CBE, for diagnostic breast services if the CBE results are suspicious for cancer, and for diagnostic cervical services if their initial/follow-up cervical cancer screening was abnormal
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Senior Rx is a prescription discount program
Coverage
Arthritis, burns, cerebral palsy, cleft lip and palate, cystic fibrosis, digestive disorders, ear infections (chronic), hearing disorders, heart disorders, hemophilia, hydrocephalus, neuromuscular disorders, orthopedic disorders, paraplegia, quadriplegia, seizures, sickle cell disease, spina bifida, spinal cord deformities, traumatic brain injury, urinary disorders
Veterans
Program
573-751-6246 800-451-0669 www.dhss.mo.gov/SHCN/ index.html
Seniors and Disabled
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered
WISEWoman: Offers access to health screenings and lifestyle education that can reduce the risk of heart disease and stroke Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Participants must meet both medical and financial eligibility guidelines
MO HealthNet for Kids: Low income children up to 300% FPL and uninsured
Both: Must be MO resident and have legal immigration status
Must reside in Missouri
WIC: pregnant women, nonbreastfeeding postpartum women (up to 6 months after delivery or termination of the pregnancy), breastfeeding women (up to 1 year after delivery as long as they are breastfeeding the baby), infants from birth up to 1 year of age, and children up to their 5th birthday; Income must be at or below 185% FPL
Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Children up to age 21
$0 or share of cost
WIC: $0 or minimal share of cost
Must be uninsured or underinsured with income under 200% of FPL
Senior Rx: To qualify for Senior RX you must have Medicare Part D. If you are single your income must be at or below $21,660 and if you are a married your income must be below $29,140
Both:
$0
Medicare: $0 and share of cost for certain services; deductibles for certain plans
Certain veterans must have completed 24 continuous months of service
$0 and share of cost and
co-pays depending on income level
Senior Rx: $0
www.coverageforall.org Missouri
Monthly Cost
MO HealthNet for Kids: $0 or share of cost. Families will pay no more than 5% of their annual income for premiums in a year.
Women age 35-64 years of age
Eligibility
GUARANTEED COVERAGE
50
Demographic
Private Health Insurance Small businesses (2-50 employees)
Already insured small businesses (2-9 employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
Insure Montana Purchasing Pool
COBRA
U.S. Uninsured Help Line
800-234-1317
Program
Group Health
Montana Association of Health Underwriters 703-276-0220 www.nahu.org
State Auditor’s Office 800-332-6148 406-444-2040 www.sao.mt.gov/ InsureMontana/index.asp
and then
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
Insure Montana Purchasing Pool
Coverage
If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply Pre-Existing Health Conditions Covered
MCHA
800-234-1317
Individual Plans
Montana Comprehensive Health Association 800-447-7828 www.mthealth.org
Montana Association of Health Underwriters 703-276-0220 www.nahu.org
State Auditor’s Office
State Auditor’s Office 800-332-6148 406-444-2040 www.sao.mt.gov/ InsureMontana/index.asp
Up to $5M lifetime maximum, assorted deductibles
Individuals with pre-existing, severe or chronic medical conditions
800-332-6148 406-444-2040 http://sao.mt.gov
Provides a refundable state income tax credit to employers who currently pay some or all of the cost of group health insurance for their employees; Also provides additional Tax Credits when employers pay for insurance for the employee’s spouse or their dependents; Approximately 40% of the available funding per year is designated to the Employer Tax Credit; The funds for tax credits will be distributed on a first come, first served basis until the money is fully allocated
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage (see MCHA for plan details)
Assorted plans depending on medical needs There is a 36-month look-back and 12-month exclusionary period limit for pre-existing conditions in the Montana individual health insurance market Pre-Existing Health Conditions Covered with Some Limitations
Comprehensive plans to choose from, the primary difference is the annual deductible Lifetime maximum of $2,000,000 Waiting period for certain pre-existing conditions may apply Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
Employer already provides employee health insurance
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Monthly Cost
Eligibility
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
51
Owner can count as an employee Owner name on business license must draw wages from the company
Employer has a number of employees that meets the eligibility criteria established by the State Auditor’s Office (between 2–5 employees; adjustable up to 9 depending on take-up and available revenue) The tax credit cannot be more than 50% of premiums paid No employee is paid more than $75,000 per year (owner excluded)
Costs depend on employer contribution and ±25% of the insurance company’s index rate
Costs depend on employer contribution
If you are denied coverage for a medical condition, you may be eligible for MCHA, see next column
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Cannot be eligible for COBRA or any other government programs (except “endstage renal disease” covered under Medicare) Must prove denial of coverage or proof of offer paying 150% higher premium than MCHA May also be automatically eligible with certain health conditions (contact MCHA)
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs
COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Montana
GUARANTEED COVERAGE Eligibility is subject to medical underwriting
Resident in state for at least 30 days
Costs for individual coverage varies
Premiums and deductibles vary depending on plan Deductibles from $1-10K, 80/20 co-payments, $5-13.5K annual maximum member liability
800.234.1317
Low-income individuals & families
Children in moderate income families
Medicaid
Healthy Montana Kids
800-362-8312 www.dphhs.mt.gov/ programsservices/medicaid. shtml
877-KIDS-NOW 877-543-7669 406-444-6971 www.chip.mt.gov
Breast and Cervical Cancer Prevention
888-803-9343 406-444-0063 www.dphhs.mt.gov/ PHSD/cancer-control/ Breast&Cerv-index.shtml
800-433-4298 406-444-4747 www.dphhs.mt.gov/PHSD/familyhealth/nutrition-wic/nutrition-wicindex.shtml
Seniors and Disabled
Trade Dislocated Workers (TAA recipients)
Medicare
Health Coverage Tax Credit
(Age 65 and up) 800-MEDICARE 800-633-4227 www.medicare.gov
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
Program
Women-InfantChildren (WIC)
Women
Demographic
Publicly Sponsored Programs
Medicare Prescription Drug Program 800-633-4227
State Health Insurance Assistance Program (SHIP) 800-551-3191 www.dphhs.mt.gov/sltc/ services/aging/ship.shtml
CHIP: Physician, inpatient and outpatient hospital services, routine sports or employment physicals, general anesthesia services, surgical services clinic and ambulatory health care services, prescriptions, laboratory and radiological services, inpatient, outpatient, and residential mental health services, inpatient, outpatient, and residential substance abuse treatment services dental, vision exams, eyeglasses, hearing exams
Pre-Existing Health Conditions Covered
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Mammograms, clinical breast exams, pap tests and pelvic exams for the early detection of breast and cervical cancer
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and ‘advantage’ plans. It also offers a prescription drug program called Medicare Part D SHIP is a Medicare counseling service
Will cover COBRA if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Coverage
Among the services the Montana program may cover are: treatment by physicians, nurse practitioners, nurse midwives, dentists, denturists, and podiatrists; lab services, including X-rays; inpatient hospital visits; outpatient hospital visits; family planning; nursing facilities; home health care; durable medical equipment; outpatient drugs; mental health; ambulance; and eyeglasses
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Newborn-No Income Limit Children (under 6): 133% FPL Pregnant women: 150% FPL Children (Ages 6-19): 100% FPL
CHIP: Children until age 19; Montana residents; US citizens or qualified aliens; Not currently insured or covered by health insurance in the past 3 months (some employmentrelated exceptions apply); Not eligible for Medicaid , Parents not employed by the State of Montana; Income at or below 250% of the FPL
Must be under the age of 65, not have insurance, be a US citizen and Montana Resident, Income cannot exceed 200% of FPL For more information, please contact your local county office
Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
Supplemental Security Income Recipients: 74% FPL
Working Parents: 58% FPL Medically Needy Couple: 54% FPL Non-Working Parents: 33% FPL
WIC: Must be a Montana resident, a pregnant woman, a breastfeeding woman, or a woman who recently had a baby. Infants from birth to 12 months, or children up to 5 years old are also covered. Income must be at or below 185% FPL
CHIP: Families with incomes above 100 percent of the FPL will pay a small co-payment when services are received, no co-payment for wellbaby or well-child care, including age-appropriate immunizations, and no co-payment for dental or eyeglasses. Max co-payment for any family is $215 per family/yr
$0 or minimal share of cost $0 and share of cost for
certain services; deductibles for certain plans
20% of the insurance premium
WIC: $0 or minimal share of cost
www.coverageforall.org Montana
Monthly Cost
$0 or small share of cost
Not enrolled in certain state plans
Eligibility
Medically Needy Individual: 73% FPL
Must not have access to employer plan that pays 50% of coverage cost.
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Demographic
Private Health Insurance Individuals recently Small businesses covered by an employer (2-50 Employees) health plan U.S. Uninsured Help Line
Program
800-234-1317
Group Health
Nebraska Association of Health Underwriters 402-397-0280 www.neahu.org
COBRA & Mini-COBRA
Individuals & families
Then convert to
U.S. Uninsured Help Line
HIPAA
Individual Plans
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
800-234-1317
Individuals with pre-existing, severe or chronic medical conditions
Low income families and medically needy
NECHIP
Medicaid
402-343-3574 877-348-4304 www.nechip.com
402-471-3121 877-255-3092 TTD: 402-471-9570 www.hhs.state.ne.us/med/ medindex.htm
Comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, transplants, rehabilitation, durable medical equipment, mental health and substance abuse, physical, speech and occupational therapy, dental care, vision care, and preventive care, among other services
Hospital, physician, laboratory and radiology (X-ray) , nurse midwife services, nurse practitioner services, clinic services, family planning, home health agency, personal care aide, medical transportation, ambulance, chiropractic, dental, durable medical equipment, orthotics, prosthetics, and medical supplies prescribed drugs, hearing aid services, therapies: physical, occupational, speech pathology & audiology, podiatry, psychiatric, adult day treatment, mental health and substance abuse, visual, mammograms
Nebraska Association of Health Underwriters 402-397-0280 www.neahu.org
HIPP
Health Insurance Premium Payment 402-471-3121 or
State Continuation Coverage Assorted deductibles
Coverage
There is a 6-month look-back/ 12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Pre-Existing Health Conditions Covered
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium
Up to $5M, assorted deductibles depending on age and residence zone Pre-Existing Health Conditions Covered with Some Limitations
HIPAA: Benefits are based on the program selected and there is no expiration of coverage HIPP: Benefits are the same as what you had with your previous employer. HIPP is a premium assistance program
There are eight different deductible options to choose from; waiting period may apply
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Eligibility
Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage Owner can count as an employee; proprietor name on license must draw wages If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions- not counting birth or adoptionmay apply, (1-6 months respectively)
Pre-Existing Health Conditions Covered
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for NECHIP, see next column
Mini-COBRA: Applies to small businesses with less than 20 employees HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Must be a legal Nebraska resident for at least six months prior to application
Pregnant Mother & Child up to 185% of FPL
Previous coverage terminated for reasons other than nonpayment of premium or fraud or rejected for coverage within previous 6 months
Children 1-5 up to 133% FPL
Infants aged 0-1 (no parents) up to 150% of FPL
Children 6-18 up to 100% FPL
You have one of the specified health conditions covered by the program (full list available on program web site)
Aged, Blind and Disabled: 100% FPL
Cannot be eligible for COBRA, or government programs
Working Parents: 58% FPL
If an individual's prior coverage was through a continuation of coverage policy or contract available under state or federal law (COBRA), a waiver may be available
Medically Needy Individual: 55% FPL
SSI Recipients: 74% FPL
Non-Working Parents: 46% FPL
Medically Needy Couple: 41% FPL
Monthly Cost
HIPP: You may be eligible for HIPP if you have a high-cost health condition (e.g., pregnancy, HIV/AIDS), and are on Medicaid
53
Costs depend on employer contribution and± 25% of the insurance company’s index rate
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Nebraska
Costs depend on age and county/zone If you are self-employed and buy your own insurance you are eligible to deduct 100% of the cost of the premium from your federal income tax
Premiums vary based on the plan and deductible you choose and underwriting guidelines, can be around 135% of regular rates
$1-$3 and may share in some
costs
800.234.1317
Low income children
Women
Native American Indians
Kids Connection Program
Nebraska Every Woman Matters Program
Indian Health Services
800-532-2227 402-471-0929 TTD: 800-833-7352 www.hhs.state.ne.us/hew/ owh/ewm
605-226-7531 www.ihs.gov
Trade Dislocated Workers (TAA recipients)
Medicare
Health Coverage Tax Credit
(Age 65 and up) 800-MEDICARE 800-633-4227 www.medicare.gov
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
Medicare Prescription Drug Program
Women-InfantChildren (WIC)
Program
(SCHIP) 402-471-8845 877-NEB KIDS 877-632-5437 www.hhs.state.ne.us/med/ kidsconx.htm
Seniors and Disabled
Demographic
Publicly Sponsored Programs
800-633-4227
800-942-1171 402-471-2781 www.dhhs.ne.gov/wic
Pelvic exam with a pap test, clinical breast exam, teaching of breast self exam, blood pressure check, cholesterol check, blood sugar (glucose) check, mammogram
Care includes medical, nursing, dental, optometry, nutrition, health education, community health nursing, mental health, social services, substance abuse, and environmental health services, well-child, chronic diseases, allergy, women's health, and podiatry pharmacy, laboratory and radiology services are all provided at the centers, including in-patient and specialty care with providers in neighboring areas
Medicare offers two standard plans, A: Hospital Insurance and B: Medical Insurance, as well as several supplemental and 'advantage' plans Pre-Existing Health Conditions Covered
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Coverage
KCP: Hospital services, physician services, laboratory and radiology (X-ray), clinic, family planning, health checks, home health agency, medical transportation, ambulance, chiropractic dental, durable medical equipment, orthotics, prosthetics, and medical supplies, prescribed drugs, hearing aid, therapies, physical, occupational, speech pathology & audiology, podiatry mental health and substance abuse, visual
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
KCP: Must not be eligible for Medicaid
Women 40 - 64 years of age
Winnebago and Omaha tribes, as well as others
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
19 years of age or younger
Do not have Medicaid
Household income of 200% FPL
Do not have Medicare
WIC: A pregnant woman, A breastfeeding woman, A woman who recently had a baby, An infant, birth to 12 months, or A child, up to age 5 years. Determined by a health professional to be at nutritional or medical risk, Reside in Nebraska, Below 185% of FPL
Have a low to medium income (Approximately 100% of FPL for free services; woman up to approximately 225% of the FPL can still receive services for a suggested $5 donation)
KCP: $0 for most members
$0 or small share of cost
WIC: $0 to minimal share of cost
Must not have access to employer plan that pays 50% of coverage cost. Not enrolled in certain state plans Also see NCHA
$0 or minimal share of cost
$0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
www.coverageforall.org Nebraska
Monthly Cost
Do not belong to an HMO (Health Maintenance Organization)
Eligibility
State resident and/or qualified immigrant
54
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Low income individuals and families
Children
U.S. Uninsured Help Line
COBRA/ Mini-COBRA
U.S. Uninsured Help Line
NV Medicaid
Nevada Check Up
Group Health
Then convert to
Individual Plans
Program
800-234-1317
Nevada Association of Health Underwriters 703-276-0220 www.nahu.org
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov
800-234-1317
Nevada Association of Health Underwriters 703-276-0220 www.nahu.org
775-684-3600 800-992-0900 http://dwss.nv.gov/ To find address and phone number of welfare office near you: http://dwss.nv.gov/index. php?option=com_content&ta sk=view&id=122&Itemid=319
877-KIDS-NOW (877-543-7669) 800-360-6044 775-684-3777 www.nevadacheckup.state. nv.us
Women-InfantChildren (WIC)
800-8-NEV-WIC 800-863-8942 http://health.nv.gov/WIC.htm
Or
State Conversion Plans www.doi.state.nv.us
Coverage
Assorted plans Carriers can impose a 6-month look-back/12-month exclusionary period for preexisting health conditions on enrollees who do not have prior creditable coverage Pre-Existing Health Conditions Covered
COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Up to $5M, assorted deductibles depending on age and residence zone Carriers do not have limits on how far back they can look at pre-existing health conditions Limits on Pre-Existing Health Conditions May Apply
Diagnosis (services to find out what is wrong), physician services, check-ups (medical and dental), family planning, maternity, prenatal, and newborn care, prescriptions, hospital services, comfort care, hospice, dental services, drug and alcohol treatment, mental health services Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage Owner can count as an employee
Eligibility
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
Proprietor-name on license must draw wages
Eligibility is subject to medical underwriting HIPAA eligible must be offered two standard policies
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Child to age 5: 133% FPL
NV Check Up: Must not be eligible for Medicaid.If not covered by employer health plan (with employer paying 50% of premium); 19 and younger, Household income between 100-200% of FPL; Eligibility is determined for one year unless child moves out of state, is enrolled in Medicaid, has other coverage, or becomes financially ineligible
Child age 6-19: 100% FPL Non-working parents: 26% FPL Working parent: 91% FPL Pregnant woman: 133% FPL
WIC: Reside in Nevada, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family of 1: $1,670 , Family of 2: $2,247, Family of 3: $2,823, Family of 4: $3,400, $555 for each additional family member
Monthly Cost
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
55
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Nevada
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services Pre-Existing Health Conditions Covered
Mini-COBRA: Applies to small businesses with less than 20 employees
Costs depend on employer contribution and ± 25% of the insurance company’s index rate
NV Check Up: Well baby/well child visits, prescription drugs, mental health benefits, immunizations, dental and vision services
Costs depend on age and county/zone If you are self-employed and buy your own insurance you are eligible to deduct 100% of the cost of the premium from your federal income tax
$0 may share in some costs
NV Check Up: $0 for most. Depending on your family income you could pay a quarterly premium of $25-$80. You are not required to pay co-payments, deductibles, or other charges for covered services. WIC: $0 or minimal share-ofcost
800.234.1317
Publicly Sponsored Programs Women
Early Intervention Services
Women’s Health Connection
800-522-0066 http://health.nv.gov/BEIS.htm
Maternal Child Health Line
800-429-2669 http://health.nv.gov/MCHL_ InfantChildCare.htm
WHC: Some diagnostic services such as ultrasound, breast biopsy, surgical consultation, colonoscopy Cancer treatment for some women qualified through Medicaid MHL: Provides prenatal care and other maternity services
Pre-Existing Health Conditions Covered
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
800-633-4227
Senior Rx
866-303-6323 775-687-8711 http://www.dhhs.nv.gov/ SeniorRx.htm
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer)
Senior RX: Offers extra coverage for medication. There are plans for seniors with Medicare Part D and for seniors without Medicare Part D
Pre-Existing Health Conditions Covered
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Comprehensive preventive and primary care, outpatient and inpatient services. Pre-Existing Health Conditions Covered
Coverage
Audiology (hearing) services family training, counseling and home visits, health services, medical services for diagnostic or evaluation purposes, nutrition counseling, occupational therapy, physical therapy, psychological services, service coordination, social work services, special instruction, speech and language services, transportation services, vision and more
Trade Dislocated Workers (TAA recipients)
Program
888-463-8942 775-684-4285 http://health.nv.gov/CD_WHC_ BreastCervical_Cancer.htm
Seniors and Disabled
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Must live in state
WHC: Age 40 or older (over 50 for annual mammogram)
Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Children who have one of the covered diagnosed developmental disorders or show significant delays in development such as talking or walking
Under-insured or uninsured Income below 250% FPL MHL: Contact program
scale
Medicare: $0 and share of cost for certain services; deductibles for certain plans
Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
20% of the insurance premium
$0 and share of cost and
co-pays depending on income level
Senior RX: $0 or minimal shareof-cost
www.coverageforall.org Nevada
Monthly Cost
$0 and share of cost sliding
Must not have access to employer plan that pays 50% of coverage cost
Eligibility
Senior RX: Age 62 or older, Seniors with an income at or below $25,477 if you are single and at or below $33,963 if you are a married couple.
Contact program for financial eligibility criteria
$0 or minimal share-of-cost
Demographic
Children with developmental delays
56
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
U.S. Uninsured Help Line
COBRA/ Mini-COBRA
U.S. Uninsured Help Line
New Hampshire Health Plan
Group Health
Then convert to
Individual Plans
Program
800-234-1317
National Association of Health Underwriters 703-276-0220 www.nahu.org
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov
800-234-1317
National Association of Health Underwriters 703-276-0220 www.nahu.org
Low income individuals and families Medicaid
603-271-5254 800-852-3345 x5254 www.dhhs.state.nh.us/ dhhs/medicaidprogram/ default.htm
877-888-NHHP 877-888-6447 www.nhhealthplan.org
Catastrophic Illness Plan
603-271-4495 800-852-3345 ext. 4495 www.dhhs.state.nh.us/dhhs/ beas/cip.htm
Or
State Conversion Plans
Coverage
Assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions- not counting birth or adoption- may apply, (1-6 months respectively) Pre-Existing Health Conditions Covered
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
Up to $5M, assorted deductibles depending on age and residence zone Limits on Pre-Existing Health Conditions May Apply
COBRA Subsidy: 15 months of partially subsidized COBRA premium
CIP: Meant to provide financial assistance to persons with cancer, hemophilia, end stage renal disease, cystic fibrosis, spinal cord injuries, and other serious illnesses or injuries. Assistance is limited to $2,500 per individual per year.
HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage
Eligibility
Owner can count as an employee Twice annually, self-employed persons can be a small group health plan with guarantee issue Proprietor name on license must draw wages
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for NHHP, see next column
Mini-COBRA: Applies to small businesses with less than 20 employees
Monthly Cost
57
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column
New Hampshire
Diagnosis (services to find out what is wrong), physician services, check-ups (medical and dental), family planning, maternity, prenatal, and newborn care, prescriptions, hospital services, comfort care, hospice, dental services, drug and alcohol treatment, mental health services Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
NHHP: Declined for health coverage because of health or medical condition Offered Coverage that is the same as NHHP but at a higher premium. You have a pre qualifying medical condition (see list on web site); Previous coverage terminated for reasons other than non-payment of premium or fraud; Federally eligible or certified as eligible for TAA or PBGC assistance; Cannot be eligible for COBRA, or government programs; New Hampshire resident
Infant: 300% FPL Child Age 1-19: 185% FPL Pregnant woman: 185% FPL Non-working parents: 41% FPL Working parent: 51% FPL Medically needy individual: 76% FPL Medically needy couple: 70% FPL
CIP: A New Hampshire Resident; A US citizen, or the parent or guardian having primary responsibility for the applicant child is a US citizen; Must be age 21 or over, Must have one of the covered health conditions
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA Costs depend on employer contribution and the Modified Community Rate
NHHP: Choose from seven plan options each with a different deductible. Hospitalization, physician care, diagnostic tests, x-rays, prescription drugs, and some mental health care services
Costs depend on age and county/zone. If you are self-employed and buy your own insurance you are eligible to deduct 100% of the cost of the premium from your federal income tax.
NHHP: Premiums vary based on the plan and deductible you choose (approximately 150% of similar plans offered to a healthy individual through private insurance options)
$0 may share in some costs
CIP: $0 to minimal share of cost
800.234.1317
Children in moderate income families
Women
Healthy Kids
Let No Woman Be Overlooked Program 800-852-3345 x4931 603-271-4931 www.dhhs.nh.gov/dhhs/cdpc/ bccp.htm
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
NH Senior Prescriptions Discounts
800-942-4321 603-271-4546 www.dhhs.state.nh.us/dhhs/ wic/default.htm
888-580-8902
Women age 18 and younger receive free Pap tests Women age 40 and over receive free mammograms every 1-2 years Cancer treatment for some women qualified through Medicaid
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer)
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Coverage
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Veterans
800-633-4227 www.expressscript.com
Women-InfantChildren (WIC)
HK: Hospital and physician care, prescription drugs, mental health care, and some other services
Trade Dislocated Workers (TAA recipients)
Program
877-464-2447 603-228-2925 www.nhhealthykids.com or www.dhhs.nh.gov/dhhs/ medassistelig/eligibility/d4.htm
Seniors and Disabled
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
HK: New Hampshire Resident, a U.S. citizen, a refugee, an asylee, or a permanent resident who has been in the U.S. for at least five years; Must not be eligible for Medicaid; Children age 1-18 who are at or below 185% FPL and infants at 300% FPL qualify for Healthy Kids Gold Program; Children age 1-18 between 185-400% FPL qualify for Silver or Buy-In Programs
Have income less than 250%
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
$0 and share of cost for
20% of the insurance premium
$0 and share of cost and
Women under age 40 are eligible for a clinical breast exam, pelvic exam and Pap smear, and a mammogram when a breast lump is found during a clinical breast exam or a breast self exam
Must not have access to employer plan that pays 50% of coverage cost
Women ages 40 to 64 are eligible for a clinical breast exam, pelvic exam, Pap smear and mammogram Women age 65+ are eligible for a clinical breast exam, pelvic exam, Pap smear and mammogram when not eligible for the Medicare program or not enrolled in Medicare Part B
$0 or nominal co-payment
certain services; deductibles for certain plans
co-pays depending on income level
WIC: $0 to minimal share of cost
www.coverageforall.org New Hampshire
Monthly Cost
HK: $0 for Gold Program. Monthly premium for Silver Program is based on family size and household income.
Under-insured or uninsured
Eligibility
WIC: Reside in New Hampshire, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be at or below 185% FPL
Demographic
Publicly Sponsored Programs
58
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
U.S. Uninsured Help Line
COBRA & Mini-COBRA and then
U.S. Uninsured Help Line
Individual Health Coverage Program
HIPAA
Individual Plans
Program
800-234-1317
Group Health
New Jersey Association of Health Underwriters www.njahu.org
Coverage
Carriers can impose a 6-month look-back/6-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage (this may only apply to certain groups) Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
800-234-1317
New Jersey Association of Health Underwriters www.njahu.org
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
Assorted plans depending on medical needs
COBRA Subsidy: 15 months of partially subsidized COBRA premium
There is a 6-month look-back and a 12-month exclusionary period limit for pre-existing conditions
HIPAA: Benefits are based on the program selected and there is no expiration of coverage (see IHC for plan details)
All carriers must guarantee issue coverage to all individuals
Pre-Existing Health Conditions Covered with Some Limitations
Pre-Existing Health Conditions Covered
(IHC) 609-633-1882 www.state.nj.us/dobi
All plans cover the following office visits, hospital care, prenatal and maternity care, immunizations, well-child care, screenings (including mammographies, pap smears and prostate examinations), X-ray and laboratory services, certain mental health and substance abuse services, prescription drugs Individuals are subject to a 12 month waiting period for coverage of preexisting conditions
Low income individuals and families Medicaid
800-356-1561 609-588-2600 www.state.nj.us/ humanservices/dmahs/home/
Inpatient and outpatient hospital treatment, laboratory tests and X-rays, early and periodic screening, diagnostic and treatment services, home health care, physician services, nursemidwife services, assistance with family planning and any necessary supplies, nursing facilities for people over 21 Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees (including owner)
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
New Jersey resident
Resident of New Jersey at least 6 months
Infants (ages 0-1): 200% FPL (mother is enrolled in Medicaid at the time of birth. If not, infants with family incomes of 185% FPL)
Two employees must work for at least 6 months out of the year, and work 25 hours per week for coverage
Monthly Cost
Eligibility
Most carriers require the most recent copy of NJ’s quarterly wage and tax filing form
59
Costs depend on employer contribution and the Modified Community Rate
Medical underwriting is not allowed If you are denied coverage for a medical condition, you may be eligible for IHC, see next column
Not eligible for coverage under a group health plan, governmental plan or church plan Not eligible for coverage under Medicare
Children (ages 1-19): 133% FPL Pregnant Women: 185% FPL (Expanded coverage for women with incomes between 186 and 200% may also be available) Qualified Parents: 100% FPL
Mini-COBRA: Applies to small businesses with less than 20 employees
Medically Needy Individual: 51% FPL Medically Needy Couple: 45% FPL
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs
SSI Recipients: 74% FPL Aged, Blind and Disabled: 100% FPL
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Costs for individual coverage varies
Costs vary based on selected carrier and plan (premiums, deductibles and co-pays)
$0 or small share of cost
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
New Jersey
800.234.1317
Moderate income families
Women
NJ Family Care Program
Cancer Education and Early Detection
800-701-0710 www.njfamilycare.org
866-44 NJ WIC 866-446-5942 609-292-9560 www.state.nj.us/health/fhs/ wic/index.shtml
Trade Dislocated Workers (TAA recipients)
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
(Age 65 and up) 800-MEDICARE 800-633-4227 www.medicare.gov
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
Program
Women-InfantChildren (WIC)
(CEED) 609-292-8540 800-328-3838 www.state.nj.us/health/cancer/ njceed/index.shtml
Seniors and Disabled
Demographic
Publicly Sponsored Programs
Medicare Prescription Drug Program 800-633-4227
Senior Gold Program 800-792-9745 www.nj.gov/health/ seniorbenefits/paadapp.htm
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Screening mammograms, clinical breast examinations, instructions on breast self-examinations, Pap tests, and pelvic examinations. Diagnostic tests such as needle biopsies, breast ultrasounds and colonoscopies. Case management, tracking and follow-up are provided to all women and major emphasis is placed on rescreening women who are currently being served by the program
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D Senior Gold: is a state funded prescription discount program
Will cover COBRA if employer contributes less than 50% (or spouses’ employer)
Comprehensive preventive and primary care, outpatient and inpatient services
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Pre-Existing Health Conditions Covered
Coverage
NJ Family Care: Physician services, preventive health care, emergency medical care, inpatient hospital services, outpatient hospital services, laboratory services, prescription drugs, eyeglasses, dental services in most cases, emergency transportation, mental health services and more
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
NJ Family Care: Uninsured children age 18 or younger with family incomes of up to 350% FPL
Income below 250% of FPL
Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Uninsured or under-insured
Qualified parents at or below 200% FPL
premiums and $0-35 co-pays depending on income WIC: $0 to minimal share of cost
$0 or minimal share of cost
$0 and share of cost for
certain services: deductibles for certain plans
Not enrolled in certain state plans Also contact Aetna of New Jersey
20% of the insurance premium
Certain veterans must have completed 24 continuous months of service
$0 and share of cost and
co-pays depending on income level
Senior Gold: $0 to minimal share of cost
www.coverageforall.org New Jersey
Monthly Cost
NJ Family Care: $0-128
Senior Gold: at least 65 years old, OR at least 18 years old and receiving Social Security Disability Title II benfits, income restrictions
Eligibility
WIC: Reside in New Jersey, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family of 1: $1604 , Family of 2: $2159, Family of 3: $2714, Family of 4: $3269, $555 for each additional family member
Must not have access to employer plan that pays 50% of coverage cost.
60
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Individuals Below 200% FPL
U.S. Uninsured Help Line
COBRA & New Mexico State Continuation
U.S. Uninsured Help Line
State Coverage Insurance (SCI)
Program
800-234-1317
Group Health
Conversion Coverage
Small Employer Insurance Program (SEIP)
HIPAA
Up to $5M lifetime maximum, assorted deductibles
Coverage
Or
New Mexico State Association of Health Underwriters www.nmsahu.org
866-901-4538 http://www.generalservices. state.nm.us/rmd/seip.html
If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply SEIP: Annual claims limit of $100,000 per enrollee Pre-Existing Health Conditions Covered
Or
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
(Waitlist is currently open The program and enrollment will be closed until further notice from the New Mexico legislature.)
INSURE New Mexico! Solutions 888-997-2583 www. insurenewmexico.state. nm.us/
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
SEIP: Offer plans to small groups and has special rules
New Mexico State Association of Health Underwriters www.nmsahu.org
888-997-2583 http://insurenewmexico.net
HIPAA: Benefits are based on the program selected and there is no expiration of coverage (benefits are similar to the NM Health Insurance Alliance or the NM Medical Insurance Pool)
COBRA Subsidy: 15 months of partially subsidized COBRA premium
GUARANTEED COVERAGE
Owner name on business license must draw wages from the company
Individual Plans
Up to $5M, assorted deductibles depending on age and ZIP code Pre-Existing Health Conditions Covered with Some Limitations
Individuals with pre-existing, severe or chronic medical conditions NMMIP
Benefits are limited to $100,000 payable per member per benefit year; Doctor visits; pre/post natal care; Preventive Services; Hospital Inpatient & Outpatient; Home Health; Physical, Occupational & Speech therapy; Medical supplies; Emergency Services; Urgent Services; Prescription Drugs; Diabetes Treatment; and behavioral health and substance abuse
Company size 2-50 employees
Owner, partners can count as an employee
800-234-1317
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
GUARANTEED COVERAGE
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Eligibility
Private/Public Program
New Mexico Medical Insurance Pool 888-997-2583 505-424-7105 800-432-0750 (Option #4) www.nmmip.com
New Mexico Health Insurance Alliance (The “Alliance”) 800-204-4700 888-997-2583 www.nmhia.com
NMMIP: Hospital and physician care, prescription drugs, and other services, limited home health visits and organ transplant coverage are available, there is no lifetime maximum per member except for certain benefits (e.g., $250,000 lifetime maximum per member for organ transplant), and maternity coverage is available The Alliance: Offers HMO, PPO and indemnity plans Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Eligibility is subject to medical underwriting
Uninsured adults between the ages of 19-64
NMMIP: Must be a resident of New Mexico
If you are denied coverage for a medical condition, you may be eligible for NMMIP, see the "Individuals with preexisting, severe or chronic medical conditions" column
At or under 200% FPL
You are eligible if your previous coverage was terminated for reasons other than non-payment or fraud
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA For HIPAA, you cannot be eligible for Medicare or other public insurance programs
Not eligible for certain government health insurance benefits (i.e. Medicaid, Medicare, CHAMPUS) Do not have other private or public health insurance
Must prove denial of coverage or offer of higher premium than NMMIP You are also eligible if you have a qualifying medical condition or have reached the maximum allowable coverage limit of your current health insurance plan
No asset test for eligibility New Mexico resident
The Alliance: Must be HIPAA eligible Do not have any health plan available, but have had 18 months of creditable coverage
Monthly Cost
In addition, if you have a policy from the Alliance, you can transfer into NMMIP
61
Costs depend on employer contribution and ± 20% of the insurance company’s index rate SEIP: Premium determined buy age, gender, and geographic location. Employers must contribute at least 50% of the monthly premium
New Mexico
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Costs for individual coverage vary according: age, gender, smoking and geographic location
Employer pays a portion ($0 to $75) of the monthly premium, the employee pays a portion ($0 to $35) of the monthly premium, and if you make less than 100% FPL the state contributes the premium payment. Individuals without an employer group pay both the employer and employee premium share which is either $0 or $95 or $110 depending on their income
NMMIP: Premiums vary according to income level. Assistance available for individuals up to 400% FPL Rates cannot be more than 25% higher than the average a healthy person would pay for a similar plan sold by a private NM insurer The Alliance: Alliance premiums for individuals are usually about 9% higher than premiums charged for similar coverage
800.234.1317
Low-income individuals & families Medicaid
888-997-2583 505-827-3100 www.state.nm.us/hsd/mad
Pregnant Women
Women
New Mexikids
Premium Assistance for Maternity (PAM)
Breast & Cervical Cancer Early Detection Program
Indian Health Services
Offers clinical breast exams (CBE), pelvic exams , mammograms (every two years for women 40-49, yearly for women 50 and older, or when medically indicated) , pap tests, as well as some additional breast and cervical tests if needed, such as ultrasound, biopsies, and other services
In New Mexico, the tribes served are the 19 Pueblos, the Jicarilla and Mescalero Apaches, and the Alamo, Canoncito and Ramah Chapters of the Navajo Nation. Headquarters of the Area are located in Albuquerque. Most health facilities are strategically located near population centers and include 5 hospitals, 11 health centers, and 12 field clinics. The Area’s extensive network provides the Indian people a wide array of inpatient and outpatient services.
888-997-2583 www.insurenewmexico.state. nm.us/default.aspx or www.newmexicokids.org
Premium Assistance for Kids (PAK) 888-997-2583 www.insurenewmexico. net/pakhome.htm
888-997-2583 www.insurenewmexico. state.nm.us/PAMHome.htm
Native American Indians
505-248-4500 www.ihs.gov
877-852-2585 www.cancernm.org/bcc
Program
Or contact local county social services agency
Children in moderate income families
Demographic
Publicly Sponsored Programs
Medicaid
888-997-2583 www.state.nm.us/hsd/mad
Women-InfantChildren (WIC)
866-867-3124 www.health.state.nm.us/phd/ wicsite/index.php Offers health, dental, vision, and prescription coverage Pre-Existing Health Conditions Covered
PAM: Pre- & Post-Natal Care, delivery, and pregnancyrelated health services.
PAK: Medical underwriting applies so pre-existing health conditions are not covered. Provides assistance with payment of the premium for commercial, comprehensive child health insurance, which usually includes preventive,primary and specialty care, inpatient and outpatient hospitalization, pharmacy, labs and x-rays, physical, occupational and speech therapy.
Medicaid: Offers health, dental, vision, and prescription coverage
Pre-Existing Health Conditions Covered
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services Pre-Existing Health Conditions Covered
If diagnosed with a cancerous or precancerous condition through the BCC Program, you may be eligible for full Medicaid services which include the cost of cancer treatment
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Ages 0-19: up to 235% FPL
New MexiKids: Children ages 0-19 between 185%-235% FPL Must be ineligible for no-cost Medicaid or employer-based coverage
PAM: Income must be too high to qualify for Medicaid. Must be pregnant, a resident of New Mexico and a U. S. citizen
Women age 30 and over
Tribal members from throughout the United States who live, work, or go to school in the urban centers of the area
PAK: Children ages 0-12 or up to age 18 if part of a sibling group that includes a child below age 12. Income must be too high to qualify for Medicaid and SCHIP
Medicaid: Pregnant women can have an income up to 185% of the FPL.
Have no health insurance or have health insurance, but deductibles and/or co-pays are too high
New MexiKids: may require a co-payment at the time each service is provided. Co-payments range from $2-$25 depending on the services, and Native Americans are exempt
PAM: One time premium of either $150 or $300. No co-payments or deductibles.
Pregnant: up to 185% FPL Supplemental Security Income Recipients-74% of FPL Working Parents: up to 69% FPL Non-Working Parents: up to 30% FPL
Parents: up to 31% FPL
Live at or below 250% of the federal poverty threshold
WIC: Reside in New Mexico, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be at or below 185% FPL
Eligibility
Working Parents: up to 71% FPL
Live in state
$0 or minimal share of cost
Coverage
New Mexikids & PAK: Doctor visits, hospital care, prescriptions, and vision, hearing, and dental care.
$0 or share of cost
$0 or share of cost
PAK: The state generally pays 50% of the premium while the family pays 50% per child. Full premiums are approximately between $70-180 monthly per child. Deductibles and co-payments apply.
www.coverageforall.org New Mexico
Monthly Cost
Medicaid & WIC: $0 or minimal share of cost
62
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
U.S. Uninsured Help Line
COBRA/Mini-COBRA
Program
800-234-1317
Group Plans
New York State Insurance Department 800-342-3736 www.ins.state.ny.us/chealth. htm
Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
Monthly Cost
63
Individuals & families
Low income individuals and families
Healthy NY
U.S. Uninsured Help Line
Medicaid
866-HEALTHY NY (866-432-5849) www.healthyny.com
Individual Plans
HIPAA
COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered
800-541-2831 877-472-8411 718-557-1399 www.health.state.ny.us
New York State Insurance Department 800-342-3736 www.ins.state.ny.us/chealth. htm
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
COBRA or Mini-COBRA: Coverage available for up to 18 months depending on qualifying events, benefits are the same as what you had with your previous employer
800-234-1317
Inpatient and outpatient hospital services; physician services; maternity care; preventive health services; diagnostic and x-ray services; and emergency services. Applicants may choose a benefit package with or without a limited prescription benefit High Deductible Plan now available
Assorted plans depending on medical needs All carriers must guarantee issue coverage to all individuals, including two comprehensive standardized plans There is a 6-month look-back and a 12-month exclusionary period limit for pre-existing conditions
Pre-Existing Health Conditions Covered with Some Limitations
No medical underwriting Pre-Existing Health Conditions Covered
Smoking cessation agents treatment and preventive health and dental care, hospital inpatient and outpatient services, laboratory and X-ray, nursing home, home health agencies and personal care, treatment in psychiatric hospitals, mental health facilities, family planning, early periodic screening, diagnosis, and treatment for children, medical equipment, and appliances, transportation to medical appointments, emergency ambulance, pre-natal care and other health services Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees (including owner)
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Must reside in New York and you or your spouse must either be currently employed or must have been employed within the past 12 months.
New York resident
Pregnant women and infants (ages 0-1): 200% FPL
Eligibility
Coverage
Carriers can impose a 6-month look-back/6-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage (this may only apply to certain groups)
or
Small businesses & working individuals
Mini-COBRA: Applies to small businesses with less than 20 employees
Costs depend on employer contribution and the Community Rate
New York
Medically Needy Couple: 93% FPL, Individual: 87% FPL,
Uninsured for the 12-month period preceding application or have lost that coverage due to a qualifying event 30% of the employees must earn wages of $40,000 or less
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
$0 for some services and $500 for hospital stays,
Qualified Parents: 150% FPL Children (ages 1-5): 133% FPL Children (ages 6-19): 100% FPL
Do not have access to employer health insurance or Medicare
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Medical underwriting is not allowed
SSI Recipients: 74% FPL Individuals may also own a home, a car, and personal property and still be eligible. The income and resources of legally responsible relatives in the household will be counted, limits on cash resources
Individuals and Sole Proprietors must have an income at or below 250%
Costs for individual coverage varies
$0 or small share of cost
monthly premiums vary but the amounts of the co payments and deductible are the same for each health plan The 2010 deductible amounts are $1,200 for individual coverage and $2,400 for family coverage for the High Deductible Plan
800.234.1317
Low and moderate income children and families Child Health Plus 800-698-4KIDS 800-698-4543 www.health.state.ny.us/ nysdoh/chplus/
877-9FHPLUS (877-934-7587) www.health.state.ny.us/ nysdoh/fhplus/
Seniors and Disabled
Trade Dislocated Workers (TAA recipients)
Veterans
Breast, Cervical, Colorectal and Prostate Cancer Program
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-4CANCER 800-422-6237 www.health.state.ny.us/ nysdoh/bcctp/bcctp.htm
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
Program
Family Health Plus
Adults
Demographic
Publicly Sponsored Programs
800-633-4227
New York Elderly Pharmaceutical Insurance Coverage (EPIC) Program 800-332-3742
Screening, treatment and comprehensive health care through Medicaid Pre-Existing Health Conditions Covered
Medicare: Offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D EPIC: A state funded prescription discount program
Will cover COBRA if employer contributes less than 50% (or spouses’ employer)
Comprehensive preventive and primary care, outpatient and inpatient services
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Pre-Existing Health Conditions Covered
Coverage
Well-child care, physical exams, immunizations, diagnosis and treatment of illness and injury, x-ray and lab tests, outpatient surgery, emergency care, prescription and non-prescription drugs if ordered, inpatient hospital medical or surgical care, short-term therapeutic outpatient services (chemotherapy, hemodialysis), limited inpatient and outpatient treatment for alcoholism and substance abuse, and mental health, dental, vision, speech and hearing, durable medical equipment, emergency ambulance transportation to a hospital, hospice
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Both: Residents of New York State and are United States citizens or fall under one of many immigration categories
For Breast/Cervical: Be 18 years of age or older; Be in need of treatment for breast and/ or cervical cancer or a precancerous condition
Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
FHP: adults between the ages of 19 and 64 who do not have health insurance - either on their own or through their employers - but have income or resources too high to qualify for Medicaid; Single Adult & Couples with no children-100% of the FPL, Parents/Guardians Living with at Least 1 Child Under 21-150% of the FPL
FHP: $0
EPIC: Seniors with other prescription coverage through Medicare or most other plans can join EPIC to cover drug costs not covered by that other coverage
Not enrolled in certain state plans Contact any HMO or Healthy New York Program
Certain veterans must have completed 24 continuous months of service
Both: Have income that is at or below 250% Federal Poverty Level (FPL); Not be covered under any creditable insurance; Be ineligible for Medicaid under other eligibility groups; Be a resident of New York State; and Be a U.S. citizen or an alien with satisfactory immigration status
$0 or minimal share of cost
$0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
$0 and share of cost and co-pays depending on income level
www.coverageforall.org New York
Monthly Cost
CHP: $0-60 premiums and no co-pays
For Colorectal/Prostate: Be screened and/or diagnosed through a CSPP partnership or CSPP provider; Be under 65 years of age; Need treatment for colorectal and/or prostate cancer or pre-cancerous condition
Must not have access to employer plan that pays 50% of coverage cost
Eligibility
CHP: Uninsured children age 18 or younger with family incomes of up to 400% FPL. Families with incomes above 400% FPL can pay the full premium for CHP.
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Demographic
Private Health Insurance Small businesses (1-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
Low-income individuals & families
U.S. Uninsured Help Line
COBRA & MiniCOBRA
U.S. Uninsured Help Line
Inclusive Health
Medicaid
Program
800-234-1317
and then
Group Plans
North Carolina Association of Health Underwriters 703-276-0220 www.ncahu.org
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
800-234-1317
Individual Plans
North Carolina Health Insurance Risk Pool 866-665-2117 www.inclusivehealth.org
800-662-7030 919-855-4400 (for Wake County) TTY: 919-733-4851 www.dhhs.state.nc.us/dma/ medicaid/
North Carolina Association of Health Underwriters 703-276-0220 www.ncahu.org
or
Conversion Plans
Coverage
All group health insurance carriers can impose a 6-month look-back/ 12-month exclusionary period for preexisting conditions on enrollees that do not have prior creditable coverage Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Assorted plans depending on medical needs There is a 6-month look-back and exclusionary period limit for pre-existing conditions in traditional individual market health insurance products Pre-Existing Health Conditions Covered with Some Limitations
Monthly Cost
May have a 6 to 12 month waiting period for pre-existing conditions Lifetime benefit maximum of $1,000,000
Inpatient hospital services outpatient hospital services, prenatal care; vaccines for children; physician services, nursing facility services for persons aged 21 or older. Family planning services and supplies; rural health clinic services; home health care for persons eligible for skilled nursing services; laboratory and x-ray services; pediatric and family nurse practitioner services; nurse-midwife services and possibly more
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 1-50 employees (including owner)
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Not eligible Medicaid or Medicare; Legal resident of the US and currently reside in North Carolina; Have been a continuous resident of North Carolina for at least 30 days; Do not have access to group coverage as an employee or as a dependent of an employee; Either rejected or refused by an insurer for similar coverage due to medical reasons, offered coverage by an insurer but with a conditional rider limiting coverage, offered coverage at higher premium rate, have been diagnosed with a medical condition that is outlined by Inclusive Health allowing automatic enrollment into Inclusive Health, federally defined HIPAA eligible individual, eligible for the HCTC.
Pregnant women and infants age 0-1: 185% FPL
Premiums vary based on age, gender, whether you are a smoker or not, and your choice of plan option.
$0 or minimal share of cost
Owner name on business license must draw wages from the company
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for guarantee issue through Inclusive Health, see next column
Mini-COBRA: Applies to small businesses with less than 20 employees HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for any other insurance programs
65
NCHIRP has several option plans that cover a broad range of services, including preventive care, urgent care, outpatient services, a prescription drug benefit and other common health care services
Pre-Existing Health Conditions Covered
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Eligibility
COBRA or Mini-COBRA: Coverage available for 12 to 18 months depending on qualifying events, benefits are the same as what you had with your previous employer
Costs depend on employer contribution and ± 20% of the insurance company’s index rate
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Costs for individual coverage varies
Pre-Existing Health Conditions Covered
Children (ages 1-5): 200% FPL, ages 6-19: 100% FPL (also aged, blind and disabled) SSI recipients: 74% FPL Working parents with incomes up to 51% FPL Non-working parents up to 37% FPL Medically Needy Individuals up to 34% FPL Medically Needy Couples up to 33% FPL
Deductible varies depending on plan chosen.
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive
North Carolina
800.234.1317
Children in moderate income families
Pregnant women and infants
North Carolina’s Health Choice
Medicaid for Pregnant Women
919-707-5700 TTD: 877-452-2514 www.dhhs.state.nc.us/dma/ medicaid
Women-InfantChildren (WIC)
919-855-4260 www.ncdhhs.gov/dma/ services/babylove.htm
919-707-5800 www.nutritionnc.com/wic
Baby Love
NC Family Health Resource Line 800-FOR-BABY 800-367-2229 TTY: 1-800-976-1922
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Medicaid for Pregnant Women: Offers prenatal care, delivery and 60 days postpartum care, services to treat medical conditions which may complicate pregnancy (some services require prior approval), childbirth and parenting classes, family planning services Baby Care: Maternity care coordination, childbirth education classes, counseling and emotional support, medical home visits, and referral to other programs NC Family Health Resource Line: Provides information, referral and advocacy services for pregnancy and child care issues
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
Will cover COBRA if employer contributes less than 50% (or spouses’ employer)
Comprehensive preventive and primary care, outpatient and inpatient services
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
800-633-4227
Senior Insurance Counseling (SHIIP) 919-807-6900 800-443-9354
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as wells several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D SHIIP answers questions and counsels Medicare beneficiaries and caregivers about Medicare, Medicare supplements, Medicare Advantage, Medicare prescription drug plans, longterm care insurance and other health insurance concerns
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Coverage
NCHC: Hospital care; outpatient care; physician and clinic services; Immunizations; surgical services; prescription drugs; laboratory and radiology services; mental health services; durable medical equipment and supplies; vision; hearing; home health care; nursing care; dental care; substance abuse treatment; physical therapy, occupational therapy and therapy for individuals with speech, hearing and language disorders; hospice care and possibly more
Trade Dislocated Workers (TAA recipients)
Program
800-662-7030 919-855-4440 (for Wake County) www.ncdhhs.gov/dma/cpcont. htm
Seniors and Disabled
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
NCHC: Family Income up to 200% of FPL; Cannot be eligible for Medicaid or have any other health insurance; Under age 19; U.S. citizen or lawful alien; North Carolina resident for at least 30 days, except for a newborn; The family’s income must not exceed specified levels
Medicaid for Pregnant Women: Resident of North Carolina
Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
$0 and share of cost for
20% of the insurance premium
WIC: Reside in North Carolina, Be a pregnant or recently pregnant woman, infant or child up to age 5, Be determined to have a nutritional risk, Income must be at or below 185% FPL
NCHC: $0-100 enrollment fee; $1-20 co-pays depending on service;
WIC: $0 to minimal share of cost
If a pregnant woman is covered by Medicaid on the date she delivers, her newborn child may be eligible for Medicaid up to age 1 without a separate application
Must not have access to employer plan that pays 50% of coverage cost. Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
Baby Love: Pregnant and postpartum women are eligible to receive services
$0 or minimal share of cost
certain services: deductibles for certain plans
$0 and share of cost and co-pays depending on income level
www.coverageforall.org North Carolina
Monthly Cost
Pre-Existing Health Conditions Covered
Eligibility
Pre-Existing Health Conditions Covered
Monthly family income cannot exceed 185% FPL
Demographic
Publicly Sponsored Programs
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Demographic Program
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA/Mini-COBRA
U.S. Uninsured Help Line
Group Plans
North Dakota Association of Health Underwriters 703-276-0220 www.nahu.org Up to $5M lifetime maximum, assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply
Coverage
or
800-234-1317
Pre-Existing Health Conditions Covered
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
800-234-1317
Individual Plans
North Dakota Association of Health Underwriters 703-276-0220 www.nahu.org Up to $5M, assorted deductibles depending on age and ZIP code Pre-Existing Health Conditions Covered with Some Limitations
COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered
Individuals with pre-existing, severe or chronic medical conditions
Low-income individuals & families
CHAND
Medicaid
Comprehensive Health Association of North Dakota 800-737-0016 701-277-2271 www.chand.org
800-755-2604 701-328-2321 701-328-8950 (TTY) www.nd.gov/dhs/services/ medicalserv/medicaid/
Two comprehensive coverage options with $500 or $1000 deductibles including: doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, transplants, rehabilitation, durable medical equipment, mental health and substance abuse, physical, speech and occupational therapy, dental care, vision care, and preventive care, and other services
Hospital, nursing facility, clinics, rural health clinics, hospice, physicians, prescription drugs, chiropractor, health tracks (EPDST), home health, durable medical equipment, and supplies, dental, family planning, sterilization, podiatry, mental health, ambulance, transportation, vision, therapies, waivered services home and community based services, traumatic brain injury, out-of-state services
Covered services have a lifetime limit of $1,000,000
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Eligibility
Owner can count as an employee Owner name on business license must draw wages from the company
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Eligibility is subject to medical underwriting
You have physically resided in ND for at least 183 days
Pregnant women and Children ages 0-5: 133% FPL
If you are denied coverage for a medical condition, you may be eligible for CHAND, see next column
You have written evidence from at least one carrier that within 183 days, you have been; denied health care coverage; offered coverage which substantially restricts benefits for specific conditions; offered an insurance rate exceeding the CHAND rate; or written evidence from a medical professional of the existence of a qualifying condition
Children ages 6-19: 100% FPL
Mini-COBRA: Applies to small businesses with less than 20 employees
Monthly Cost
67
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column
North Dakota
Medically Needy: 83% FPL SSI Recipients: 74% FPL People with high medical expenses that when subtracted from income they may be eligible
Must be ineligible for health benefits under ND's medical assistance program, COBRA or certain other government programs
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Costs depend on employer contribution and ± 35% of the insurance company’s index rate
Parents: 38% FPL
A Medicare supplement plan is also available
Costs for individual coverage varies
Once deductible is met, CHAND will pay 80% of allowed charges. $3,000 annual limit on out-of pocket spending on deductibles and co-insurance. After that, CHAND pays 100% of covered services
$0 or minimal share of cost
Price depends on age and location CHAND premiums are limited to 135% of the premiums charged in North Dakota for similar coverage.
800.234.1317
Children in moderate income families
Women
Native American Indians
Trade Dislocated Workers (TAA recipients)
Healthy Steps
Caring for Children Program
Women’s Way
Indian Health Services
Health Coverage Tax Credit
877-KIDSNOW 877-543-7669 www.nd.gov/dhs/services/ medicalserv/chip
800-342-4718 701-277-2227 www.ndcaring.org
800-44WOMEN 800-449-6636 www.womensway.net
605-226-7582 www.ihs.gov/FacilitiesServices/ AreaOffices/Aberdeen
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
Women-InfantChildren (WIC)
Program
Children in low income families
Demographic
Publicly Sponsored Programs
800-472-2286 www.health.state.nd.us/wic Primary and preventive health, physician office visits and routine physicals, emergency accident care, well child care and immunizations, limited inpatient and surgical services, mental health and chemical dependency, preventive dental service
Provides clinical breast exams, pap tests, pelvic exams
Pre-Existing Health Conditions Covered
The Aberdeen Area Office in Aberdeen, South Dakota, works in conjunction with its 13 Service Units to provide health care to approximately 94,000 Indians on reservations located in North Dakota, South Dakota, Nebraska, and Iowa Pre-Existing Health Conditions Covered
Will cover COBRA if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Pre-Existing Health Conditions Covered
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Coverage
HS: Offers inpatient hospital stay, medical & surgical services; outpatient hospital and clinic services; mental health and substance abuse services; prescription medications; routine preventive services (i.e. well-baby check-ups and immunizations); dental and vision services; prenatal services. Some plans offer preventive services and some dental and vision services
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
HS: Uninsured children age 18 and younger who live in families with qualifying incomes. Single 18-year-olds with eligible incomes may also apply. Income cannot exceed 160% of the FPL
Be younger than age 19
Must be a woman age 40 through 64
Must be receiving TAA (Trade Adjustment Assistance)
WIC: Reside in North Dakota, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL
Be without comprehensive medical coverage through Medicaid, Healthy Steps or a private insurance carrier
Four federally recognized tribal nations exist in North Dakota: the Turtle Mountain Band of Chippewa, Three Affiliated Tribes - Mandan, Hidatsa, and Arikara Nation, the Spirit Lake Nation, and the Standing Rock Sioux Nation. The state is also home to the Trenton Indian Service Area
$0 or minimal share of cost
20% of the insurance premium
Be a resident of the state of North Dakota Be a U.S. citizen or legal permanent resident
No health insurance, or unable to pay insurance deductibles and/or co-payments, or Pap smears and/or mammograms not covered by insurance plan
Must not have access to employer plan that pays 50% of coverage cost. Not enrolled in certain state plans
A client must be a resident of the United States for at least 30 days to be eligible for Women's Way
Eligibility
Income must be between 161% and 200% FPL
At or below 200% FPL
No documentation is required to verify residency
HS: Co-pays vary depending on
$0 or minimal share of cost
$0 or minimal share of cost
WIC: $0 or minimal share of cost
www.coverageforall.org North Dakota
Monthly Cost
service from $0-50
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Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Low income children and families
Children
U.S. Uninsured Help Line
COBRA/ Mini-COBRA
U.S. Uninsured Help Line
Healthy Families Medicaid
Healthy Start Medicaid
Program
800-234-1317
Group Health Ohio Association of Health Underwriters 330-273-5756 www.ohioahu.org/
Then convert to
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov
800-234-1317
Individual Plans
800-324-8680 800-292-3572 TDD http://jfs.ohio.gov/OHP/
800-324-8680 800-292-3572 TDD http://jfs.ohio.gov/OHP/
Ohio Association of Health Underwriters 330-273-5756 www.ohioahu.org/
Women-InfantChildren (WIC)
614-644-8006 800-755-GROW 800-755-4769 www.odh.ohio.gov/ odhPrograms/ns/wicn/wic1. aspx
or
State Conversion Plans Pre-existing conditions can be excluded for a limited time depending upon the type of group plan you are joining
Coverage
Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered with Some Limitations
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
Covers certain state mandated items
COBRA Subsidy: 15 months of partially subsidized COBRA premium
Coverage options vary by carrier, but most offer plans that are HSA (Health Savings Account) compatible
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Annual open enrollment regardless of pre-existing conditions
Medical, dental and vision, prescriptions, hospitalization and more depending on program Pre-Existing Health Conditions Covered
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Pre-Existing Health Conditions Covered with Some Limitations
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Owner can count as an employee
Eligibility
Proprietor-name on license must draw wages
HS: Comprehensive care including but not limited to doctor visits, mental, dental, prescriptions, hospitalization and more
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Eligibility is based on medical underwriting
Ohio resident or documented immigrant
There is a 12 month look back period during first two years of coverage. If condition is deemed preexisting there can be a 24 month exclusionary period.
Limited assets such as cash, savings, stocks and bonds AND...
HS: Uninsured children under age 19 and Pregnant women may have an income at or below 200% FPL
Must be resident of state or documented immigrant
Uninsured children under age 19 and Pregnant women may have an income at or below 200% FPL
Families with Children under the age of 19 Income at or below 90% FPL
WIC: Reside in Ohio, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL
Disabled and elderly up to 64% FPL
Mini-COBRA: Applies to small businesses with less than 20 employees
Monthly Cost
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
69
Costs depend on employer contribution and ± 35% of the insurance company’s index rate
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Various price ranges depending on deductible and what plan you buy.
$0 or minimal share of cost
HS & WIC: $0 or minimal share of cost
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates, individual coverage may be less expensive, see next column
Ohio
800.234.1317
Women
Individuals with genetic disorders
Breast and Cervical Cancer Protection Program
Ohio Genetics Program
Services provided include mammograms, pap tests, office visits, clinical breast exams, colposcopies, breast utlrasounds, biopsies and other diagnostic procedures
Pre-Existing Health Conditions Covered
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
800-633-4227
Ohio Genetics Program is not insurance, but is a system of clinics for individuals with genetic illnesses Genetic services include, but are not limited to genetic counseling, education, diagnosis and treatment for all genetic conditions and congenital abnormalities.
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer)
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
$0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
$0 and share of cost and
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Comprehensive preventive and primary care, outpatient and inpatient services. Pre-Existing Health Conditions Covered
Coverage
If screened and diagnosed for breast or cervical cancer may be eligible for complete health coverage through Medicaid
614-728-4677 www.odh.ohio.gov/ odhprograms/cmh/genserv/ genserv1.aspx
Trade Dislocated Workers (TAA recipients)
Program
614-728-2177 (Ohio Department of Health) www.odh.ohio.gov/ odhPrograms/hprr/bc_canc/ bcanc1.aspx
Seniors and Disabled
Demographic
Publicly Sponsored Programs
Genetic services are covered by most insurance companies & Medicaid Those who do not have medical coverage are billed based on their income level: No one is turned away from the genetics clinics for not having insurance
GUARANTEED COVERAGE Must be Ohio resident and have legal immigration status For mammograms must be between 50 and 64 years of age For pelvic and pap test must be between 40 and 64 years of age
$0
Individuals/families might benefit from genetic services if they have questions about: the cause of a medical condition or developmental problem; the chance of the same condition showing up in their children or other relatives; how to prepare for and have a healthy pregnancy; available choices based on an understanding of medical genetics, existing treatments, and other factors; recent genetic discoveries and current research about their condition; where to find medical specialists, community resources and parent support groups in their area or nationally.
co-pays depending on income level
www.coverageforall.org Ohio
Monthly Cost
There are different costs for the various services at genetics clinics. Most insurance companies and third party payers cover the costs of most services. Those who do not have medical coverage are billed based on their income level.
Must not have access to employer plan that pays 50% of coverage cost
Eligibility
Must be uninsured or underinsured with income under 200% of FPL
Anyone can call and get information regarding genetic disorders
70
Demographic
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
U.S. Uninsured Help Line
COBRA/Mini-COBRA
800-234-1317
Program
Group Plans
Oklahoma Association of Health Underwriters 703-276-0220 www.osahu.org
Insure Oklahoma
Coverage
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
888-3-OK-EPIC 888-365-3742 www.insureoklahoma.org
HMOs cannot look-back at or issue exclusions for pre-existing conditions. Other carriers can impose a 6-month look-back/12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
Company size 2-50 employees (including owner)
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Owner name on business license must draw wages from the company Most small group carriers also require 75% employee participation and accept employees who sign a waiver indicating other coverage as counting towards the 75%
Low income individuals and families
U.S. Uninsured Help Line
Oklahoma Health Insurance High Risk Pool
Medicaid SoonerCare
800-234-1317
Individual Plans
Oklahoma Association of Health Underwriters 703-276-0220 www.osahu.org
800-987-7767 www.okdhs.org/ programsandservices/health/ med or www.ohca.state.ok.us/ about.aspx?id=32
877-793-6477 www.okhrp.org
Family Planning
Insure Oklahoma
405-271-4476 www.okdhs.org/ programsandservices/health/ famplan
888-3-OK-EPIC 888-365-3742 www.insureoklahoma.org
GUARANTEED COVERAGE
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Eligibility
and then
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
Mini-COBRA: Applies to small businesses with less than 20 employees
Assorted plans depending on medical needs
Lifetime maximum of $1,000,000
All carriers must guarantee issue coverage to all individuals with at least 12 months of prior coverage
Comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, home health visits, transplants, rehabilitation, durable medical equipment, and mental health and substance abuse, among other services
Except for those with 12 months of prior coverage, there is a 36-month look-back and 12-month exclusionary period limit for pre-existing conditions Benefits will vary depending on plan chosen Pre-Existing Health Conditions Covered with Some Limitations
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for an Oklahoma Health Insurance High Risk Pool plan, see next column Insure Oklahoma: US citizen or legalized alien, resident of Oklahoma age 19-64. Not currently on Medicare or any Medicaid program, employer must be located in Oklahoma and have 99 or fewer employees, income level cannot exceed 200% FPL
Applicants are subject to a 12-month pre-existing condition exclusion
Monthly Cost
71
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column
Oklahoma
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
Resident of Oklahoma for at least one year and turned down by at least two insurance carriers
SoonerCare: Pregnant women and children ages 0-19: 185% FPL
Cannot be eligible for group coverage or COBRA, or government programs (must have exhausted this option)
Working Parents: 48% FPL Non-Working Parent: 32% FPL
Designated as a “guaranteed” option for those who are HIPAA-eligible
Aged, blind and disabled: 100% FPL Supplemental Security Income Recipients: 74% FPL Medically Needy couple: 34% FPL Medically Needy individual: 36% FPL
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs Costs depend on employer contribution and ± 25% of the insurance company’s index rate
Family planning, home health inpatient, laboratory and x-ray nurse-midwife, nursing facility outpatient, physician, ambulatory surgical center, hearing, chiropractic, dental durable medical equipment, prescription drugs, prosthetics mental health, rehabilitative services, transportation services, dental and vision for some people …and more
Legal OK residents; asset limits for some people Family Planning: Income 100% or below Federal Poverty Level (FPL).
Costs for individual coverage varies Insure Oklahoma: Premiums vary according to income level,
Costs vary based on applicant and plan; cannot be more than 50% higher than standard rates
Both: $0 or share of cost
Co-pays range from $5-50 depending on service
800.234.1317
Children
Native American Indians
Child and Adolescent Health Clinical Services
Indian Health Services
405-951-3820 www.ihs.gov/FacilitiesServices/ AreaOffices/oklahoma/index. cfm
Women-InfantChildren (WIC)
Trade Dislocated Workers (TAA recipients)
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
Program
405-271-4471 www.ok.gov/health/Child_ and_Family_Health/index.html
Seniors and Disabled
800-633-4227
405-271-4676 888-OKLAWIC 888-655-2942 www.ok.gov/health/Child_ and_Family_Health/WIC/index. html
Demographic
Publicly Sponsored Programs
Senior’s Health Insurance Counseling Program (SHIP) 800-763-2828 405-521-6628 www.oid.state.ok.us
7 Indian hospitals and 40 outpatient health centers located throughout Oklahoma
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
26 are totally managed by tribes under compact/contract, 12 are operated directly by the IHS, and 2 are operated under contract with Indian organizations
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D SHIP is a Medicare counseling service
Will cover COBRA if employer contributes less than 50% (or spouses’ employer)
Comprehensive preventive and primary care, outpatient and inpatient services
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Pre-Existing Health Conditions Covered
Coverage
CAHCS: Well child care and treatment for minor acute illnesses
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
CAHCS: Children and adolescents at or below 185% of Federal Poverty Level (FPL) who are uninsured or underinsured for health care services
American Indians residing in Oklahoma
Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
WIC: Reside in Oklahoma, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL
Not enrolled in certain state plans See OHIHRP
Certain veterans must have completed 24 continuous months of service
Eligibility
$0 or minimal share of cost
Medicare: $0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
$0 and share of cost and co-pays depending on income level
www.coverageforall.org Oklahoma
Monthly Cost
CAHCS & WIC: $0 or minimal share of cost
Must not have access to employer plan that pays 50% of coverage cost.
72
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer plan
Individuals & families
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Program
800-234-1317 www.coverageforall.org
Group Plans
Oregon Association of Health Underwriters 877-412-OAHU 877-412-6248 www.orahu.org
Or
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
800-234-1317 www.coverageforall.org
Individual Plans Oregon Association of Health Underwriters 877-412-OAHU 877-412-6248 www.orahu.org
Individuals with pre-existing, severe or chronic medical conditions
Low income children and families
OMIP
Oregon Health Plan
(Oregon Medical Insurance Pool) 503-225-6620 800-848-7280 TTY: 800-375-2863 (Regence Blue Cross Blue Shield of Oregon is the plan administrator) www.omip.state.or.us
(OHP/Medicaid) 503-945-5772 800-527-5772 TTY: 800-375-2863 www.oregon.gov/DHS/ healthplan
Or
State Continuation Coverage
Coverage
Up to $2M lifetime maximum, assorted deductibles Under Oregon law, newborns and adopted children are automatically covered under parents’ fully insured health plan for the first 31 days, if the plan provides dependent coverage Pre-Existing Health Conditions Covered
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium
Up to $2M, assorted deductibles depending on age and residence zone Pre-Existing Health Conditions Covered with Some Limitations
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Max lifetime benefit is $2 million per covered person. Choose from 4 policy options In some cases benefits will not be provided during the first six months of enrollment for expenses resulting from a preexisting condition
Provides diagnosis, physician services, check-ups (medical and dental), family planning, maternity, prenatal, and newborn care, prescriptions, hospital services, comfort care, hospice, dental services, drug and alcohol treatment, mental health services Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must work 17.5 hrs/week for coverage Owner can count as an employee
Monthly Cost
Eligibility
Proprietor-name on license must draw wages
73
Credit for pre-existing conditions apply for individuals with no more than a 63 day break in coverage
Costs depend on plan choice and the Modified Community Rate
If you are denied coverage for a medical condition, you may be eligible for OMIP, see next column
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Oregon
Eligibility is subject to medical underwriting
Costs depend on age and county If you are self-employed and buy your own insurance you can deduct 100% of the cost of the premium from your federal income tax
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Previous coverage terminated for reasons other than nonpayment of premium or fraud
Child to Age 5: 133% FPL
Cannot be eligible for COBRA, or government programs
Child Age 6-18 or parent: 100% FPL Pregnant woman: 185%
Oregon resident
SSI Recipients: 74% FPL
Have one of the listed medical conditions
Medically Needy Individual: 58% FPL
Credit toward 6 month waiting period may apply for prior coverage
Medically Needy Couple: 54% FPL
The plans offer a range of deductibles including $500, $750, $1,000 and $1,500
$0 to a share of the monthly premium for Standard or Plus plans
Similar to private rates if qualified for portability policy; 25% higher for the high risk pool rate
Oregon resident and documented immigrant
800.234.1317
Children in moderate income families
Families
Women
Native American Indians
Trade Dislocated Workers (TAA recipients)
Oregon Health Plan Plus
Family Health Insurance Assistance Program
Oregon Breast and Cervical Cancer Program
Indian Health Services
Health Coverage Tax Credit
Healthy Kids
503-378-2666 877-314-5678 www.oregonhealthykids.gov
Coverage lasts for at least one full year or more as long as the child remains eligible
971-673-0984 877-255-7070 www.oregon.gov/DHS/ph/bcc
The program is currently not accepting new applications. If you would like to receive an application when the program reopens you may sign up; however, the wait list is approximately 1.5 to 2 years.
800-723-3638 http://oregon.gov/DHS/ph/wic/ about_us.shtml
Use FHIAP to buy the private health insurance plan you choose
BCCP: Some diagnostic services such as ultrasound, breast biopsy, surgical consultation, colonoscopy
If employer-sponsored plan is available then you must use FHIAP assistance to enroll in that plan
(Subsidy program) 866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
Women-InfantChildren (WIC)
Cancer treatment for some women qualified through Medicaid Referral to treatment services WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Pre-Existing Health Conditions Covered
503-326-2020 www.ihs.gov/FacilitiesServices/ AreaOffices/Portland/
A number of services covered for eligible Native American Indians. Current areas of emphasis are: Infant Health, High Risk Maternal & Child Health, Tobacco Use, Intervention, Domestic Violence, Diabetes, Women's Health Care, and Cancer Screening. Pre-Existing Health Conditions Covered
Will cover COBRA if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Coverage is received through one of the four health plans OMIP offers. Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Both: Children under age 19
Oregon resident and legal immigrant
BCCP: Age 40-64
Must be receiving TAA (Trade Adjustment Assistance)
Income below 250% FPL
Health services from the Indian Health Service is that the individual is an enrolled member of a Federally recognized Tribe. Resides on tax-exempt land or owns restricted property
Oregon resident and legal immigration status (exceptions granted for certain groups)
Uninsured for at least 6 months unless coming off OHP
Under-insured or uninsured
Savings less than $10k (including rental property)
Older than 64 and not eligible for Medicare Part B
Household income at or below 200% FPL
Not eligible for Medicare
WIC: Reside in Oregon, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL
Healthy Kids: Child must have been without health insurance for two months (though there are exceptions to this rule for special circumstances, like a parent’s job loss or a child’s serious medical need)
Must be uninsured for the previous two months, unless you are leaving the Oregon Health Plan (OHP)/Medicaid program and have income up to approximately 200% FPL
Must not have access to employer plan that pays 50% of coverage cost Not enrolled in certain state plans
Eligibility
OHP Plus: Must be uninsured for 6 months
Coverage
Both: Coverage includes medical, dental and vision care regular checkups and preventive care, prescription medicines, medical equipment, mental health and chemical dependency services
(Subsidy program) 503-373-1692 888-564-9669 www.fhiap.oregon.gov
Program
(Apply through the Oregon Health Plan) 800-359-9517 (Applications) 503-378-2666 (Eligibility) www.oregon.gov/DHS/ healthplan/
Demographic
Publicly Sponsored Programs
For free or low-cost coverage, household income cannot exceed 300% FPL If income exceeds 300% FPL, it is still possible to receive coverage, but share of cost may be higher
OHP Plus: No premium or co-pays
Both: $0 and share-of-cost sliding scale
$0 or minimal share of cost
20% of the insurance premium
www.coverageforall.org Oregon
Monthly Cost
Healthy Kids: Premiums vary depending on income level
Depending on family size and income FHIAP pays up to 95% of premium. FHIAP members are responsible for co-pays, deductibles and coninsurance.
74
Demographic
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Blue Cross Blue Shield
Program
800-234-1317
Group Plans
Pennsylvania Association of Health Underwriters 717-232-0022 www.pahu.org
and then
HIPP
Health Insurance Premium Payment 800-644-7730 or
800-234-1317
Individual Plans
Low income individuals and families Medicaid
866-542-3015 www.dpw.state.pa.us
(Contact regional carriers) 800-275-2583 www.ibx.com
For more information call your local county office:
Pennsylvania Association of Health Underwriters 717-232-0022 www.pahu.org
www.dpw.state.pa.us/About/ OIM/003670281.htm
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
Coverage
All group health insurance carriers can impose a 6-month look-back/ 12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium
Assorted deductible and plan design options available for selection Limits on pre-existing health conditions may apply
Guaranteed issue coverage is available for five counties Philadelphia, Delaware, Chester, Montgomery, and Buck
HIPP: Benefits are the same as what you had with your previous employer, HIPP is a premium assistance program
GUARANTEED COVERAGE COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Eligibility
Owner name on business license must draw wages from the company Most small group carriers also require 75% employee participation and accept employees who sign a waiver indicating other coverage as counting towards the 75%
Eligibility is subject to medical underwriting
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Been refused health insurance by other carriers
Pregnant women and infants age 0-1: 185% FPL
If you are denied coverage for a medical condition, you may be eligible for guarantee issue through Blue Cross Blue Shield, see next column
Children (ages 1-5): 133% FPL Ages 6-19: 100% FPL (also aged, blind and disabled) Parents with incomes up to 200% FPL can also apply for the Adult Basic program (which currently has a waiting list for coverage) SSI recipients: 74% FPL
HIPP: You may be eligible for HIPP if you have a high-cost health condition, and are on Medicaid
Medically Needy Individual: 59% FPL Medically Needy Couple: 46% FPL
Monthly Cost
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs Costs depend on employer contribution (also see HIPP) with rate variations allowed up to 300% of the base rate
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Company size 2-50 employees (including owner)
Office visits, prescription drugs, immunizations, vision testing and eyeglasses, emergency room care, lab testing and X-rays, hearing testing and hearing aids, mental and substance abuse treatment
Exclusion period for pre-existing conditions for 1 year
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
GUARANTEED COVERAGE
Blue Cross/Blue Shield plans operating in the state voluntarily serve as the carriers-of-last-resort for people seeking coverage in the individual market through a year-round open enrollment for specified products
Costs for individual coverage varies
Prices based on age and several coverage options, applicant needs etc.
$0
COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column HIPP: $0 or minimal share of cost
75
Pennsylvania
800.234.1317
Children
Women
Adults
Trade Dislocated Workers (TAA recipients)
Veterans
CHIP
Healthy Woman Program
adultBasic
Health Coverage Tax Credit
VA Medical Benefits Package
800-215-7494 www.pahealthywoman.com
Healthy Baby Help Line 800-986-BABY 800-986-2229
Clinical breast examination, mammogram, pelvic examination and pap smear, education on breast self-exam, follow-up diagnostic care for an abnormal result Pre-Existing Health Conditions Covered
Hospitalization (unlimited days), physician services (primary care and specialists), emergency services, diagnostic tests (e.g. X-rays, mammograms and laboratory tests), maternity care, rehabilitation and skilled care (in lieu of extended hospitalization) Pre-Existing Health Conditions Covered
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
877-222-8387 www.va.gov
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Coverage
CHIP: Immunizations; routine check-ups; diagnostic testing; prescription drugs; dental, vision, hearing services; emergency care; maternity care; mental health benefits; up to 90 days hospitalization in any year; durable medical equipment; substance abuse treatment; partial hospitalization for mental health services; rehabilitation therapies; home health care
800-GO-BASIC 800-462-2742 www.ibx.com/health_plans/ low_income/adultbasic.html or www.portal.state.pa.us/ portal/server.pt/community/ health_insurance/9189/ adultbasic/592645
Program
(Children’s Health Insurance Plan) 800-986-5437 www.chipcoverspakids.com
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered
Healthy Baby: Provides health insurance assistance information and referral service for pregnant women Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
CHIP: Must not be eligible for Medical Assistance or any other health insurance,
Women 40 to 64 years old (or under 40 if they are symptomatic of breast cancer, require follow-up for an abnormal Pap test, or have not been screened in the past five years for cervical cancer)
You are between the ages of 19 and 65
Must be receiving TAA (Trade Adjustment Assistance)
You do not have any other healthcare coverage (including Medicaid or Medicare); you have been without health insurance for 90 days prior to enrollment, except if you or your spouse lost health insurance coverage because you are no longer employed
Must not have access to employer plan that pays 50% of coverage cost.
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Child must be under age 19 Must be a Pennsylvania resident and citizen
Must have no insurance or limited insurance that does not cover breast and cervical cancer screening services Must have income below 250% FPL
CHIP: Cost depends on whether your child qualifies for free, low cost, or full cost health coverage. Average Premiums
$0
range between $0-195 with co-payments of $0-50.
Certain veterans must have completed 24 continuous months of service
20% of the insurance
$0 and share of cost and
Your family income is below certain income limits (approximately 200% of FPL) You are a resident of Pennsylvania for at least 90 days prior to enrollment; and have U.S. citizenship or permanent legal alien status
$36 per month premium
payment if enrolled in the program or $600 per month premium payment if purchasing coverage while on the waitlist, Co-pays vary
premium
co-pays depending on income level
between $10-50
www.coverageforall.org Pennsylvania
Monthly Cost
Families with income below 200% FPL will receive free coverage, 200-300% FPL will receive discounted coverage, and 300% FPL or more will have to pay full cost
Not enrolled in certain state plans
Eligibility
Covers all uninsured children under the age of 19 despite their families income level
76
Demographic
Private Health Insurance Small businesses (1-50 Employees)
Individuals recently covered by an employer health plan
U.S. Uninsured Help Line
COBRA/Mini-COBRA and then
Program
800-234-1317
Group insurance carriers may not look-back at, issue exclusions for, or consider pre-existing conditions when issuing small group coverage Benefits will vary depending on the chosen plan
Coverage
HIPAA
Group Plans
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
Rhode Island Association of Health Underwriters 703-276-0220 www.nahu.org
Pre-Existing Health Conditions Covered
COBRA or Mini-COBRA: Coverage available for 12 to 18 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
Low income individuals and families
U.S. Uninsured Help Line
Blue Cross Blue Shield of Rhode Island
RI Medical Assistance Program
Assorted plans depending on medical needs
Plan options vary based on applicant needs
All carriers must guarantee issue coverage to all individuals with at least 12 months of prior coverage
Pre-Existing Health Conditions Covered
Family planning, home health inpatient, laboratory and x-ray nurse-midwife, nursing facility outpatient, physician, ambulatory surgical center, hearing, chiropractic, dental, durable medical equipment, ElderChoices, prescription drugs, prosthetics, psychology services, rehabilitative services for persons with mental illness, rehabilitative services for persons with physical disabilities, targeted case management, transportation services, ventilator equipment, visual services ...and more
800-234-1317
Individual Plans
Rhode Island Association of Health Underwriters 703-276-0220 www.nahu.org
(Medicaid) 401-462-5300 401-462-3363 TTY www.dhs.state.ri.us
800-639-2227 401-459-5000 401-831-2202 TTD www.bcbsri.com
Except for those with 12 months of prior coverage, there is a 36-month look-back and 12-month exclusionary period limit for pre-existing conditions Pre-Existing Health Conditions Covered with Some Limitations
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 1-50 employees (including owner)
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Eligibility
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage Owner name on business license must draw wages from the company Most small group carriers also require 75% employee participation and accept employees who sign a waiver indicating other coverage as counting towards the 75%
Eligibility is subject to medical underwriting If you are denied for a medical condition, you may be eligible for coverage through BCBSRI, see next column
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Resident of RI
Pregnant women and children ages 0-19: 250% FPL
Cannot be eligible for group coverage or COBRA, or government programs (must have exhausted this option)
Working Parents: 192% FPL Non-working Parents: 185% FPL Aged, blind and disabled: 100% FPL
Limited annual open enrollment period
Medically Needy individual: 69% FPL; Medically Needy couple: 87% FPL Supplemental Security Income Recipients: 74% FPL
Mini-COBRA: Applies to small businesses with less than 20 employees
Legal RI residents; asset limits for some people
Monthly Cost
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for any other public or private insurance programs
77
Costs depend on employer contribution and ± 10% of the insurance company’s index rate
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Costs for individual coverage varies
Costs vary based on applicant and plan; cannot be more than 50% higher than standard rates
$0
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column
Rhode Island
800.234.1317
Moderate income families
Adults
RIteShare/RiteCare
Women’s Cancer Screening
401-462-5300 401-462-3363 TTY www.dhs.state.ri.us
800-942-7434 401-222-5960 www.health.ri.gov/family/wic/ index.php
General Public Assistance
www.dhs.ri.gov/Adults/ GeneralPublicAssistance/ tabid/244/Default.aspx
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
Program
Women-InfantChildren (WIC)
401-222-4324 401-222-1161 www.health.ri.gov/disease/ cancer/women-screening.php
Seniors and Disabled
Trade Dislocated Workers (TAA recipients)
Demographic
Publicly Sponsored Programs
800-633-4227
Senior’s Health Insurance Program 401-462-0524 www.dea.state.ri.us
WCS: Offers pelvic exams, Pap tests, clinical breast exams, and mammograms (breast x-rays) to eligible women. Also covers diagnostic tests and possibly full treatment through Medicaid GPA: Covers primary care doctors’ office visits/ health centers visits and most generic prescription medications
Medicare offers two standard plans, A: Hospital Insurance and B: Medical Insurance, as well as several supplemental and advantage plans
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer)
SHIP is a Medicare counseling service
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered
Coverage
RIteShare: Comprehensive coverage through different options. RIteShare is a premium assistance program that helps families get health insurance coverage through their employer (or spouse’s employer). RIteShare pays for all or part of the employee’s share of the health insurance premium. RIteShare also pays for co-payments in the employer’s health insurance plan WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
RIteShare: Children and adolescents at or below 250% of Federal Poverty Level (FPL) who are uninsured or underinsured for health care services
WCS: Must be a resident of Rhode Island, have no health insurance coverage for the services provided by the program, have a family income less than 250% of the FPL and be between 50-64 years old. Women younger than 40 may receive services if they are found to have a palpable lump or a clinical finding of something suspicious for cancer. Women over 65 who are enrolled in Medicare but do not have Medicare part B may also be eligible for the program, as are undocumented women over 65
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
$0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
$0 and share of cost and co-pays depending on income level
Eligibility
WIC: Reside in Rhode Island, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL
Must not have access to employer plan that pays 50% of coverage cost.
GPA: Must be a Rhode Island resident between the ages of 19 and 64, have an illness, injury, or medical condition, which is expected to last at least 30 days and prevents you from working, have a monthly income of $327 or less, have resources of less than $400 and an automobile with a value of less than $4,650. You must also not be eligible for any other federal assistance programs
WIC: $0 or minimal share of cost
Both: $0 or minimal share of cost
www.coverageforall.org Rhode Island
Monthly Cost
RIteShare: $0-92 per month depending on income
78
Demographic
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA/Mini-COBRA
U.S. Uninsured Help Line
Group Plans
HIPAA
and then
Program
800-234-1317
South Carolina Association of Health Underwriters 703-276-0220 www.scahu.org
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov or
800-234-1317
Individual Plans
South Carolina Association of Health Underwriters 703-276-0220 www.scahu.org
Individuals with pre-existing, severe or chronic medical conditions SCHIP
South Carolina Health Insurance Pool 803-788-0500 x46401 (Columbia) 800-868-2500 x46401 (Outside Columbia) www.doi.sc.gov/consumer/ schip.htm
Low income individuals and families Medicaid
888-549-0820 803-898-2500 www.dhhs.state.sc.us
SC Healthy Connections Kids
877-552-4642 www.scchoices.com/ SCSelfService/en_US/kids.html
Conversion Plans
Coverage
All group health insurance carriers can impose a 6-month look-back/12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
COBRA or Mini-COBRA: Coverage available for 12 to 18 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Assorted plans depending on medical needs There is a 12-month look-back and exclusionary period limit for pre-existing conditions in traditional individual market health insurance products Pre-Existing Health Conditions Covered with Some Limitations
Comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, transplants, durable medical equipment, mental health and substance abuse, physical, speech and occupational therapy among other services Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Eligibility
Owner can count as an employee Owner name on business license must draw wages from the company
Both: Hospitalization, well child/ adult appointments, lab and X-rays, doctor visits, vision, dental prescription drugs, family planning, medical equipment, hospice, ambulance, transportation, nursing facility, ICF for the mentally retarded, Inpatient psychiatric care, home health, physical therapy, speech therapy, mental health, family support services, targeted case management, behavioral health, home and community based LTC services and more Pre-Existing Health Conditions Covered
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for SCHIP, see next column
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Been refused health insurance by any insurer for health reasons;
Medicaid: Pregnant women and infants age 0-1: 185% FPL; Children age 1-19: up to 150% FPL; Working Parents: 97% FPL; Non-Working Parents: 49% FPL; Supplemental Security Income Recipients: 74% FPL; Aged, Blind & Disabled: 100% FPL; Low Income Medicare Benefeciaries: 120% FPL; Worked Disabled: 250% FPL; Family Planning Services: 185% FPL; Legal residents with asset limits for some people
Refused insurance except with a reduction or exclusion of coverage for a preexisting condition exceeding 12 months; Refusal of comparable coverage except at a rate exceeding 150 percent of the pool rate
Mini-COBRA: Applies to small businesses with less than 20 employees
Eligible for SCHIP with HIPAA
SCHCK: Children under the age of 19 must have a family income at or below 200% of the FPL
Several PPO coverage options with a $500 deductible and various coinsurance requirements
Both: $0 or minimal share of cost
Monthly Cost
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs
79
Costs depend on employer contribution and ± 25% of the insurance company’s index rate
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Costs for individual coverage varies
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column
South Carolina
800.234.1317
Children with special health care needs
800-868-0404 www.scdhec.gov/health/mch/ cshcn/programs/crs/index.htm
BabyNet
803-734-0479 800-868-0404 www.scdhec.gov/health/mch/ cshcn/programs/babynet/ CRS: Covers nursing services, pharmacy, durable medical equipment, physician services, genetics, social work, nutrition, transition, and parent-toparent support
Pre-Existing Health Conditions Covered
800-868-0404 803-545-4102 803-545-4145 www.dhec.sc.gov/health/ chcdp/cancer/bcn.htm
South Carolina Maternity/Prenatal Care Services 803-898-3432
Trade Dislocated Workers (TAA recipients)
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
800-633-4227
State Health Insurance Assistance Program (SHIP) www.aging.sc.gov/seniors/ ICare.htm
BCN: Program covers mammograms, clinical breast exams, Pap tests, pelvic exams, diagnostic procedures, case management, community education on breast/cervical cancer and early detection Maternity/Prenatal Care Services: Services are offered to women during their prenatal periods and emphasize primary and preventive care including health promotion and education
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D SHIP is a Medicare counseling service
Will cover COBRA if employer contributes less than 50% (or spouses’ employer)
Comprehensive preventive and primary care, outpatient and inpatient services
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Pre-Existing Health Conditions Covered
Coverage
BabyNet: Provides services to infants and toddlers with developmental delays or diagnosed disabilities
Best Chance Network
Seniors and Disabled
Program
South Carolina Children’s Rehabilitative Services
Women
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
CRS: To participate in the CRS program, a child must be a legal resident of the United States, live in South Carolina, be under 21 years old, be diagnosed with a covered medical condition, and must meet certain income guidelines
BCN: Must lack insurance or have insurance that only covers hospital care, Must be between the ages of 40 and 64, and have income at or below 200% FPL
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
$0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
$0 and share of cost and co-pays depending on income level
Both: $0 or minimal share of cost
www.coverageforall.org South Carolina
Monthly Cost
Both: $0 or minimal share of cost
Eligibility
BabyNet: Infants and toddlers from birth to three years may be eligible for BabyNet services if they are developing more slowly
Maternity/Prenatal Care Services: Program available to pregnant women with incomes at or below 185% FPL. Pregnancy includes the 60-day postpartum period. The 60 days begin on the date of delivery or termination of the pregnancy
Must not have access to employer plan that pays 50% of coverage cost.
80
Demographic
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
U.S. Uninsured Help Line
COBRA/Mini-COBRA then
Program
800-234-1317
Group Plans
South Dakota Association of Health Underwriters 703-276-0220 www.nahu.org
Coverage
Up to $5M lifetime maximum, assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply Pre-Existing Health Conditions Covered
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
Low income families
U.S. Uninsured Help Line
South Dakota Risk Pool
South Dakota Medical Assistance
800-234-1317
Individual Plans
605-773-3148 www.state.sd.us/bop/ riskpool.htm
800-305-3064 www.state.sd.us/social
South Dakota Association of Health Underwriters 703-276-0220 www.nahu.org
Up to $5M, assorted deductibles depending on age and ZIP code Pre-Existing Health Conditions Covered with Some Limitations
COBRA Subsidy: 15 months of partially subsidized COBRA premium
Offers four health plan options
Full medical assistance coverage
Each plan offers similar benefits including daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, and out-of-hospital care including pharmaceuticals
Covered services include doctor appointments, hospital stays, dental and vision services, prescription drugs, rehab/ therapy, chiropractic, etc.
Pre-Existing Health Conditions Covered
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Medical coverage may begin three months prior to the application date Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage Owner can count as an employee
Monthly Cost
Eligibility
Owner name on business license must draw wages from the company
81
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for the South Dakota Risk Pool, see next column
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
GUARANTEED COVERAGE
Be a resident of South Dakota
Families with or without private health insurance
Uninsured children under age 19 who have been denied or offered coverage by two insurance companies and have been without health insurance for the last 6 months may be eligible. Children enrolled under this eligibility criteria will have a 6 month pre-existing condition waiting period Individuals who have received notice from their insurance carrier that they are near or have reached their lifetime maximum benefit may be eligible for the program
Mini-COBRA: Applies to small businesses with less than 20 employees
Costs depend on employer contribution and ± 25% of the insurance company’s index rate
GUARANTEED COVERAGE
Must apply within 63 days of losing your prior coverage and must have had at least 12 months of continuous creditable coverage
Family must consist of a parent or other adult caretaker relative (grandparent, brother, sister, stepparent, etc. ) and a dependent child Child under age 18: if a child is 18 years old and still a full time student in high school, the child is considered a dependent child if he or she is expected to complete school before reaching age 19 Ages 1-19 - 140% FPL Prengnant Women - 133% FPL Parents - 64% FPL
Must have used up COBRA or state continuation coverage Cannot be covered under any other form of health insurance and not had your most recent coverage terminated due to nonpayment of premiums or fraud Costs for individual coverage varies
Costs vary depending on age, region and program
$0 or minimal share of cost
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column
South Dakota
800.234.1317
Children
Women
Refugees newly arriving in U.S.
Native American Indians
CHIP
All Women Count
South Dakota Medical Assistance
Indian Health Services
800-738-2301 http://doh.sd.gov/ AllWomenCount/default.aspx
800-305-3064 www.state.sd.us/social
605-226-7582 www.ihs.gov/FacilitiesServices/ AreaOffices/Aberdeen
Or contact local department of social services
Women-InfantChildren (WIC)
Medicare
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program 800-633-4227
Senior Health Information & Insurance Education (SHIINE)
800-738-2301 http://doh.sd.gov/WIC/default. aspx
Program
(Children’s Health Insurance Program) 800-305-3064 http://dss.sd.gov/ medicalservices/chip/
Seniors and Disabled
Demographic
Publicly Sponsored Programs
800-536-8197 www.shiine.net
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Covers pelvic exams, Pap smears, clinical breast exams, mammograms, and some additional diagnostic services Pre-Existing Health Conditions Covered
Covered services include doctor appointments, hospital stays, dental and vision services, prescription drugs, rehab/ therapy, chiropractic, etc. Coverage is limited to 8 months from a person's entry to the United States
Provide inpatient and outpatient care and conduct preventive and curative clinics. Pre-Existing Health Conditions Covered
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D SHIINE is a Medicare counseling service
Pre-Existing Health Conditions Covered
Coverage
CHIP: covers doctor appointments, hospital stays, dental and vision services, prescription drugs, mental health care and other medical services
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
CHIP: Children below 200% FPL who already have private health insurance may also be eligible for CHIP paying deductibles, co-payments and other medical services not covered by their private policy. If a child’s income puts the family over the income limit the family’s other children may still be eligible. A baby living with his or her teen parents may be eligible without looking at grandparents’ income
Women whose income is below 200% FPL are eligible for Pap tests if they are 30-64 and for mammograms if they are 40-64
Must be a refugee
Health services from the Indian Health Service is that the individual is an enrolled member of a Federally recognized Tribe.
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)
Income limit is 62% FPL
Resides on tax-exempt land or owns restricted property
Eligibility
WIC: Reside in South Dakota, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL
$0 or minimal share of cost
$0 or minimal share of cost
$0 or minimal share of cost
$0 and share of cost for certain services; deductibles for certain plans
www.coverageforall.org South Dakota
Monthly Cost
CHIP & WIC: $0 or minimal share of cost
82
Demographic
Private Health Insurance Individuals recently Small businesses covered by an (2-50 employees) employer health plan U.S. Uninsured Help Line 800-234-1317
Program
Group Plans
Tennessee Association of Health Underwriters 703-276-0220 www.tnahu.org
COBRA/Mini-COBRA and then
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
Low income individuals and families
U.S. Uninsured Help Line
AccessTN
Medicaid
800-234-1317
866-268-3786 www.covertn.gov/web/ access_tn.html
Individual Plans
(TennCare) 866-311-4287 www.state.tn.us/tenncare
Families First
Tennessee Association of Health Underwriters 703-276-0220 www.tnahu.org
888-863-6178 www.state.tn.us/tenncare/
CoverTN
888-887-3224 www.covertn.gov
Coverage
(Effective December 1, 2009, new enrollment in CoverTN is suspended until further notice as a result of reaching budget capacity. Current members and participating businesses, as well as those who have been approved for coverage effective in January 2010, will be unaffected by the suspension)
Carriers can impose a 6-month look-back/12month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage (this may only apply to certain groups) Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
COBRA or Mini-COBRA: Coverage available for 12 to 18 months depending on qualifying events, benefits are the same as what you had with your previous employer
Assorted plans depending on medical needs
COBRA Subsidy: 15 months of partially subsidized COBRA premium
There is a 6-month lookback and a 12-month exclusionary period limit for pre-existing conditions
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
All carriers must guarantee issue coverage to all individuals
Pre-Existing Health Conditions Covered with Some Limitations
Three plans to choose from offering comprehensive health coverage similar to the benefits offered to state employees. Participants will be able to select the plan that is best for their situation. Refer to the benefit plan for more information on covered services. Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Medicaid: Inpatient hospital services, outpatient hospital services, prenatal care, vaccines for children, physician services, nursing facility services for persons aged 21 or older, family planning services and supplies, rural health clinic services, home health care for persons eligible for skilled-nursing services, laboratory and x-ray services, pediatric and family nurse practitioner services, nurse/midwife services FF: Provides coverage to low income families with Children under age 19, Individuals who meet FF requirements, and Pregnant Women CoverTN: Limited-benefit health plan designed to cover the medical services needed by most people. Services include coverage for doctor visits, emergency treatment, inpatient and outpatient care, as well as pharmacy coverage. Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
Company size 2-50 employees (including owner)
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Eligibility
GUARANTEED COVERAGE
Must be a TN resident Individuals must pass medical underwriting so it is possible they can be turned down for pre-existing conditions If you are denied coverage for a medical condition, you may be eligible for AccessTN, see next column
Mini-COBRA: Applies to small businesses with less than 20 employees
Monthly Cost
83
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive
Tennessee
GUARANTEED COVERAGE
Must be a Tennessee resident, U.S. citizen or qualified legal alien.
Medicaid: Pregnant women & infants: 185% FPL; Children (ages 1-5): 133% FPL; Children (Ages 6-19): 100% FPL; All above must meet a medical eligibility test; Other infants and children with family incomes of 100% FPL are eligible; Working or non-working parents: 100%FPL; Qualified Disabled & Working Individuals: 200% FPL; Instituitionalized Individuals: $2022 Monthly Income; Medically Needy (Children up to age 18 or pregnant women): Family of 1, $241, Family of 2, $258; Family of 3, $317; Family of 4, $325; Family of 5, $392; Family of 6, $408; Family of 7, $467
Age 19 or older Uninsurable by medical or insurance determination No access to employersponsored health insurance (other than CoverTN) at the time of application Denial by two unaffiliated insurance carriers for individual coverage due to a health-related condition
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for any other insurance programs Costs depend on employer contribution and ± 35% of the insurance company’s index rate
GUARANTEED COVERAGE
Without health coverage six months, no access to insurance at time of application, exhausted continuation coverage including COBRA
Costs for individual coverage varies
Cost depends on age, tobacco use, etc. Premiums could be $284-1225, financial assistance for certain income levels could reduce price 30%-70%
FF: Family of 1, $1288, Family of 2, $1658; Family of 3, $1972; Family of 4, $2240; Family of 5, $2470; Family of 6, $2666; Family of 7, $2838 CoverTN: A U.S. citizen or qualified legal alien; 19-years-old or older; Tennessee resident for six months (employees at non-participating employers or self-employed); Earns $55,000 or less per year in adjusted gross income (employees at non-participating employers or self-employed); Works an average of at least 20 hours per week; Has not had health insurance in the previous six months (individual or group coverage)
Medicaid & FF: $0 or small share of cost CoverTN: Premiums are based on an individual’s age, weight and tobacco use. Must agree to pay one-third or two thirds share of premium depending on qualifications.
800.234.1317
Children
Women
Native American Indians
TENNderCare
Breast and Cervical Cancer Screening Program
Indian Health Services
866-311-4287 http://state.tn.us/tenncare/ tenndercare/index.html
615-467-1500 www.ihs.gov/FacilitiesServices/ AreaOffices/Nashville/
Trade Dislocated Workers (TAA recipients)
Medicare
Health Coverage Tax Credit
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
Program
CoverKids
888-325-8386 www.coverkids.com
(BCCSP) 877-96-WOMEN 877-969-6636 http://health.state.tn.us/BCC/ index.htm
Seniors and Disabled
Demographic
Publicly Sponsored Programs
800-633-4227
Medicare Supplement Insurance Policy 888-486-9355
TENNderCare: A full program of check ups and health care services for children who have TennCare
Pre-Existing Health Conditions Covered
A number of services covered for eligible Native American Indians by the Nashville Area clinics. Pre-Existing Health Conditions Covered
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D The Department of Commerce and Insurance regulates providers of supplemental policies to help cover Medicare co-pays and deductibles
CoverKids: Preventive Care, Office Visits, Inpatient Hospital Services, Hospital emergency care, Urgent care services, Outpatient Facility Services and Outpatient Surgery, Prescription drug coverage, vision services
Will cover COBRA if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Pre-Existing Health Conditions Covered
Coverage
These services make sure babies, children, teens and young adults receive the health care they need
Clinical breast exams, mammograms, and Pap tests
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
TENNderCare: Children with TennCare up to age 21
Must be uninsured or underinsured with income at or below 250% FPL
GUARANTEED COVERAGE
Health services from the Indian Health Service is that the individual is an enrolled member of a Federally recognized Tribe.
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
$0 and share of cost for
20% of the insurance premium
Resides on tax-exempt land or owns restricted property
Must not have access to employer plan that pays 50% of coverage cost. Not enrolled in certain state plans
$0
$0 or minimal share of cost
certain services; deductibles for certain plans
www.coverageforall.org Tennessee
Monthly Cost
TENNderCare & CoverKids: $0 or significant share of premium cost and co-pays
GUARANTEED COVERAGE
Eligibility
CoverKids: Age 18 or younger, A Tennessee resident, U.S. citizen or qualified legal alien, Uninsured for at least three months prior to application, Not eligible for TennCare, No access to state employee health insurance, Income up to 250% of FPL, Maternity coverage available for pregnant women who meet eligibility criteria. Children above 250% can buy into the program.
GUARANTEED COVERAGE
84
Demographic
Private Health Insurance Small businesses (2-50 employees)
U.S. Uninsured Help Line
Program
800-234-1317
Group Plans
Individuals recently covered by an employer health plan COBRA then convert to
HIPAA
Texas Association of Health Underwriters 703-276-0220 www.tahu.org
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
Texas Employee Group Insurance Program (GBP)
and also
Individuals & families
U.S. Uninsured Help Line 800-234-1317
Individual Plans
Texas Association of Health Underwriters 703-276-0220 www.tahu.org
Individuals with Children with pre-existing, expensive medical severe or chronic conditions medical conditions Texas Health Insurance Risk Pool
TX Children with Special Needs
(Medical Expense Deduction Program) 888-398-3927 TDD 800-735-2989 www.txhealthpool.com
800-252-8023 www.dshs.state.tx.us/cshcn
Hospitalization, physician care, maternity, prescriptions, drugs, treatment for serious mental health illnesses and other services
There is a 12 month waiting period for people with preexisting health conditions where the policy will not pay any expenses for the condition. If you were covered by creditable coverage in place during the 12 months before your effective date your wait time will be reduced.
Ambulances, Ambulatory Surgery, Primary & Preventative Care, Inpatient rehabilitation and Outpatient Care, Speech and Hearing Services, Vision & Dental Care, Family Support Services, Mental Health Services, Diagnosis & Evaluation, Laboratory and Radiology Services, Equipment & Medical Supplies, Home Health Nursing, Hospice & Hospital Care, Meals, Lodging and Transportation when needed to obtain medical care, Medicines, Physician and Occupational Therapy, Orthotics and Prosthetics, Special Nutritional Products & Services and Insurance Premium Payment Assistance
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Individuals with applicable pre-existing conditions should qualify
A person younger than 21 years of age who has a chronic physical, developmental, or emotional condition that will last or is expected to last for at least 12 months
Conversion Policies
877-275-4377 Austin: 512-867-7711 www.ers.state.tx.us
Coverage varies according to plan
Coverage
By law all insurers must offer at least one plan that includes coverage for state mandated benefits such as preventive care, mammograms etc. Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees (or self-employed)
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Eligibility Monthly Cost
COBRA Subsidy: 15 months of partially subsidized COBRA premium
Up to $5M, assorted deductibles depending on age and ZIP code
Pre-Existing Health Conditions Covered
Insurance companies may require minimum participation
85
COBRA: Coverage available for up to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for the Texas Health Insurance Risk Pool, see next column
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Texas
Renewable as long as you pay your premiums and continue to reside in Texas and meet other conditions: Ineligible for public or employer-based coverage If one family member qualifies then all are qualified
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA Costs depend on employer contribution and ± 25% of the insurance company’s index rate
5 plans to choose from including the new HSAQualified Plan.
Person of any age with cystic fibrosis Must have applied for Medicaid and CHIP and used those benefits
You must have had 18 months of continuous coverage with the last day in a group health plan
Costs for individual coverage varies
Premiums vary based on health plan chosen, age, gender and geographic zone
$0
Rates are limited to twice the amount a healthy person in a similar plan pays
800.234.1317
Children in moderate income families
Low income families and adults
CHIP
Medicaid
In Texas: 2-1-1 800-252-8263 877-541-7905 www.hhsc.state.tx.us/ medicaid/index.html
State Kid Insurance Program (SKIP)
Native American Indians
Breast and Cervical Cancer Treatment Program
Indian Health Services
(BCCTP) 512-458-7796 www.dshs.state.tx.us/ bcccs/default.shtm
Nashville Offices 615-467-1500 www.ihs.gov/FacilitiesServices/ AreaOffices/Nashville/
877-KIDS-NOW 877-543-7669 www.ers.state.tx.us/insurance/ skip/default.aspx
Both: Doctor and nurse care immunizations, preventive care, health clinics, laboratory tests, prescriptions, medical equipment, transportation, hospitalization, mental health services, well child visits, dental, vision and more
Albuquerque Area office 505-248-4500 www.ihs.gov/FacilitiesServices/ AreaOffices/Albuquerque/
Oklahoma City Area www.ihs.gov/FacilitiesServices/ AreaOffices/oklahoma/index. cfm Comprehensive health, dental, vision, and prescription coverage Pre-Existing Health Conditions Covered
Offers clinical breast examinations, mammograms, pelvic examinations, and pap tests at little or no cost to eligible women Referrals to treatment services
A number of services covered for eligible Native American Indians by the Nashville Area clinics. Pre-Existing Health Conditions Covered
Medicare
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program 800-633-4227
Employee Retirement System (ERS) Of Texas 877-275-4377 Austin: 512-867-7711 www.ers.state.tx.us
Medicare: Offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug coverage plan, known as Medicare Part D Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Both: Children age 19 and younger at or below 200%FPL; Must be ineligible for Medicaid
Residents and some legal immigrants
Diagnosed with breast or cervical cancer
Retired or disabled people with low income and Medicare may also qualify for Medicaid assistance
At or below 200% FPL
At or below 100% FPL
Resides on tax-exempt land or owns restricted property
No access to other health insurance including Medicare
$0 or minimal share of cost
$0 or minimal share of cost
$0 or minimal share of cost
$0 and share of cost for certain services; deductibles for certain plans
range between $3 to $10.
SKIP: Ranges between $15 to
$25 per month
www.coverageforall.org Texas
Monthly Cost
family; most co-payments
Age 50-64 priority for breast screening
Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Texas resident and qualified resident
SKIP: Available to Children of employees in ERS' insurance program or Texas Employee GBP
$50 covers all children in
Women under age 65
Health services from the Indian Health Service is that the individual is an enrolled member of a Federally recognized Tribe.
Age 18-64 priority for cervical cancer screening if no Pap in previous years
No health insurance for the last six months at time of application
CHIP: $0 or share of cost;
GUARANTEED COVERAGE
Eligibility
CHIP: No limit on resources; Texas residents, qualified immigrants, and pregnant women can also qualify for CHIP; Must be ineligible for employer-based coverage
GUARANTEED COVERAGE
Coverage
Pre-Existing Health Conditions Covered
CHIP: Children enrolling in CHIP for the first time after being covered by private health insurance will have a 90-day waiting period before benefits can be used
Seniors and Disabled
Program
(Children’s Health Insurance Program and Medicaid) 800-647-6558 877-KIDS NOW www.chipmedicaid.org
Women
Demographic
Publicly Sponsored Programs
86
Demographic
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA and Mini-COBRA
U.S. Uninsured Help Line
Program
800-234-1317
Group Plans
Utah Association of Health Underwriters 703-276-0220 www.uahu.org
Utah’s Premium Partnership for Health Insurance (UPP)
888-222-2542 http://health.utah.gov/upp
Coverage
Assorted deductibles There is a 6-month look-back/12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage UPP is a program for adults and children who do not currently have health insurance or COBRA coverage. UPP will help pay for monthly insurance premiums for individuals enrolled in their employer’s health insurance plan or COBRA
Then convert
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
800-234-1317
Individual Plans Utah Association of Health Underwriters 703-276-0220 www.uahu.org
Or
Individuals with pre-existing, severe or chronic medical conditions
Low income families and medically needy
HIPUtah
Medicaid
(Utah Comprehensive Health Insurance Pool) Application Help: 800-705-9173 801-442-6660 Member Services 800-538-5038 801-442-5038 www.selecthealth.org www.insurance.utah.gov/ hiputah/index.html
800-662-9651 801-538-6155 http://health.utah.gov/ medicaid
Coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, transplants, rehabilitation, durable medical equipment, mental health and substance abuse, physical, speech and occupational therapy, and preventive care, among other services
Inpatient hospital, outpatient hospital services, prenatal care, vaccines for children, physician, nursing facility services, family planning, rural health clinic services, home health care for persons eligible for skilled nursing services, laboratory and x-ray services, pediatric and family nurse practitioner services, nursemidwife services and more
State Conversion Policies COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
Up to $5M, assorted deductibles depending on age and residence zone Limits on Pre-Existing Health Conditions May Apply
COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage; owner can count as an employee
Monthly Cost
Eligibility
Proprietor-name on license must draw wages
87
If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions- not counting birth or adoption- may apply, (1-6 months respectively) UPP: Must be between the ages of 0-64; not be covered by other health insurance; be a U.S. citizen or legal resident; be able to get health insurance through an employer’s health plan; have your cost of health insurance be more than 5% of your income; meet income guidelines (Adults approximately 150% FPL, Children 200% FPL).
Costs depend on employer contribution and ± 30% of the insurance company’s index rate UPP: Up to $150 per adult and up to $120 per child in the family, every month
If you are denied coverage for a medical condition, you may be eligible for HIPUtah, see next column
GUARANTEED COVERAGE
Previous coverage terminated for reasons other than non-payment of premium or fraud or rejected for coverage within previous 6 months
Parents: 70% FPL
Cannot be eligible for COBRA, or government programs Must have resided in Utah for 12 consecutive months immediately preceding the date of application for HIPUtah (the 12 month requirement can be waived if moving from another state’s high risk pool)
Mini-COBRA: Applies to small businesses with less than 20 employees
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Children Age 0-6 and pregnant women: 133% FPL Children Age 6-18: 100% FPL (also aged, blind and disabled) SSI Recipients: 74% FPL Medically Needy Individual: 53% FPL Medically Needy Couple: 48% FPL Working legally disabled 250% Parent or caretaker relative of a child 54% to 60%
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or any other public or private insurance programs
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column
Utah
Eligibility is subject to medical underwriting
GUARANTEED COVERAGE
Some services are based on age of member
Costs depend on age and county/zone
Premiums vary based on the plan, can be 150% of average rate
If you are self-employed and buy your own insurance you are eligible to deduct 100% of the cost of the premium from your federal income tax
Three available deductible options of $500 medical/$150 pharmacy, $1000 medical/$250 pharmacy and $2500 medical/$500 pharmacy
$0 or small share of cost; no copays
High deductible plan is also available with a $5,000 deductible
800.234.1317
Low income children
Women
Native American Indian
Trade Dislocated Workers (TAA recipients)
Veterans
Utah CHIP
Utah Cancer Control
Indian Health Services
Health Coverage Tax Credit
VA Medical Benefits Package
800-717-1811 801-538-6157 www.cancerutah.org
(Navajo Area Office) 928-871-4811 www.ihs.gov
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
Program
(Children’s Health Insurance Program) 877-KIDS-NOW 877-543-7669 866-772-1261 866-435-7414 801-538-9004 www.utahchip.org
Demographic
Publicly Sponsored Programs
Women-InfantChildren (WIC)
877-WIC KIDS www.health.utah.gov/wic/ index.html Pap test, pelvic examination, clinical breast examination, referral for a free mammogram, education on breast self examination
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Inscription House Health Center provides pediatrics, internal medicine and family medicine ambulatory care, services provided include laboratory, pharmacy, dental, public health nursing, mental health, health education, x-ray, and optometry care. As is true for other Navajo Area Indian Health facilities, leading reasons for outpatient visits include respiratory illness, preventive health activities, diabetes, well child exams and prenatal care
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Will cover COBRA if employer contributes less than 50% (or spouses’ employer)
Comprehensive preventive and primary care, outpatient and inpatient services
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Pre-Existing Health Conditions Covered
Coverage
Utah CHIP: Well-child exams, immunizations, health care provider visits, prescriptions, hearing and eye exams, mental health services, dental services for prevention and treatment of tooth decay
Can also use funds to purchase coverage through the State of Utah's Department of Workforce Services Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Utah CHIP: Must be a U.S. Citizen or legal resident, Under age 19, Not currently covered by health insurance, Income must be at or below 200% FPL
Women 50 - 64 years of age
Navajo indian, possibly others
Must be receiving TAA (Trade Adjustment Assistance)
WIC: Reside in Utah, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL
Do not have Medicaid or Medicare
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Utah CHIP: $0-75 per quarter depending on income
$0
Must not have access to employer plan that pays 50% of coverage cost.
Uninsured or unable to afford insurance premium
Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
20% of the insurance premium
$0 and share of cost and
Eligibility
Income at or below 250% of FPL
$0 or minimal share of cost
co-pays depending on income level
www.coverageforall.org Utah
Monthly Cost
WIC: $0 or minimal share of cost
Do not belong to an HMO (Health Maintenance Organization)
88
Demographic
Private Health Insurance Small business (1-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
Low Income Families & Medically Needy
Low Income Children & Pregnant Women
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Medicaid
Dr. Dynasaur
Program
800-234-1317
Group Plans
Vermont Association of Health Underwriters 703-276-0220 www.nahu.org
Then convert to
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov Or
State Conversion Policies
Coverage
Assorted deductibles There is a 6-month look-back/12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Pre-Existing Health Conditions Covered
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered
800-234-1317
Individual Plans
800-250-8427 www.ovha.vermont.gov or www.greenmountaincare.org
National Association of Health Underwriters (To find and agent) 703-276-0220 www.nahu.org
Up to $5M, assorted deductibles depending on age and residence zone There is a 9-12 month look-back period limit on pre-existing health conditions Limits on Pre-Existing Health Conditions May Apply
(Children’s Health Insurance Program) 800-250-8427 www.ovha.vermont.gov or www.greenmountaincare.org
Women-InfantChildren (WIC)
800-649-4357 802-863-7333 http://healthvermont.gov/ family/wic/wic_vt.aspx Doctor visits, prescriptions, hospital care (including emergency care), tests, x-rays, family planning, mental health services, substance abuse services, home health care, dental care, eye care, occupational therapy, physical and speech therapy, and more
Dr. Dynasaur: Doctor visits, checkups, dental care, immunizations, vision, hospital care, prescriptions, physical therapy, speech therapy, mental health care. Pregnant women receive doctor visits, hospital care, lab work & tests, prescriptions, prenatal vitamins and other services
Pre-Existing Health Conditions Covered
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 1-50
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage. Applies to businesses with more than 20 employees
Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage Owner can count as an employee
Monthly Cost
Eligibility
Proprietor-name on license must draw wages
89
If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions- not counting birth or adoption- may apply, (1-6 months respectively)
Costs depend on employer contribution and the Modified Community Rate
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Eligibility is NOT subject to medical underwriting
Children ages 0-18 300% FPL Pregnant Women: 200% FPL
Dr. Dynasaur: Provides coverage for children under 18 and pregnant women. Household income must be at or below 200% FPL for pregnant women, and up to 300% FPL for children. Cannot have had prior health coverage in the last month to be eligible, unless the coverage was dropped because of unemployment, death or divorce, or loss of dependent eligibility
Non-working Parents: 185% FPL Working Parents: 192% FPL Medically Needy Individual: 102% FPL (or 111% of the Federal Poverty Level for residents of Chittenden County only) Couple: 76% FPL (or 82% FPL for residents of Chittenden County only)
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or any other public or private insurance programs
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Vermont
GUARANTEED COVERAGE
SSI Recipients: 74% FPL
Costs depend on age and county/zone If you are self-employed and buy your own insurance you are eligible to deduct 100% of the cost of the premium from your federal income tax
$0 or small share of cost; no copays
WIC: Reside in Vermont, Nutritionally or medically at risk pregnant, postpartum or breastfeeding women, and children younger than 5 years old. Must be at or below 185% FPL
Dr. Dynasaur: $0 or $60 premium for children with family incomes between 200% and 300% FPL WIC: $0 to minimal share of cost
800.234.1317
Women
Ladies First
VHAP
(Vermont Health Access Plan) 800-250-8427 888-834-7898 TTY www.dsw.state.vt.us or www.greenmountaincare.org
Seniors and Disabled
Trade Dislocated Workers (TAA recipients)
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
800-633-4227
Program
800-508-2222 802-863-7200 TDD 800-319-3141 http://healthvermont.gov/ prevent/ladies_first.aspx
Adults
Demographic
Publicly Sponsored Programs
State Health Insurance Assistance Program (SHIP) 800-642-5119 www.medicarehelpvt.net
Annual mammograms, clinical breast exams, pelvic exams, Pap tests, instruction in breast self-exam, and cardiovascular disease risk factor (cholesterol, high blood pressure, diabetes) screening
Full coverage for some women
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D SHIP is a Medicare counseling service Pre-Existing Health Conditions Covered
Will cover COBRA if employer contributes less than 50% (or spouses’ employer)
Comprehensive preventive and primary care, outpatient and inpatient services
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Pre-Existing Health Conditions Covered
Coverage
Repeat mammograms, ultrasounds, biopsies, and colonoscopies
Doctor visits, prescriptions, visits to specialists, emergency room care, inpatient hospital care - emergency and urgent admissions only, outpatient care, tests and x-rays, family planning, mental health services, substances abuse services, home health care
Can also use funds to purchase coverage through the Blue Cross Blue Shield of Vermont and MVP Health Plans Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Age 40 years or older without Medicaid, VHAP, or Medicare Part B
Must have income between 50185% FPL
Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
Medicare: $0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
$0 and share of cost and co-pays depending on income level
Age 18-39 without Medicaid, VHAP, or Medicare Part B Income at or below 250% FPL
Must have been uninsured for 12 months or more – with exceptions for Vermonters who recently lost their insurance because of a life change such as a divorce or loss of a job
Must not have access to employer plan that pays 50% of coverage cost.
Eligibility
If you have breast symptoms or an abnormal Pap test, you are eligible for a limited membership. This includes breast and cervical screening and diagnostic tests, but not screenings for heart disease risk factors.
VHAP is a health insurance program for adults age 18 and older
In addition, all women who have been screened through Ladies First and need treatment for breast and cervical cancer may be eligible for full Medicaid benefits during treatment, including coverage for pre-malignant conditions
$7-$49
www.coverageforall.org Vermont
Monthly Cost
$0
90
Demographic
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Program
800-234-1317
Group Health
Virginia Association of Health Underwriters 703-276-0220 www.vahu.org
or
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov or
800-234-1317
Individual Plans Virginia Association of Health Underwriters 703-276-0220 www.vahu.org
Individuals with pre-existing, severe or chronic medical conditions
Low income individuals and families
Anthem
Medicaid
800-304-0372 www.anthem.com
804-786-4231 www.dmas.virginia.gov
CareFirst
866-520-6099 www.carefirst.com
Continuation and Conversion Policies Pre-existing conditions can be excluded for a limited time depending upon the type of group plan you are joining
Coverage
Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered with Some Limitations
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium
Plans will vary but insurers are required to offer certain benefits such as postpartum care and mammograms
Plans will vary but these two insurers offer plans to individuals denied coverage due to medical conditions
Medical, dental and vision, prescriptions, hospitalization and more depending on program
Pre-Existing Health Conditions Covered with Some Limitations
All insurers are required to offer certain benefits such as postpartum care and mammograms
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered with Some Limitations
HIPAA: Benefits are based on the program selected and there is no expiration of coverage State conversion plans offered through private health insurance market will vary Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Owner can count as an employee
Eligibility
Proprietor-name on license must draw wages
Medical underwriting will determine eligibility If you are denied coverage for a medical condition, you may be eligible for coverage through Anthem or CareFirst, see next column
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Must not be eligible for any other insurance, including individual, group or public
Pregnant women, infants and children up to 133% FPL
Plan availability will depend on county residence Virginia resident
Medically needy couples up to 47% FPL Medically needy individuals 42% FPL Working parents up to 30% FPL Aged, blind, and disabled up to 80% FPL Non-working parents up to 24% FPL
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
High cost of medical conditions subtracted from income may make eligible
Monthly Cost
Must be a Virginia resident
91
Costs depend on employer contribution and for standardized plans, ± 25% of the insurance company’s index rate
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Depends on plan selected
Each individual plan is priced differently depending on age and gender, no family rates
$0 or minimal share of cost
COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Virginia
800.234.1317
Children In Moderate Income Families
Women
Individuals with life-threatening illness or injury
Trade Dislocated Workers (TAA recipients)
Veterans
Family Access to Medical Insurance Security
Breast and Cervical Cancer Early Detection Program
Uninsured Medical Catastrophe Fund
Health Coverage Tax Credit
VA Medical Benefits Package
866-395-4968 804-864-7761 www.vahealth.org/ breastcancer
(UMCF) 800-432-5924 www.dmas.virginia.gov
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
Women-InfantChildren (WIC)
Program
(FAMIS) 866-873-2647 888-221-1590 (TDD) www.famis.org
Demographic
Publicly Sponsored Programs
888-942-3663 www.vahealth.org/wic
FAMIS: Doctor visits, check-ups, immunizations, preventive care, dental, mental, hospitalization
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Inpatient and outpatient hospital services and surgical centers, ambulatory care, laboratory and x-ray, physician, ambulatory care, medical care furnished by licensed practitioners, prescribed drugs and rehabilitative services to recover from medical treatment; the only organ and tissue transplant procedures covered are: kidney, liver, heart, lung and bone marrow
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Comprehensive preventive and primary care, outpatient and inpatient services. Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Coverage
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
If screened and diagnosed for breast or cervical cancer may be eligible for complete health coverage through Medicaid, including dental, prescriptions etc.
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
FAMIS: Low income children under age 19, Uninsured and ineligible for Medicaid, Virginia resident, Income below 200% of FPL
Must be Virginia resident Women between 40-64 years of age. Women ages 18-39 can also qualify for tests but may need to pay for them
Citizen or a legal resident
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Must be uninsured or underinsured, ineligible for Medicaid
Have a life threatening illness or injury, be uninsured for the needed treatment and not eligible for coverage for the needed treatment through private health insurance or federal, state, or local government medical assistance programs
WIC: Reside in Virginia, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL
At or below 200% FPL
Resident of VA Gross family income at or below 300% of the FPL
Must not have access to employer plan that pays 50% of coverage cost Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
20% of the insurance premium
$0 and share of cost and
Eligibility
GUARANTEED COVERAGE
Identify a provider who is willing to accept the global fee established for the medical treatment plan
$0 or nominal co-payment
$0 or minimal share of cost
co-pays depending on income level
WIC: $0 or minimal share of cost
www.coverageforall.org Virginia
Monthly Cost
FAMIS: $2-5 co-pays, $0 for well-child and well-baby check-ups
92
Demographic
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA or
U.S. Uninsured Help Line
HIPAA
Individual Plans
Program
800-234-1317
Group Health Plans www.dol.gov/ebsa
Washington Association of Health Underwriters 206-623-8632 www.wahu-online.org
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov or
State Continuation Coverage
Coverage
Up to $2M lifetime maximum, assorted deductibles Under Washington law, newborns and adopted children are automatically covered under parents’ fully insured health plan for three weeks (60 days to notify carrier to add) if the plan provides dependent coverage. Pre-Existing Health Conditions Covered
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Eligibility
Name on license must draw wages If uninsured for previous 64-90 days, a waiting period for coverage of pre-existing conditions- not counting birth or adoption- may apply,; up to 3 months for 51+ employees; up to 9 mos. 20-50 employees, for HIPAA - up to 12 months
Costs depend on plan choice and + 375% of the Modified Community Rate
Healthy Options (Medicaid Managed Care Program) 800-562-3022 TTD: 800-848-5429 http://maa.dshs.wa.gov/ HealthyOptions
Medicaid
Up to $2M, assorted deductibles depending on age and county of residence Limits on Pre-Existing Health Conditions May Apply
Department of Social and Health Services 800-737-0617 800-562-3022 www1.dshs.wa.gov
Max lifetime benefit is $1 million per covered person
HO: Choose from several different plans
Choose from Medicare and Non-Medicare plans
Medicaid: Physician services, checkups (medical and dental), family planning, maternity, prenatal, and newborn care, prescriptions, mental health, hospital services, comfort care, hospice, dental services, drug and alcohol treatment, eye glasses, hearing aids
6 months pre-existing condition exclusion period. Exceptions apply. For example if applicant signs up through a portability policy Pre-Existing Health Conditions Covered
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for WSHIP, see next column
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Must be a Washington resident
HO: Low income families; Pregnant women; Children under age 19
Must have been rejected for coverage by an insurance carrier Cannot have any other health coverage Individuals who are eligible for Medicare may qualify for the WSHIP Medicare plan
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Medicaid: Child age 0-19: 200% FPL Working parents: up to 77% FPL Non-working parents: up to 38% FPL Pregnant woman: 185% FPL Parent: 50% FPL with resource test
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Washington
WSHIP
Washington State Health Insurance Pool 800-877-5187 www.wship.org
Washington Association of Health Underwriters 206-623-8632 www.wahu-online.org
Pre-Existing Health Conditions Covered
Company size 2-50 eligible employees
Low Income Individuals & Families
800-562-6900 (Consumer Hotline)
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
GUARANTEED COVERAGE
Owner can count as an employee with proprietor
Monthly Cost
COBRA Subsidy: 15 months of partially subsidized COBRA premium
GUARANTEED COVERAGE
Two employees must work 30 hrs/week for coverage
93
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
800-234-1317
Individuals with pre-existing, severe or chronic medical conditions
Washington resident and qualified immigrant
Costs depend on age and county/zone. If you are self-employed and buy your own insurance you are eligible to deduct 100% of the cost of the premium from your federal income (your taxable income)
Plan usually pays 80% of most benefits. Choice of annual deductibles $500-$1,500, subsidies for age 50+
Both: $0 or minimal share of cost
800.234.1317
Individuals and Families
Children
Women
Native American Indians
Washington Basic Health Plan
Apple Health for Kids (CHIP)
Washington Breast and Cervical Cancer Program
Indian Health Service
(Basic Health is no longer processing applications and has officially implemented a waiting list)
Washington Prescription Drug Discount Card
877-KIDS NOW 877-543-7669 800-562-3022 http://hrsa.dshs.wa.gov/ applehealth/index.shtml
888-438-2247 www.doh.wa.gov/wbchp
503-326-2020 (Portland-based) www.ihs.gov
Seattle Indian Health Board
Women-InfantChildren (WIC)
206-324-9360 www.sihb.org
800-841-1410 www.doh.wa.gov/cfh/wic/ default.htm
Medicare
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program 800-633-4227
Program
(Subsidy program) 800-826-2444 800-660-9840 www.basichealth.hca.wa.gov
Seniors and Disabled
Demographic
Publicly Sponsored Programs
877-208-1131 www.rx.wa.gov
Apple Health: Some children may qualify to have unpaid medical bills for the last three months covered
Some diagnostic services such as ultrasound, breast biopsy, surgical consultation, colonoscopy
Not all plans are offered in all counties
Full medical, dental and vision coverage
Comprehensive coverage including preventive care, office visits, pharmacy, emergency care, and maternity care
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Cancer treatment for some women qualified through Medicaid
WPDD: Provides prescription drug discounts to all Washington state residents Pre-Existing Health Conditions Covered
Referral to treatment services
Pre-Existing Health Conditions Covered
IHS: Programs vary depending on health center: primary & well child care, prenatal and post delivery care, family planning (birth control), minor surgical and orthopedic care, Pharmacy, dental and orthodontics, optometry, nursing, mental health, laboratory & radiology SIHB: multi-service non-profit community health center dedicated to improving the health and well-being of urban Indians living in the greater Seattle-King County area
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
BHP: 9 month waiting period of pre-existing conditions except of maternity care and prescriptions
Apple Health: Children age 18 and under who are Washington residents
Age 40-64
Member of a federally recognized tribe
Family income up to 300% (some children with higher incomes may still qualify)
Income below 250% FPL
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
$0 or sliding scale depending
$0 and share of cost for certain services; deductibles for certain plans
Washington resident Not eligible for Medicare
Apple Health: $0-30 a month depending on income. No
WPDD: $0
family pays more than $60
$0 and share of cost sliding scale
on income
WIC: $0 or minimal share of cost
www.coverageforall.org Washington
Monthly Cost
BHP: Premiums vary depending on plan chosen
Under-insured or uninsured
Eligibility
WPDD: Must live in Washington state. There are no income or age requirements to qualify for this prescription card.
WIC: Reside in Washington, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL
At or below 200% FPL
Coverage
BHP: Choose from plans from Kaiser Permanente, Columbia United, Molina, Community Health Plan of Washington
94
Demographic Program
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
U.S. Uninsured Help Line
COBRA
Group Health
National Association of Health Underwriters 703-276-0220 www.nahu.org
Assorted deductibles
Coverage
Then
800-234-1317
There is a 6-month look-back/12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Pre-Existing Health Conditions Covered
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium
Individuals & families
Individuals with pre-existing, severe or chronic medical conditions
Low Income families & medically needy
U.S. Uninsured Help Line
Carefirst Blue Cross Blue Shield
Medicaid
800-234-1317
Individual Plans
At least three plans must be offered on a “guarantee issue” basis to all consumers
Comprehensive plans available depending on needs of applicant
Pre-Existing Health Conditions Covered
D.C. does require all policies to cover certain benefits – such as mammograms, prostate cancer screening, and diabetes treatment
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Two month waiting period Pre-Existing Health Conditions Covered
Doctor visits, immunizations (shots), school physicals, emergency care, hospital stays, prescriptions, prenatal labor and delivery, vision care and glasses, dental, family planning, transportation to doctor appointments, home health care, durable medical equipment, health education services, mental health services, drug and alcohol treatment and more Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage. Applies to businesses with more than 20 employees
Eligibility is NOT subject to medical underwriting
If you are not HIPAA eligible and buy a GUARANTEED COVERAGE policy, CareFirst can impose a 10-month pre-existing condition exclusion period
Children Ages 0-19 and Pregnant Women may have an income up to 300% of the FPL
Eligibility
Most carriers require proof of the business or business owner, viability etc.
Monthly Cost
202-727-5355 202-442-5988 http://doh.dc.gov/doh
National Association of Health Underwriters 703-276-0220 www.nahu.org
Pre-Existing Health Conditions Covered
95
800-321-3497 www.carefirst.com
There is a 12-month exclusionary period limit for pre-existing conditions for HMOs, and a 10-month exclusionary period limit for pre-existing conditions for Carefirst Blue Cross Blue Shield (except for those qualified under HIPAA)
CareFirst is not required to credit your prior health coverage toward preexisting condition exclusion periods
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Costs depend on employer contribution
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
CareFirst can exclude conditions for which you ever got care or for which the insurer thought you should have sought care; this is called the prudent person rule
Costs depend on age and county/zone
Aged, Blind and Disabled: 100% FPL SSI Recipients: 74% FPL Medically Needy Individual: 53% FPL Medically Needy Couple: 41% FPL Resource requirements for everyone but children or pregnant mothers
Premiums can vary due to age, gender, health status, family size, and other factors.
$0 or share of cost
COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Washington D.C.
800.234.1317
Moderate income families
D.C. Healthy Families
Project Wish
(Breast and Cervical Cancer Early Detection Program) 202-442-5900 202-442-9128 (Spanish) http://doh.dc.gov/doh
Seniors and Disabled
Trade Dislocated Workers (TAA recipients)
Veterans
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
800-633-4227
Choose one of three health plans: Unison Health Plan DC Chartered Health Plan Health Right
Pre-Existing Health Conditions Covered
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D Pre-Existing Health Conditions Covered
Will cover COBRA if employer contributes less than 50% (or spouses’ employer)
Comprehensive preventive and primary care, outpatient and inpatient services
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Pre-Existing Health Conditions Covered
Coverage
Doctor visits, immunizations (shots), school physicals, emergency care, hospital stays, prescriptions, prenatal labor and delivery, vision care and glasses, dental, family planning, transportation to doctor appointments, home health care, durable medical equipment, health education services, mental health services, drug and alcohol treatment and more
Cancer education, screening, and diagnostic services
Program
202-639-4030 TTY: 202-639-4041 http://doh.dc.gov/doh
Women
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
For children, adolescents under age 19 who live alone, pregnant women, and parents/guardians
Must be a resident of Washington D.C.
Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
$0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
$0 and share of cost and co-pays depending on income level
Ages 50 and older are also eligible for a free annual mammogram
Up to 200% FPL for entire family, up to 300% for children only
Free transportation and interpreter services
$0 or share of cost
$0
Must not have access to employer plan that pays 50% of coverage cost.
Eligibility
Must be a resident of Washington D.C.
Monthly Cost
www.coverageforall.org Washington D.C.
96
Demographic
Private Health Insurance Small businesses (2-50 employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA/Mini-COBRA
U.S. Uninsured Help Line
and then
Program
800-234-1317
All group health insurance carriers can impose a 6-month look-back/ 12-month exclusionary period for preexisting conditions on enrollees that do not have prior creditable coverage
Coverage
HIPAA
Group Plans
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov
West Virginia Association of Health Underwriters 703-276-0220 www.nahu.org
Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered
800-234-1317
Individual Plans
Individuals with pre-existing, severe or chronic medical conditions
Low income families
Access WV
Medicaid
(WV Health Insurance Plan) 866-445-8491 304-558-8264 www.accesswv.org
304-348-3365 888-483-0797 www.wvdhhr.org/bcf/family_ assistance/medicaid.asp
Physician's services, hospital inpatient care, outpatient hospital services, emergency room services, X-ray and laboratory services prescribed by an authorized practitioner, routine dental care for children and with approval some medically necessary special care such as braces, adult dental limited to removal of cysts or tumors, biopsies, treatment of fractures of the jaw bones and some emergency services, prescribed drugs, ambulance, artificial limbs, braces etc., vision, nursing facilities, family planning services, outpatient mental health services
West Virginia Association of Health Underwriters 703-276-0220 www.nahu.org
COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer
Assorted plans depending on medical needs There is a 12-month look-back and 24-month exclusionary period limit
Four plan options including doctor visits, hospital care, labs, prescription drugs, transportation, routine shots for children, mental health and substance abuse services
COBRA Subsidy: 15 months of partially subsidized COBRA premium
Pre-Existing Health Conditions Covered
Annual benefit maximum $200K and lifetime $1M Must meet a 6-month waiting period for pre-existing conditions. This means that AccessWV will not provide benefits for services related to these conditions, including prescriptions, for 6 months after coverage is effective
HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees (including owner)
COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Eligibility
Owner name on business license must draw wages from the company Most small group carriers also require 75% employee participation and accept employees who sign a waiver indicating other coverage as counting towards the 75%
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for Access WV, see next column
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Previous coverage terminated for reasons other than nonpayment of premium or fraud
Pregnant Women and infants (ages 0-1): 150% FPL
Cannot be eligible for COBRA, or government programs (must have exhausted this option)
Children ages 6-19: 100% FPL
Must prove denial of coverage or offer of higher premium than Access WV
Children ages 1-5: 133% FPL
Supplemental Security Income Recipients: 74% FPL Working Parents: 34% FPL Medically Needy: 28% FPL Non-Working Parents: 19% FPL
Mini-COBRA: Applies to small businesses with less than 20 employees
Age limits for certain services
Monthly Cost
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs
97
Costs depend on employer contribution and ± 30% of the insurance company’s index rate
COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Costs for individual coverage varies
$0 or share of cost; no copays
$400-2,000 deductible for one person depending on the plan Premium prices vary based on family or single, region, age and plan selected
COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column
West Virginia
800.234.1317
Children in moderate income families
Women
WVCHIP
Breast and Cervical Cancer Screening 800-642-8522 304-558-5388 www.wvdhhr.org/bccsp
Women-InfantChildren (WIC)
Medicare
Health Coverage Tax Credit
VA Medical Benefits Package
800-MEDICARE 800-633-4227 www.medicare.gov
Medicare Prescription Drug Program
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
877-222-8387 www.va.gov
WVSHIP
304-558-3317 877-987-4463 www.wvship.org Mammograms for women age 50 and older Pap tests and pelvic exams for women age 25 and older Surgical breast consults, diagnostic mammograms, fine needle aspirations, breast biopsies, breast ultrasounds, and colposcopies with or without biopsies available if deemed necessary Pre-Existing Health Conditions Covered
Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D WVSHIP is a Medicare counseling service
Will cover COBRA if employer contributes less than 50% (or spouses’ employer)
Comprehensive preventive and primary care, outpatient and inpatient services
Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits
Pre-Existing Health Conditions Covered
Coverage
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Veterans
800-633-4227
304-558-0030 http://ons.wvdhhr.org/
WVCHIP: Doctor visits, check-ups, hospital visits, immunizations, prescriptions, tests and x-rays, dental care, vision, emergency care, 24 hour nurse-line, mental health, diabetic supplies, urgent care or after hour clinic visits, case management for special needs and other services
Trade Dislocated Workers (TAA recipients)
Program
(Children’s Health Insurance Plan) 877-WVA-CHIP 877-982-2447 304-558-2732 www.wvchip.org
Seniors and Disabled
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
No health insurance, or your health insurance does not cover the services
Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Must be receiving TAA (Trade Adjustment Assistance)
”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions
Not enrolled in certain state plans
Certain veterans must have completed 24 continuous months of service
$0 and share of cost for certain services; deductibles for certain plans
20% of the insurance premium
$0 and share of cost and co-pays depending on income level
Age restrictions for each service, 25-64 Income at or below 200% FPL
Must not have access to employer plan that pays 50% of coverage cost.
Eligibility
WVCHIP: Must be a West Virginia resident currently living in the state, Must be 18 or younger, Cannot have health insurance now and cannot have had it in the past six months (for the Basic CHIP plans) or the past twelve months for the CHIP Premium Plan. Also cannot be eligible for the West Virginia State Employee Health Insurance or Medicaid; Must have a family income at or below 250% FPL WIC: Reside in West Virginia, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL
$0 or minimal share of cost
WIC: $0 or minimal share of cost
www.coverageforall.org West Virginia
Monthly Cost
WVCHIP: $0-35 co-pays for drugs and services with a maximum of $0-750 annually depending on family size and income
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Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA or HIPP
U.S. Uninsured Help Line
Program
800-234-1317
Group Health
Wisconsin Office of the Commissioner of Insurance 800-236-8517 608-266-3585 http://oci.wi.gov
Then convert to
HIPAA
(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov
800-234-1317
Individual Plans
Wisconsin Office of the Commissioner of Insurance 800-236-8517 608-266-3585 http://oci.wi.gov
Individuals with pre-existing, severe or chronic medical conditions
Low income children and families
HIRSP
Medicaid
(Wisconsin Health Insurance Risk Sharing Plan) 800-828-4777 608-221-4551 www.hirsp.org
800-362-3002 www.dhfs.state.wi.us/Medicaid
Or
State Conversion Plans Pre-existing conditions can be excluded for a limited time depending upon the type of group plan you are joining
Coverage
Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered with Some Limitations
COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPP: Benefits are the same as what you had with your previous employer, HIPP is a premium assistance program
Covers certain state mandated items, Annual open enrollment regardless of pre-existing conditions
HIRSP offers five plan options: Plan 1 is for people not eligible for Medicare and offers two deductible choices, and Plan 2 is only for people eligible for Medicare
Coverage options vary by carrier, but most offer plans that are HSA (Health Savings Account) compatible
Hospital and physician care, prescription drugs and insulin, maternity care and other services
Pre-Existing Health Conditions Covered with Some Limitations
Pre-Existing Health Conditions Covered with Some Limitations
Medical, dental and vision, prescriptions, hospitalization and more depending on program Pre-Existing Health Conditions Covered
HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Owner can count as an employee
Eligibility
Proprietor-name on license must draw wages
HIPP: Pays employer premiums for families that have high cost medical conditions and are eligible for Badger Care
Eligibility is based on medical underwriting There is a 12 month look back period during first two years of coverage. If condition is deemed preexisting there can be a 24 month exclusionary period Must be resident of state or documented immigrant If you are denied coverage for a medical condition, you may be eligible for HIRSP, see next column
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Must be under age 65
Limited assets such as cash, savings, stocks and bonds AND...
Must be Wisconsin resident
Parents, children 1-19, pregnant women and infants at 185% FPL
Must demonstrate uninsurability Cannot be eligible for employeroffered group health insurance Cannot be eligible for comprehensive Wisconsin Medicaid services or BadgerCare Plus
Medically needy individuals up to 83% FPL Medically needy couples up to 61% FPL Wisconsin resident or documented immigrant
Cannot be eligible for COBRA, or government programs (must have exhausted this option)
Automatically covered if on cash assistance or SSI
Premiums vary based on plan. Plan 1: Option A has annual deductible of $1000 and 20% co-pay with out-of-pocket max of $2,000; Option B has deductible of $2500 with $3500 out-of-pocket max and 20% co-pays Plan 2: $500 annual deductible and HIRSP pays 100%
$0 or minimal share of cost
Monthly Cost
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA Costs depend on employer contribution and ± 30% of the insurance company’s index rate
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Various price ranges depending on deductible and what plan you buy
HIPP: $0 or minimal share of cost
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Wisconsin
800.234.1317
Children
Women
Individuals with chronic health conditions
Adults
Trade Dislocated Workers (TAA recipients)
Badger Care Plus
Wisconsin Well Women Program
Wisconsin Chronic Disease Program
BadgerCare Core
Health Coverage Tax Credit
800-362-3002 www.badgercareplus.org
(WCDP) 866-908-1363 http://dhfs.wisconsin.gov/wcdp
800-722-2295 http://dhs.wisconsin.gov/wic/ index.htm
BCP: Comprehensive care including but not limited to doctor visits, mental, dental, prescriptions, hospitalization and more (offers same as Medicaid)
Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
The Wisconsin Chronic Disease Program (WCDP) offers assistance to Wisconsin residents with chronic renal disease, hemophilia and adult cystic fibrosis The WCDP is funded entirely by state dollars; the program pays health care providers for disease related services and supplies provided to certified Wisconsin Chronic Disease Program participants after all other sources of payment have been exhausted
Doctor visits, Hospital services, Emergency room visits, Emergency ambulance rides, Emergency dental services, Some prescription drugs, Physical therapy, Occupational therapy, Speech therapy, Cardiac rehabilitation, Durable medical equipment, Disposable medical supplies, Dialysis/ kidney-related services
Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Pre-Existing Health Conditions Covered
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
BCP: All children under 19 years old without access to health insurance; Pregnant women with a monthly income up to 300% of the FPL; Parents and Caretakers up to 200% of the FPL
Must be Wisconsin resident and have satisfactory immigration status 45 to 64 years of age with no insurance Must be uninsured or underinsured with income under 250% of FPL
Wisconsin resident; U.S. citizen or legal immigrant; Age 19 through 64; Do not have children or dependent children, under age 19 living with you; Are not pregnant; Have family income at or below 200%; Do not have private health insurance or employer coverage 12 months before the application date; Do not currently have access to insurance from an employer; Are not getting BadgerCare Plus, Medicaid or Medicare.
Must be receiving TAA (Trade Adjustment Assistance)
WIC: Reside in Wisconsin, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL
Chronic Disease Program participants are responsible for certain co-payments and annual deductible determined by the program. Participants whose annual income exceeds 300% of the federal poverty level must pay a certain percent of out-of-pocket expense before becoming eligible to receive WCDP benefits. The state seeks repayment of WCDP benefits provided to Participants under the Estate Recovery Program
Both: $0 to minimal share of cost
$0
$0 or minimal share of cost
$0 or minimal share of cost
20% of the insurance premium
Coverage
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
If screened and diagnosed for breast or cervical cancer may be eligible for complete health coverage through Well Woman Medicaid
(Effective October 9, 2009, enrollment process for BadgerCare Plus Core Plan has been suspended because the total number of applications received is greater than the number of slots available. A waitlist has been created and those on the waitlist will be able to enroll as space becomes available)
866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
Program
Women-InfantChildren (WIC)
608-266-8311 800-218-8408 www.dhfs.wisconsin.gov/ womenshealth/wwwp
800-291-2002 http://dhs.wisconsin.gov/ badgercareplus/core/index.htm
Demographic
Publicly Sponsored Programs
Must not have access to employer plan that pays 50% of coverage cost Not enrolled in certain state plans
Eligibility Monthly Cost
www.coverageforall.org Wisconsin
100
Demographic
Private Health Insurance Small businesses (2-50 Employees)
Individuals recently covered by an employer health plan
Individuals & families
U.S. Uninsured Help Line
COBRA
U.S. Uninsured Help Line
Group Plans
Conversion Plans
Program
800-234-1317
National Association of Health Underwriters 703-276-0220 www.nahu.org
Up to $5M lifetime maximum, assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply
Or
and then
HIPAA
Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium
800-234-1317
Individual Plans
National Association of Health Underwriters 703-276-0220 www.nahu.org
Up to $5M, assorted deductibles depending on age and ZIP code Limits on Pre-Existing Health Conditions May Apply
Coverage
HIPAA: Benefits are based on the program selected and there is no expiration of coverage
Individuals unable to obtain private health insurance due to a medical condition
Low-income individuals & families
WHIP
Medicaid EqualityCare
Wyoming Health Insurance Pool 800-442-2376 307-634-1393 http://insurance.state.wy.us/ whip.html
The pool plan options provide comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, rehabilitation, durable medical equipment, and mental health and substance abuse, among other services
800-251-1268 http://wdh.state.wy.us/ healthcarefin/equalitycare Contact local public or health services department
Offers health, dental, vision, hospitalization and prescription coverage Treatment for special health problems like breast cancer, kidney problems, nursing home needs, and AIDS Pre-Existing Health Conditions Covered
The pool provides enrollees with two plan choices, the Brown Plan and the Gold Plan
Pre-Existing Health Conditions Covered
Effective January 1, 2010, the lifetime maximum paid for the Brown and Catastrophic Plan is increasing to $750,000. The Gold Plan’s life time maximum will also increase to $1,000,000 Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Company size 2-50 employees
COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage
Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage
Eligibility
Owner can count as an employee Owner name on business license must draw wages from the company
Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for WHIP, see next column
GUARANTEED COVERAGE
GUARANTEED COVERAGE
Applicant has been refused coverage for health reasons by one insurer
Ages 0-5 and pregnant women up to 133% FPL
or Applicant has health insurance coverage more restrictive than the Pool or
Ages 6-18 up to 100% FPL Working Parents up to 52% FPL Non-Working Parents up to 54% FPL Live in Wyoming
Applicant has health insurance coverage at a rate exceeding the Pool
HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA
Must be a Wyoming resident Waiting periods may apply Applicants will be assigned to the proper eligibility level based on adjusted gross income. Level 2 is below 250% FPL, Level 1 is above 250% FPL
Monthly Cost
Church organizations may be excluded
101
Costs depend on employer contribution and ± 35% of the insurance company’s index rate
COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium
Costs for individual coverage varies
Costs vary depending on age, region and program. Cannot exceed 200% of market rate
$0 or minimal share of cost
COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column
Wyoming
800.234.1317
Children
KidCare CHIP
Women-InfantChildren (WIC)
Women
Pregnant Women
Native American Indians
Children’s Special Health Program (CSH)
Breast and Cervical Cancer Screening
Best Beginnings Wyoming Baby
Indian Health Services
800-438-5795 307-777-7941 http://wdh.state.wy.us/ familyhealth/csh/index.html Contact local public or health services department
KidCare CHIP: Inpatient and outpatient hospital services, doctor visits, laboratory and x-ray services, well-baby, well-child and well-adolescent care, including age appropriate immunizations, prescriptions, mental health services, dental services (no braces, only preventive and some basic, services are covered) $750 maximum per benefit year, vision services (no contacts), physical therapy, other health benefits
Covered services include care coordination, specialty medical care, some equipment and medications, lab/X-rays related to diagnosis services, support services, and diagnostic evaluations There is an annual limit of up to $40,000 Pre-Existing Health Conditions Covered
307-777-7275 http://wdh.state.wy.us/ familyhealth/bestbeginnings/ index.html
406-247-7107 www.ihs.gov
Contact local public or health services department
Medical assistance is available for most women through Medicaid if their breast or cervical cancer exams were paid for by WBCCEDP and they were found to have breast or cervical cancer, including pre-cancerous conditions Pre-Existing Health Conditions Covered
Financial assistance for eligible women, pregnancy counseling and teaching, referrals to appropriate resources in the community, educational materials relating to pregnancy, smoking cessation assistance and referral, prenatal class/ support group, parenting classes for parents of newborns, home visits for moms and babies, breast feeding support
Comprehensive health care services available through a Service Unit located on the Wind River Reservation and three hospitals on the Blackfoot, Crow, and Fort Belknap Reservations Pre-Existing Health Conditions Covered
Coverage
800-994-4769 307-777-7494 http://wdh.state.wy.us/ familyhealth/wic/index.html
307-777-6006 800-264-1296 http://wdh.state.wy.us/phsd/ bccedp/index.html
Pre-Existing Health Conditions Covered
WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services
Program
877-KIDSNOW 877-543-7669 http://wdh.state.wy.us/ healthcarefin/chip/index.html
Children’s special health
Demographic
Publicly Sponsored Programs
Pre-Existing Health Conditions Covered
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
GUARANTEED COVERAGE
KidCare CHIP: At or below 200%FPL, A US Citizen or lived in the US for 5 years, A Wyoming resident, Age 18 or younger, No insurance within last 30 days
Your child must be a Wyoming resident under 19 years of age and suspected or known to have one of the medically eligible conditions, i.e. chronic illness or disability. Your child may also have insurance, KidCare CHIP, or EqualityCare (Medicaid).
Women age 50 to 64 years
Eligibility requirements vary from county to county
Member of a federally recognized tribe
Women age 18-50 with certain abnormal breast or cervical exams may also qualify Income must be at or below 250% of federal poverty guidelines Cannot have insurance coverage, including Medicaid
$0 or sliding scale share-of-
cost
$0 or minimal share of cost
$0
$0 or minimal share of cost
WIC: $0 or minimal share of cost
www.coverageforall.org Wyoming
Monthly Cost
KidCare CHIP: $3-5 co-pays with an annual family maximum of $200
Be sure to call your local office
Eligibility
WIC: Reside in Wyoming, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL
Women age 30-64 may be eligible if they have not had a pap test in past 5 years
102
Appendices
103
how to understand
The COBRA Subsidy Affordable COBRA For workers who were involuntarily terminated between September 1, 2008 and May 31, 2010, the government will subsidize 65% of their premiums under COBRA for fifteen months. This subsidy also applies to healthcare continuation coverage if required by the state. 2nd Chance for COBRA For workers who were involuntarily terminated between September 1, 2008 and the day the stimulus Law goes into effect, and who did not sign up for COBRA, will get an additional 60 days to do so and receive the subsidy. This special election period opportunity does not apply to coverage sponsored by employers with less than 20 employees that is subject to State law. Employer Notification Within 60 days of enactment, the Employer or COBRA Administrator shall provide an additional notification to any Assistance Eligible Employee who became entitled to elect COBRA before enactment of this Law. Tax Credit for Employers To offset the employer’s expense, the employer may take a full tax credit for its expenditures out of its payroll taxes including both income tax withholding and FICA. High Income Exclusion If the modified adjusted gross income (AGI) of a participant exceeds $125,000 a year, or a family’s AGI exceeds $250,000, their income tax will be raised by the premium reduction amount – effectively removing the subsidy. Plan Options Qualified Beneficiaries (QBs) under the stimulus will have the option to change plans to another product offered by the Employer with the following requirements: • Employer agrees to allow QBs to enroll in different coverage • The selected plan does not exceed the premium for coverage in which the individual was enrolled at the time the qualifying event occurred • Plan cannot be Dental, Vision, Counseling, Referral or FSA • Coverage is also offered to active employees
104
other services (by state) Alabama WIC (Women-Infant-Children) 888-942-4673 800-654-1385 www.adph.org/wic
Family Planning 800-545-1098
Vaccines for Children 800-469-4599
Alabama Department of Insurance 334-269-3550 800-433-3966 (in state) www.aldoi.gov
Alabama Department of Public Health 334-206-5300 www.adph.org
Alaska Anchorage Neighborhood Health Center 907-257-4600 www.anhc.org
Anchorage Community Health Services 907-343-4605
Women-Infant-Children (WIC)
907-465-3100 www.hss.state.ak.us/dpa/programs/nutri/wic/ default.htm
Alaska Division of Insurance 800-467-8725 (in state) 907- 465-2515 www.dced.state.ak.us/insurance
Alaska Health and Social Services 800-211-7470 907-562-3671 www.hss.state.ak.us
Arizona Women-Infant-Children (WIC) 800-252-5942 www.azwic.gov
Health Care Group of Arizona 602-417-6755 802-247-2289
Federal Emergency Services (FES)
(for people who cannot verify Citizenship or immigration) 800-352-8401 www.ahcccs.state.az.us
Arizona Department of Insurance 800-325-2548 www.id.state.az.us
Arizona Department of Economic Security 800-352-8401 www.azdes.gov
Arkansas Women-Infant-Children 800-445-6175 501-661-2905 http://www.healthyarkansas.com/ breastfeeding/wic_about.html
DDS Children’s Services 800-482-5850 x22277 501-682-8207 www.medicalhomear.org
Immunization Program 501-661-2793
AR Family Planning 501-661-2531
Women’s Health
Health Consumer Alliance
www.healthconsumer.org (13 different languages; information about programs and legal rights by county)
California Department of Health Services
916-445-4171 (English and Spanish) TTY 888-757-6034 www.dhcs.ca.gov (For information about Medi-Cal, Medicare, SSI, Food Stamps, Cash Assistance, CMSP, MISP, Healthy Families Program, CCS, MTP and more)
California Department of Insurance
800-927-4357 www.insurance.ca.gov (English and Spanish; general information on all types of insurance)
California Department of Managed Health Care
888-466-2219 www.hmohelp.ca.gov (English and Spanish; general information on all types of insurance)
BABY CAL
800-BABY-999 (800-222-9999)
WISEWOMAN
800-511-2300 www.dhs.ca.gov/cancerdetection
Women-Infant-Children (WIC)
501-661-2480
888-WICWORKS 888-942-9675 www.wicworks.ca.gov
Arkansas Department of Insurance
Colorado
501-371-2600 800-282-9134 http://insurance.arkansas.gov
Arkansas Department of Human Services 501-682-1001 800-482-8988 www.arkansas.gov/dhhs
California Indian Health Services 916-930-3927 www.ihs.gov
California Children’s Services
www.dhs.ca.gov/pcfh/cms/ccs Or contact local county social services agency
Women-Infant-Children (WIC) 800-688-7777 www.cdphe.state.co.us/ps/wic
Colorado Indigent Care Program (CICP) 303-866-3513 (Denver Metro Area) 800-221-3943 www.chcpf.state.co.us
Colorado Division of Insurance
303-894-7490 www.dora.state.co.us/insurance/
Colorado Department of Human Services 303-866-5700 www.cdhs.state.co.us
105
Connecticut Women-Infant-Children (WIC)
Florida Office of Insurance Regulation
860-509-8084 www.ct.gov (Search “WIC”)
800-342-2762 www.floir.com
Connecticut Insurance Department
Florida Health and Human Services
Connecticut Department of Social Services
Georgia
800-203-3447 860-297-3900 www.state.ct.us/cid
800-842-1508 860-424-5016 www.dss.state.ct.us
Delaware Women-InfantChildren (WIC)
800-222-2189 www.dhss.delaware.gov/dph/chca/ dphwichominf01.html
Immunization Services 800-282-8672
Family Planning
http://dhss.delaware.gov/dhss/dph/chs/ chsfamilyplanning.html
Child Development Watch
http://dhss.delaware.gov/dhss/dph/chs/chscdw. html
Delaware Insurance Department 800-282-8611 www.delawareinsurance.gov
Delaware Department of Health and Social Services 800-464-4357 800-273-9500 www.dhss.delaware.gov
Florida Women-InfantChildren (WIC)
800-342-3556 www.doh.state.fl.us/family/wic
Florida Alzheimer’s Disease Initiative 850-414-2000
Florida AIDS Insurance Continuation Program
305-592-1452 www.doh.state.fl.us/disease_ctrl/aids/care/aicp. html
106
www.dcf.state.fl.us/ess www.doh.state.fl.us
Georgia Insurance Commission 800-656-2298 www.inscomm.state.ga.us
Immunization Program 404-657-3158
Idaho Indian Health Services 503-326-2020 www.ihs.gov
Women-Infant-Children (WIC)
800-926-2588 http://healthandwelfare.idaho. gov/FoodCashAssistance/ WomenInfantsandChildren/tabid/92/Default. aspx
Idaho Department of Insurance 208-334-4250 www.doi.idaho.gov
Idaho Department of Health and Welfare
Tobacco Use Prevention
800-926-2588 www.healthandwelfare.idaho.gov
Emergency Food Assistance
Illinois
404-657-6611
404-463-2607 404-463-8042 404-657-3742
Georgia Department of Family and Children Services 404-656-4507 http://dfcs.dhr.georgia.gov
Georgia Department of Community Health http://dch.georgia.gov
Hawaii PACE Hawaii (age 55 and older) 808-832-6131
Hawaii Immunization Program 800-933-4832 808-586-8300 www.vaxhawaii.com
STD/AIDS Prevention Branch 808-733-9281
Women-Infant-Children (WIC)
Oahu: 586-8175 Neighbor Islands: 888-820-6425 http://hawaii.gov/health/family-child-health/ wic/index_html
Hawaii Division of Insurance 808-586-2790 808-586-2799 http://hawaii.gov/dcca/ins
Hawaii Department of Health 808-586-4400 www.hawaii.gov/health
Health Benefits for Workers with Disabilities 800-226-0768 www.hbwdillinois.com
Women-Infant-Children (WIC) 800-843-6154 www.dhs.state.il.us/page aspx?item=30513
Illinois Department of Insurance 877-527-9431 http://insurance.illinois.gov
Illinois Department of Human Services 800-843-6154 www.dhs.state.il.us
Indiana Women-InfantChildren (WIC)
800-522-0874 www.in.gov/isdh/19691.htm
Indiana Department of Insurance 800-622-4461 317-232-2385 www.in.gov/idoi
Indiana Family and Social Services 317-232-4946 www.in.gov/fssa
Iowa
Louisiana
Women-Infant-Children (WIC)
Louisiana KidMed
Iowa Insurance Division
Public Health Units
800-532-1579 www.idph.state.ia.us/wic/default.asp
800-325-2548 515-281-5705 www.iid.state.ia.us
Iowa Department of Human Services
800-259-4444 www.la-kidmed.com
(community care) www.oph.dhh.louisiana.gov/ophregions
Louisiana Department of Insurance
www.dhs.state.ia.us
800-259-5300 www.ldi.la.gov
Kansas
Louisiana Department of Health and Hospitals
Kansas Foundation for Medical Care 800-432-0770 785-273-2552 www.kfmc.org
225-342-9500 www.dhh.louisiana.gov
Maine
Senior Health Insurance Counseling of Kansas
Maine Genetics Program
Kansas Insurance Department
Maine Rx Plus
800-860-5260 www.agingkansas.org/SHICK/shick_index.html
207-287-4623 TTY: 800-606-6015 www.medicare.gov
785-296-3071 800-432-2484 http://ksinsurance.org
866-796-2463 TTD: 800-423-4331 www.maine.gov/dhhs/mainerx
Kansas Department of Social and Rehabilitation Services
Maine Bureau of Insurance
785-296-3959 888-369-4777 www.srskansas.org
Kentucky State Health Insurance Assistance Program
(counseling for seniors and disabled) 877-293-7447 http://chfs.ky.gov/dail/ship.htm
ICARE
877-422-7307 http://icare.ky.gov
Kentucky Office of Insurance 502-564-3630 800-595-6053 800-462-2081 (TDD) http://doi.ppr.ky.gov/kentucky
Kentucky Cabinet for Health and Family Services 800-372-2973 800-627-4702 (TDD) www.chfs.ky.gov
207-624-8475 800-300-5000 TTY: 888-577-6690 www.maineinsurancereg.org
Maine Department of Health and Human Services 207-287-3707 www.maine.gov/dhhs
Maryland
Maryland Department of Health and Mental Hygiene 410-767-6500 877-463-3464 www.dhmh.state.md.us
Massachusetts MASS Medline
866-633-1617 www.massmedline.com
MASSCare (AIDS)
617-994-9819 www.mass.gov/dph/fch/masscare.htm
AIDS Action Committee Hotline 800-235-2331 617-437-6200 617-437-1394 TTY www.aac.org
Massachusetts Division of Insurance 617-521-7794 www.mass.gov/doi
Massachusetts Department of Public Health 617-624-6000 617-624-6001 www.mass.gov/dph
Healthcare for Artists 617-784-4652
[email protected] www.healthcareforartists.org
Health Care For All Help Line 800-272-4232 www.hcfama.org
The Access Project
Family Planning
617-654-9911
[email protected] www.accessproject.org
Vaccines for Children
Michigan
410-767-6723 www.fha.state.md.us/mch/fp_home.cfm
410-767-6030 http://edcp.org/html/vaccine.html
Maryland AIDS Insurance Assistance Program
410-767-5227 800-358-9001 http://dhmh.state.md.us/AIDS/HIV_index.html
Maryland Insurance Administration
410-468-2000 800-492-6116 800-735-2258 www.mdinsurance.state.md.us
Family Planning 800-642-3195 866-501-5656 TTY
Children’s Special Health Care Services 800-359-3722
Michigan Department of Financial Insurance Services 517-373-0220 877-999-6442 www.michigan.gov/cis
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Michigan Department of Community Health 517-373-3740 www.michigan.gov/mdch
Missouri Missouri CLAIM
800-390-3330 www.missouriclaim.org
775-684-3499
Nevada Department of Insurance
Disabilities Linkage Line
800-219-3224
775-687-4270 702-486-4009 http://doi.state.nv.us
Missouri Department of Insurance
Nevada Department of Health and Human Services
Family Planning
573-751-4126 www.insurance.mo.gov
775-684-4000 http://dhhs.nv.gov/
Missouri Department of Social Services
New Hampshire
Minnesota 866-333-2466 http://www.semcil.org/dll.html
800-78FACTS 800-783-2287 www.stdhotline.state.mn.us www.health.state.mn.us/divs/fh/mch/ familyplanning
Indian Health Services 218-444-0458 www.ihs.gov
Minnesota Department of Commerce 651-296-4026 TTD: 651-296-2860 www.commerce.state.mn.us
Minnesota Department of Human Services 651-431-2000 TTD: 800-627-3529 www.dhs.state.mn.us
Mississippi
Vaccines for Children
573-751-4815 www.dss.mo.gov
Montana
Montana State Auditor’s Office
New Hampshire Department of Insurance
800-332-6148 406-444-2040 http://sao.mt.gov
603-271-2261 800-852-3416 www.nh.gov/insurance
Montana Department of Public Health and Human Services
New Hampshire Department of Health and Human Services
800-551-3191 www.dphhs.mt.gov
www.dphhs.mt.gov
Mississippi Care For Yourself
Nebraska Health Insurance, Information, Counseling and Assistance Program
Donated Dental Services 601-368-9823 800-366-3640
Mississippi Department of Insurance 601-359 3569 800-562 2957 www.mid.state.ms.us
Mississippi Department of Health 866-458-4948 601-576-7400 www.msdh.state.ms.us
603-271-4517 800-852-3345 ext.4517 TTD: 800-735-2964
New Hampshire Medication Bridge Program
Nebraska
(Family Planning) 800-421-2408 www.msdh.state.ms.us/care
Family Planning
Montana State Health Insurance Assistance Program
Children's Medical Program (Chronic illnesses) 800-844-0898
603-225-0900
800-852-3345 www.dhhs.state.nh.us
New Jersey Special Child Health and Early Intervention Services
(for seniors) 800-234-7119 402-471-2201 TTD: 800-833-7352
609-984-0755 www.nj.gov/health/fhs/sch/ index.shtml
Nebraska Department of Insurance
800-356-1561
402-471-2201 TTD: 800-833-7352 www.doi.ne.gov
Nebraska Health and Human Services
Medicaid Dental Family Planning 609-292-8104
New Jersey Department of Banking and Insurance
402-471-3121 www.hhs.state.ne.us/index.htm
800-446-SHOP 800-446-7467 www.state.nj.us/dobi
Nevada
New Jersey Department of Human Services
Vaccines for Children 775-684-5900
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AIDS Drug Assistance
609-292-3717 www.state.nj.us/humanservices/
New Mexico MEDBANK
(Emergency Prescription Drug Program) 800-432-2080 www.nmaging.state.nm.us/medbank2.html
New Mexico Health Policy Commission
North Carolina Health CARE LINE English/Español 800-662-7030 TTP: 919-733-4851
North Carolina Department of Insurance
505-827-6201 www.hpc.state.nm.us
800-546-5664 919-807-6800 www.ncdoi.com
New Mexico Public Regulations Commission
North Carolina Department of Health and Human Services
Chronic Disease Service
405-271-4072 http://www.ok.gov/health/Disease, Prevention,_Preparedness/Chronic_Disease_ Service
Family Planning
405-271-4476 www.health.state.ok.us/Program/whd/fpp. html
RX for Oklahoma 877-794-6552 www.RX4OKLA.com
888-4ASK-PRC 888-427-5772 505-827-3928 www.nmprc.state.nm.us/id.htm
800-662-7030 877-452-2514 (TTY) 919-855-4400 919-733-4851 (TTY) www.dhhs.state.nc.us/
Oklahoma Department of Business Regulation
New Mexico Human Services Department
North Dakota
Oklahoma Department of Health
505-827-3100 888-997-2583 www.state.nm.us/hsd/mad
New York Women-Infant-Children (WIC) 800-522-5006 www.health.state.ny.us/ prevention/nutrition/wic
Family Planning
800-541-2831 www.health.state.ny.us/health_care/medicaid/ program/longterm/familyplanbenprog.htm
Growing Up Healthy
Children’s Special Health Services 800-755-2714 TTY: 701-328-2436 www.ndhealth.gov/CSHS/
North Dakota Insurance Department 701-328-2440 800-247-0560 www.nd.gov/ndins
North Dakota Department of Human Services 701-328-2310 800-472-2622 www.nd.gov/dhs/
800-522-5006 (in state)
NY AIDS - HIV Counseling and Testing 800-541-AIDS 800-541-2437 (in state)
New York Insurance Department 212-480-6400 800-342-3736 www.ins.state.ny.us
New York Department of Health
Ohio Ohio Department of Insurance 800-686-1526 614-644-2658 www.ohioinsurance.gov
Ohio Department of Health www.odh.ohio.gov
Help Me Grow Program 614-644-8389 www.ohiohelpmegrow.org
866-881-2809 www.health.state.ny.us
HIV Drug Assistance Program
North Carolina
Oklahoma
Safety Net Dental Services
SoonerStart
919-707-5480 www.communityhealth.dhhs.state.nc.us/ dental/access_2.htm
614-466-6374
(child development) 405 522-5167 www.okdhs.org/programsandservices/dd/ss/
405-521-2828 800-522-0071 www.oid.state.ok.us
405-271-5600 800-522-0203 www.ok.gov/health
Oregon Oregon Insurance Division 503-947-7980 www.oregoninsurance.org
Oregon Department of Human Services 503-945-5944 www.oregon.gov/DHS/
Oregon Health Authority 503-947-2340 877-398-9238 www.oregon.gov/oha
Oregon Helps
(Program screener tool) http://oregonhelps.org
Pennsylvania APPRISE
(Medicare advice) 717-783-1550 www.aging.state.pa.us
Family Planning
877-PA-HEALTH 877-724-3258 www.dpw.state.pa.us/ServicesPrograms/ MedicalAssistance/003670181.htm
Women-InfantChildren (WIC) 800-WIC-WINS 800-942-9467 www.pawic.com
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Pennsylvania Insurance Department 877-881-6388 www.ins.state.pa.us
Pennsylvania Department of Health 877-PAHEALTH 877-724-3248 www.dsf.health.state.pa.us
Rhode Island RI Early Intervention (child development) 401-462-2501 TTY 401-462-6353
Immunization Program 401-222-5960 www.health.ri.gov/immunization
Rhode Island Pharmaceutical Program for Elderly 401-462-3000 TTY 401-462-0740 www.dea.state.ri.us
Indian Health Services
605-226-7531 www.ihs.gov/FacilitiesServices/AreaOffices/ Aberdeen
South Dakota Division of Insurance
605-773-3563 www.state.sd.us/drr2/reg/insurance
South Dakota Department of Social Services 605-773-3165 www.state.sd.us/social
Tennessee Tennessee Health Options Services 888-486-9355
Women-Infant-Children (WIC)
TX Children with Special Needs 800-252-8023 www.dshs.state.tx.us/cshcn
Texas Department of Insurance 800-252-3439 512-463-6464 www.tdi.state.tx.us
Texas Department of State Health Services 888-963-7111 www.dshs.state.tx.us
Utah RxConnect
866-221-0265 http://health.utah.gov/rxconnectutah
Health Insurance Information Program 800-541-7735
800-DIAL-WIC 800-342-5942 http://health.state.tn.us/WIC
Utah Insurance Department
Rhode Island Department of Business Regulation
CoverRX
Utah Department of Health
401-462-9500 www.dbr.state.ri.us
888-560-2649 866-268-3786 www.covertn.gov/web/cover_rx.html
Rhode Island Department of Health
Prescription Assistance
Vermont
Family Planning
Vermont Refugee Health Program
401-222-2231 www.health.state.ri.us
South Carolina South Carolina Family Planning Services 803-898-3432
888-486-9355
615-741-7353 http://health.state.tn.us/womenshealth/
Tennessee Department of Commerce and Insurance 615-741-2218 800-342-4029 www.state.tn.us/commerce/insurance
801-538-3800 www.insurance.utah.gov 801-538-6101 888-222-2542 801-538-9936 www.health.utah.gov
800-464-4343 802-863-7200
VScript
800-250-8427 TTD: 1-888-834-7898
Tennessee Department of Health
Vermont Department of Banking, Insurance, Securities & Health Care Administration
615-741-3111 http://health.state.tn.us/
802-828-3301 www.bishca.state.vt.us
803-737-6180 800-768-3467 www.doi.sc.gov
Texas
Vermont Agency of Human Services
Women-Infant-Children (WIC)
800-942-3678 www.dshs.state.tx.us/wichd/default.shtm
South Carolina Health Insurance Assistance 800-868-9095
South Carolina Department of Insurance
800-868-0404 www.dhec.sc.gov/health/mch/wic/index.htm
South Carolina Department of Health and Human Services 888-549-0820 www.dhhs.state.sc.us
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South Dakota
Women-Infant-Children (WIC)
800-287-0589 802-241-2800 www.ahs.state.vt.us
Texas Family Planning
Virginia
Texas Vaccines for Children
Virginia Bureau of Insurance
512-458-7796
800-252-9152 www.dshs.state.tx.us/immunize/tvfc/default. shtm
804-371-9741 877-310-6560 www.scc.virginia.gov/division/boi
Virginia Department of Health www.vdh.virginia.gov
Washington Washington Office of the Insurance Commissioner 800-562-6900 www.insurance.wa.gov
Washington Department of Social and Health Services 800-737-0617 www.dshs.wa.gov
Washington D.C. D.C. Health Program for Refugees 202-442-9380
D.C. Healthcare Alliance 202-639-4030 TTY: 202-639-4041 http://doh.dc.gov/doh
Women-Infant-Children (WIC) 800-345-1942 202-442-9397 http://doh.dc.gov/doh
District of Columbia Department of Insurance, Securities and Banking
Wisconsin Wisconsin Office of the Commissioner of Insurance 800-236-8517 608-266-3585 http://oci.wi.gov
Wisconsin Department of Health Services 608-266-1865 http://dhs.wisconsin.gov
Wyoming Wyoming Seniors
307-856-6880 www.wyomingseniors.com
Wyoming State Health Insurance Assistance Program 800-856-4398 307-856-6880
http://wdh.state.wy.us
West Virginia
Department of Health and Human Services
West Virginia Health and Human Resources 304-558-0684 www.wvdhhr.org
Medicare Prescription Drug Program 800-633-4227
Partnership for Prescription Assistance 888-4PPA-NOW 888-477-2669 www.pparx.org
Substance Abuse and Mental Health Services Administration
www.cfda.gov (Search tool for grants, loans and other benefits)
304-558-3386 888-TRY WVIC 888-879-9842 www.wvinsurance.gov
800-MEDICARE 800-633-4227 www.medicare.gov
Wyoming Department of Health
202-727-1000 http://doh.dc.gov/doh
West Virginia Offices of the Insurance Commisioner
Medicare
www.mentalhelp.net/selfhelp (Search tool for people sharing information on hundreds of diseases, health conditions and other health care related situations)
Catalog of Federal Domestic Assistance
304-558-5388 800-642-8522 304-558-7164 (TTD) www.wvdhhr.org/mcfh/wvfp/index.asp
www.ihs.gov 301-443-3024 (Department of Public Health)
307 777-7401 800-438-5768 http://insurance.state.wy.us
District of Columbia Department of Health
WV Family Planning
Indian Health Services (IHS)
Self Help Clearing House
National Resources
800-642-8522 www.wvdhhr.org/birth23
Find a Health Center www.findahealthcenter.hrsa.gov
Wyoming Department of Insurance
202-727-8000 http://disb.dc.gov
WV Birth to Three
Health Resources and Services Administration
National Mental Health Information Center http://mentalhealth.samhsa.gov/databases/ (Mental Health Services Locator)
Veterans Health Administration 877-222-8387 www.va.gov
www.hhs.gov (Various health care search tools)
Employee Benefits Security Administration
www.dol.gov/ebsa (Official information and rules from the U.S. Department of Labor)
Government Benefits Finder 800-FED-INFO www.govbenefits.gov (Search tool for grants, loans and other benefits)
Health Coverage Tax Credit 866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)
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state-by-state comparison State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
HighHighGuaranteed deductible deductible Coverage premium for premium for for Small 26-year-old 35-year-old Groups $50.00 $63.00 Yes $60.00 $80.00 Yes $46.00 $52.00 Yes $55.00 $60.00 Yes $47.00 $64.00 Yes $45.00 $54.00 Yes $41.00 $61.00 Yes $45.00 $55.00 Yes $58.00 $78.00 Yes $65.00 $90.00 Yes $50.00 $66.00 Yes $86.00 $113.00 Yes $33.00 $44.00 Yes $48.00 $67.00 Yes $46.00 $59.00 Yes $31.00 $40.00 Yes $60.00 $74.00 Yes $35.00 $43.00 Yes $32.00 $36.00 Yes $100.00 $148.00 * Yes $49.00 $66.00 Yes $334.00 $334.00 * Yes $57.00 $71.00 Yes $70.00 $80.00 Yes $54.00 $72.00 Yes $36.00 $46.00 Yes $75.00 $100.00 Yes $39.00 $52.00 Yes $55.00 $81.00 Yes $79.00 $102.00 Yes $157.00 $183.00 Yes $45.00 $70.00 Yes $279.00 $415.00 * Yes $64.00 $70.00 Yes $47.00 $60.00 Yes $52.00 $68.00 Yes $52.00 $64.00 Yes $65.00 $90.00 Yes $50.00 $59.00 Yes $100.00 $142.00 * Yes $50.00 $74.00 Yes $57.00 $74.00 Yes $50.00 $77.00 Yes $62.00 $70.00 Yes $60.00 $71.00 Yes $394.00 $394.00 * Yes $43.00 $59.00 Yes $57.00 $70.00 Yes $153.00 $168.00 Yes $40.00 $65.00 Yes $57.00 $69.00 Yes
Guarantee IncomeMedical Parental High Issue MiniCOBRA Based Underwriting Coverage Risk Employee Groups< 20 Options Buy-In for through Size Plan Individuals CHIP 2+ No Yes No Yes No 2+ No Yes No Yes No 2+ No Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 1+ Yes Yes No Yes No 1+ Yes Yes No Yes Yes 1+ No No No Yes No 2+ Yes Yes No Yes Yes 1+ Yes Yes No Yes No 2+ Yes No No Yes No 1+ No No Yes Yes No 2+ Yes No No Yes No 2+ No Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes Yes Yes No 2+ Yes Yes No Yes Yes 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 1+ Yes No Yes No No 2+ Yes Yes No Yes No 1+ Yes No Yes No No 2+ No Yes No Yes No 2+ Yes Yes No Yes Yes 1+ Yes Yes No Yes No 2+ No Yes No Yes Yes 2+ No Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes No No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No No Yes 2+ Yes Yes Yes Yes No 2+ Yes No Yes No Yes 1+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes Yes Yes No 2+ No Yes No Yes No 1+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 1+ Yes No Yes No No 2+ Yes Yes No Yes No 2+ Yes Yes Yes Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No
Indian Health Services Yes Yes Yes No Yes Yes Yes No No Yes No Yes Yes No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes No No Yes No Yes Yes
Note: Premiums are based on the following information and may be subject to change — $2-5K deductible; male; nonsmoker; approximately 20% co-insurance; usually no office visits.. Plans were generated by ehealthinsurance.com using zip codes from major cities. In most cases the second least expensive plan is shown. * Coverage has serious limitations, short-term/12 months only or other restrictions.
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The Uninsured in America How does your STATE compare to the rest of America? Source: US Census Bureau, 2002; BCBSA Analysis, Congressional Budget Office
State
Uninsured Population
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Total US
549,000 123,000 1,164,000 451,000 6,613,000 801,000 326,000 96,000 55,000 3,648,000 1,662,000 96,000 209,000 1,700,000 717,000 275,000 345,000 570,000 776,000 115,000 762,000 340,000 1,151,000 433,000 545,000 729,000 146,000 232,000 441,000 137,000 1,348,000 437,000 2,519,000 1,510,000 61,000 1,322,000 631,000 632,000 1,176,000 113,000 721,000 80,000 883,000 5,962,000 340,000 69,000 1,135,000 737,000 254,000 451,000 70,000 45,657,000
% of Uninsured Eligible for Government Programs 28% 30% 30% 33% 44% 23% 33% 52% 53% 28% 30% 56% 24% 30% 31% 38% 24% 39% 27% 42% 33% 60% 36% 41% 31% 40% 30% 36% 23% 25% 24% 28% 35% 31% 28% 31% 27% 46% 48% 55% 42% 33% NA 24% 26% 60% 25% 34% 38% 37% 23% 34%
% of Uninsured with Income $50K + 32% 32% 32% 32% 32% 32% 32% 32% 31% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 33% 32% 32% NA 32% 32% 33% 32% 32% 32% 32% 32% 32%
% of Uninsured that is Short-term (Less than 1 Yr) 16% 15% 15% 14% 10% 18% 14% 7% 6% 16% 16% 4% 18% 15% 15% 13% 18% 12% 17% 11% 14% 3% 13% 11% 15% 12% 16% 13% 19% 18% 18% 16% 14% 15% 17% 15% 17% 9% 8% 5% 11% 14% NA 18% 17% 3% 17% 14% 12% 12% 18% 14%
% of Uninsured that is Long-term (More than 1 Yr) 23% 22% 22% 20% 15% 26% 20% 10% 9% 24% 23% 7% 26% 22% 22% 18% 26% 17% 24% 15% 21% 5% 19% 16% 22% 17% 22% 19% 27% 25% 26% 23% 20% 22% 23% 22% 24% 13% 12% 8% 15% 20% NA 26% 25% 5% 25% 20% 18% 18% 27% 20%
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glossary of terms Agent
A person who has a license to sell insurance in California. He or she might work alone or with a large firm and may sell all kinds of insurance. Some agents work as an employee of an insurance company and sell plans just from that company.
Cal-COBRA
Cal-COBRA (also called MiniCOBRA) is simply “continuation coverage.” It is a law that helps people losing their employee health plan stay insured. It is for companies with 2 to 20 employees. (See COBRA.)
Carrier
Carrier is another name for insurance company.
CHIP
Sometimes this is called S-CHIP (State Children’s Health Insurance Plan). Every state has a plan for children who are not eligible for Medicaid because the family income is too high or they don’t have access to group coverage. The name of the program is usually called something like Healthy Families or Healthy Children and care is delivered by regular doctors through the state’s major insurance companies. In a handful of states, coverage is extended to the parents (as with Medicaid).
Claim
114
COBRA
COBRA is a federal law that helps an insured person keep their health insurance when they lose their employee health plan. It’s also called continuation coverage. COBRA stands for Consolidated Omnibus Budget Reconciliation Act. It applies to companies with 20 or more employees. Cal-COBRA is for companies with less than 20 employees.
Coinsurance
An arrangement under which the insured person pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, the insurance company might pay 80% of the allowable charge, with the insured person responsible for the remaining 20%, which is then referred to as the coinsurance amount.
Conversion Privilege
The right given to an insured person to change insurance without evidence of medical insurability, usually to an individual policy upon termination of coverage under a group contract.
Co-Pay
An arrangement where the insured person pays a specified amount for various services and the insurance company pays the remainder. The insured person usually must pay his or her share when the service is rendered. Similar to coinsurance, except that coinsurance is usually a percentage of certain charges where the co-payment is a dollar amount.
Coverage
Another name for “health insurance.” It refers to the scope of health benefits and financial risk protection provided under a contract of insurance.
A request for payment of benefits received or services rendered. A billing record is generated and submitted by a provider or subscriber using paper or electronic media.
Coverage Termination
The end of an insured person’s coverage due to loss of employment, reduction of hours, gross misconduct, covered employee and spouse divorce or become legally separated, or death of the covered employee.
Creditable Coverage
There are rules about when insurance companies have to start paying for your health benefits when you’re a new member or whether or not you get COBRA (continuation) coverage when your group plan ends. For example: to get COBRA, you have to have had insurance (creditable coverage) for 18 months.
Deductible
An amount which an insured person agrees to pay, per claim or per accident, before the insurance company has to pay their part.
Employee Contribution
The employee’s share of the monthly premium (payment).
Employer Based Coverage
Companies who offer health coverage at no or minimal charge to the employee.
Employer Contribution
The employer’s share of the monthly premium (payment).
Federal Poverty Level
This is a percentage level assigned based on the number of people and income per household. The percentages are created by the government, and then the public programs use those percentages in a chart to decide who can qualify for what programs.
Guaranteed Coverage
An underwriting term used to describe the fact that a small business group cannot be turned down for insurance because of poor health conditions either current or past.
Guaranteed Coverage for Individual Plans
This means that no one can be turned down for insurance because of a health condition, or in other words there is no “medical underwriting.” Only three states have guaranteed coverage for individuals: Maine, New York and Vermont.
High Risk Pool Insurance
This is health coverage for people who may have been denied access to a health insurance plan because of their serious medical conditions . In some states every insurance company must guarantee access to plans for these people. In other states there is an organization that oversees a program that involves a few plans from different insurance companies.
HIPAA
The right to transfer from a group health plan to an individual plan if the insured person is leaving the company or their group plan is being terminated. HIPAA is a law that has to do with both portability and privacy of medical records. It stands for Health Insurance Portability and Accountability Act.
Income Based Buy-In Plan
Some states have plans for people who have no access to group coverage and aren’t eligible for Medicaid or other public programs. Similar to public programs, the monthly premiums are determined by the applicant’s income level.
115
Indian Health Services
116
This is a federal organization that has medical facilities in states where there is a high populations of Native American or Alaskan Indians. Services range from full health care benefits to mobile clinics that cater to the needs of local tribes.
Individual Insurance
Health Insurance policies which provide protection to the insured person and/or his/her family (also called dependents).
Max out-of-pocket
The most an insured person will pay considering co-payments, coinsurance, deductibles, etc.
Medicaid
Medicaid is a state health coverage program that primarily covers emergencies, pregnancy-related services, kidney dialysis and treatment for breast and cervical cancer.
Medi-Cal
Medi-Cal is a California’s health coverage program that primarily covers emergencies, pregnancy-related services, kidney dialysis and treatment for breast and cervical cancer.
Medical Underwriting
Before you can buy a policy you must give the insurance company information about your health. This process is called underwriting. The company uses underwriting information to predict what the likelihood is that you will file claims against the insurance policy. Each company has its own underwriting standards, which means one insurance company could reject your application but another may be willing to accept it.
Pre-existing Conditions
When applying for health insurance, the insurance company requests the applicants medical history. A “pre-existing condition” is an illness, physical or mental, that was treated before getting insurance.
Premium
The payment an insured person makes to keep their insurance policy, usually monthly.
Provider
Your doctor, a hospital, clinic and anyone else that provides health care services to you is called a “provider.”
Qualifying Event
An occurrence (such as death, termination of employment, divorce, etc.) that changes an insured person’s protection under COBRA, which requires continuation of benefits under a group insurance plan for former employees and their families who would otherwise lose health care coverage.
Small Group or Small Business
A small group or business in most states is 2-50 employees, although some states consider a self-employed person or 1 employee to be a small group. Small groups or business are guaranteed health insurance coverage and can not be turned down for preexisting conditions.
Stop Loss
This is a special type of re-insurance that protects an individual or group who goes over their coverage limit.
For more information on your state’s health coverage options, we encourage you to utilize our other valuable health coverage resources.
U.S. Uninsured Help Line
800.234.1317
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How to use this Directory: Use the Income Worksheet(page “v”) to determine the Federal Poverty Level percentage of you or the person whom you are trying to assist. This percentage usually determines if an individual is eligible for various public programs. Find your state’s Health Care Options Matrix for a complete list of private and public health coverage programs, along with additional valuable resources. Consult the Appendices for COBRA subsidy information, state-by-state program contact information, uninsured statistics for each state, as well as the glossary of terms found within this book.
Foundation for Health Coverage Education “Coverage for All Through Education” 101 Metro Drive, Suite 250 • San Jose, CA 95110 • www.coverageforall.org ISBN-13: 978-1-42432862-8 © Copyright 2010 by Philip Lebherz and the Foundation for Health Coverage Education All Rights Reserved. Printed in the U.S.A.
Printing for this version of the U.S. Directory of Health Care Options provided by the generous support of Pfizer, Inc.
Vol. IV, July 2010 The U.S. Directory of Health Coverage Options
U.S. Directory of Health Care Options A state-by-state guide to helping Americans navigate their public and private health coverage options
FHCE
