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Guide to All States Gov\'t and Private Health Insurance Plans
 

Guide to All States Gov\'t and Private Health Insurance Plans

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Comprehensive guide on all 50 states government sponsored and private insurance major medical plans

Comprehensive guide on all 50 states government sponsored and private insurance major medical plans

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    Guide to All States Gov\'t and Private Health Insurance Plans Guide to All States Gov\'t and Private Health Insurance Plans Document Transcript

    • U.S. Directoryof Health Coverage Options
    • How to use this Directory: Use the Income Worksheet(page “iii”) 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 Coverage Options Matrix for a complete list of private and public health coverage programs, along with additional valuable resources. Consult the Appendices for our QR code, 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 101 Metro Drive, Suite 250 • San Jose, CA 95110 • www.CoverageForAll.org ISBN-13: 978-1-42432862-8 © Copyright 2012 by Philip Lebherz & Foundation for Health Coverage Education All Rights Reserved. Updated February 2012 For the most up-to-date version, please visit: www.CoverageForAll.org.iv
    • U.S. Directoryof Health Coverage OptionsA state-by-state guide to helping Americans navigate their public and private health coverage options Created by Phil Lebherz Foundation for Health Coverage Education
    • table of contents Acknowledgments ii New Mexico 61 Income Worksheet iii New York 63 Federal Poverty Level Chart iv North Carolina 65 Health Care Options Matrices by State 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 Appendices Maryland 39 Other Services (by State) 103 Massachusetts 41 State-by-State Comparison 110 Michigan 43 The Uninsured In America 111 Minnesota 45 Glossary of Terms 112 Mississippi 47 Missouri 49 About FHCE 115 Montana 51 Nebraska 53 Nevada 55 New Hampshire 57 New Jersey 59i
    • I want to dedicate this book to the thousands of workers in the private and public health insurance systemsacross the country who are attempting to reach our goal of lowering the number of uninsured people inAmerica. I especially want to thank Leonard Schaeffer who provided his knowledge, inspiration, and visionto this project. - Phil LebherzAcknowledgmentsThe following individuals and associations generously donated their time, energy, and resources tocreating this resource:Aetna Foundation Health Coverage Foundation, Inc. Professional ExchangeAlain Enthoven Health Net of California Service CorporationBeere & Purves, Inc. Kaiser Foundation Rio Grande AssociationBlue Shield of California Los Angeles Unified School District Saint Joseph Health Center FoundationCAHU Charitable Larry GlasscockCommunity Foundation Schmitt Family Foundation Leonard & Pamela SchaefferCal Locket San Diego Office of Education LISICAHU Sharp Health Plan NAHU (& State Chapters)California State Legislators Spahr Insurance Peter & Renuka PatelCathay Post No. 384 The Rauser Agency Peter FarrellDavid & Nancy Helwig Family The Sugg Group Pfizer, Inc.Fund Word & Brown Philip & Vivian ReedDickerson Employee Benefits, Inc. Warner Pacific Placer County Office of EducationErnie Ramirez WellPoint Foundation Poizner Family TrustGeorge & Clare SchmittCollaborative EffortsWe would like to recognize the following organizations for their collaborative efforts in helping lower theranks of the uninsured by using FHCE’s resources:Aetna Inc. California Department of Insurance NAICAmerican Cancer Society Community Medical Centers Sharp HealthCareAmerican Diabetes Association Daughters of Charity Health Systems United Way-211 Call CentersAmerican Heart Association eHealthInsurance United Health CareAmerican Lung Association Google, Inc. WellPoint, Inc.Dignity Health NAHUAppreciated Media SupportFHCE’s resources have had over 4 billion media impressions thanks to the following media outlets:AARP Hospital Access Management San Francisco Business TimesABC News Kiplinger’s Personal Finance San Francisco ChronicleAmerican Medical News KFWB 980 AM Self MagazineBecker’s Hospital Review KTLA TV Channel 5 Smart Money, AOL Money &CBS Bay Sunday Los Angeles Times FinanceChicago Tribune Men’s Health Magazine The Angie Strader ShowCNN Modern Healthcare The New York TimesConsumer Digest MSNBC The Wall Street JournalCostco Connection New York Daily News The Washington PostDailyFinance Parenting.com USA TodayHealth Affairs Parents Magazine U.S. News & World Report ii
    • 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 - __________________ T OTAL 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. 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.iii
    • Federal Poverty Level Chart Your Federal Poverty Level (FPL) Based on monthly family gross income Family Size (House- 100% 133% 175% 200% 250% 300% 400% hold) 1 $931 $1,238 $1,629 $1,862 $2,327 $2,793 $3,723 2 $1,261 $1,677 $2,206 $2,522 $3,152 $3,783 $5,043 3 $1,591 $2,116 $2,784 $3,182 $3,977 $4,773 $6,363 4 $1,921 $2,555 $3,361 $3,842 $4,802 $5,763 $7,683 5 $2,251 $2,994 $3,939 $4,502 $5,627 $6,753 $9,003 6 $2,581 $3,433 $4,516 $5,162 $6,452 $7,743 $10,323 7 $2,911 $3,871 $5,094 $5,822 $7,277 $8,733 $11,643 8 $3,241 $4,310 $5,671 $6,482 $8,102 $9,723 $12,963 Based on yearly family gross income 1 $11,170 $14,856 $19,548 $22,340 $27,925 $33,510 $44,680 2 $15,130 $20,123 $26,478 $30,260 $37,825 $45,390 $60,520 3 $19,090 $25,390 $33,408 $38,180 $47,725 $57,270 $76,360 4 $23,050 $30,657 $40,338 $46,100 $57,625 $69,150 $92,200 5 $27,010 $35,923 $47,268 $54,020 $67,525 $81,030 $108,040 6 $30,970 $41,190 $54,198 $61,940 $77,425 $92,910 $123,880 7 $34,930 $46,457 $61,128 $69,860 $87,325 $104,790 $139,720 8 $38,890 $51,724 $68,058 $77,780 $97,225 $116,670 $155,560• A pregnant woman counts as two for the purpose of this chart.• Add $330/month for each additional family member after eight.•  ontact individual programs for deduction allowances on child/dependent care; working parent’s work expenses; C alimony/child support received or court ordered amount paid.The following figures are the 2012 HHS poverty guidelines as of January 26, 2012. (Source: http://aspe.hhs.gov/poverty/12poverty.shtml)Monthly percentage data calculated by FHCE and rounded to the nearest dollar.Please visit www.CoverageForAll.org for further details and updates on the 48 continuous states, Hawaii and Alaska FPL charts. ReminderThere is no universal administrative definition of income that is valid for all programs that use thepoverty guidelines. The office or organization that administers a particular program or activity isresponsible for making decisions about the definition of income used by that program (to the extentthat the definition is not already contained in legislation or regulation). To find out the specific definitionof income used by a particular program or activity, you must consult the office or organization thatadministers that program. iv
    • Demographic Private Health Insurance Individuals Individuals with Low-Income Small Businesses Recently Covered Individuals Pre-Existing, Severe, Individuals (2-50 Employees) by an Employer & Families or Chronic Medical & Families Health Plan Conditions Group Plans COBRA Individual Plans Alabama Health Medicaid National Association of Health Then convert to a plan under: National Association of Insurance Plan (AHIP) (SOBRA & MLIF) Underwriters Health Underwriters Alabama Health 334-242-5000 703-276-0220 703-276-0220 Insurance Plan SOBRA: 800-362-1504 www.nahu.org HIPAA www.nahu.org 866-833-3375 MLIF: 800-362-1504 Health Insurance Portability & 334-263-8311 insurealabama.adph.state.al.us Accountability Act www.alseib.orgProgram 866-487-2365 www.dol.gov Pre-Existing Condition Insurance Plan (PCIP) HIPP Run by the U.S. Department of Health Insurance Premium Health and Human Services Payment Program 866-717-5826 334-242-3722 www.PCIP.gov www.medicaid.state.al.us There is a maximum 6-month COBRA: Coverage available for Assorted plans depending on AHIP: Two plans offered: indemnity Medicaid (SOBRA and MLIF): Among look-back/12-month 18–36 months depending on medical needs. and managed care. Both cover some of the services: Ambulatory exclusionary period for qualifying events. Benefits Prescription drugs, Outpatient surgical center, Birth center pre-existing conditions on are what you had with your There is a maximum look- and in-patient care, Durable services, Child health check- enrollees that do not have prior previous employer. back period of 60 months medical equipment, Mental up, Chiropractic care, Durable coverage. and a maximum exclusion health, Substance abuse, and medical equipment and supplies, HIPAA: Benefits are based on period of 24 months for Away-from-home emergency care. Federally qualified health centers, Benefits will vary depending program selected. There is no pre-existing conditions on Managed care also covers Labs, Home health, Hospital inpatient/Coverage on the chosen plan. expiration of coverage. enrollees that do not have X-rays, Transplants, Maternity, and outpatient care, Laboratory, prior coverage. Rehabilitation care. Licensed midwife, Physician, Pre-Existing Health HIPP: Benefits are the same Podiatry, Prescriptions, Rural health Conditions Covered as what you had with your Elimination riders are PCIP: Covers broad range of clinics, Therapy, and X-rays. previous employer, HIPP is a permitted. benefits, including primary and premium assistance program. specialty care, hospital care, and SOBRA: Pregnant women ONLY Limits on Pre-Existing Health prescription drugs. get pregnancy related services Pre-Existing Health Conditions May Apply covered. Conditions Covered Pre-Existing Health Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size 2-50 employees. COBRA: Available for employees Eligibility is subject to AHIP: You must have chosen to Medicaid (SOBRA and MLIF): Must be who work for businesses with medical underwriting. extend coverage under COBRA, a U.S. citizen or legal alien and an Eligible employees must work 20 or more employees. Have 60 group health plan, government Alabama resident. at least 30 hours a week. days from date of termination If you are denied coverage plan, or church plan and to sign up for COBRA coverage. for a medical condition, you exhausted those benefits and Income limits: Owner can count as an may be eligible for AHIP, or submitted your application employee. HIPAA: Must have had 18 months PCIP. within 63 days of your last day of Pregnant Women: 133% FPL. of continuous coverage and coverage to sign up for AHIP. Children (ages 0–5): 133% FPL. Owner name on business completely exhausted COBRA Must be a permanent Alabama license must draw wages from or state continuation coverage. resident with at least 18 months Children (ages 6–18): 100% FPL. the company. Must not have lost coverage of continuous coverage withoutEligibility due to fraud or non-payment of being terminated due to fraud or Parents/caretakers living with premiums. You have 63 days to failure to pay. children ages 0–18: 24% FPL. enroll in a HIPAA-eligible plan. Aged, blind and disabled: Singles AHIP is specifically aimed at those with incomes up to 75% FPL and HIPP: You may be eligible for HIPP who have purchased coverage asset limit of $2,000, and couples if you have a high-cost health from their employer and whose with incomes up to 83% FPL with condition. benefits have run out. asset limit of $3,000. PCIP: Must have been uninsured for at least 6 months prior to applying. SOBRA: Must not be eligible for ALL Must prove being a U.S. citizen or Kids. legal U.S. resident, an Alabama resident, and having problems getting insurance due to a pre- existing condition. Costs depend on employer COBRA: Premiums range from Costs for individual coverage AHIP: Traditional Indemnity Plan Medicaid: $0–$3 for office visits, contribution and ± 20% of the 102%–150% of group health vary. There are no rate caps. premiums could range between prescription drugs and some other insurance company’s index rates. $147 to $1,150 depending on age, services. rate. sex, smoker or non-smoker, and planMonthly Cost HIPAA: Premiums will depend you choose. SOBRA: $50 co-payment for each on plan chosen. inpatient hospital stay. Managed Care Plan premiums could HIPP: $0 or minimal share of range between $283 to $1,068 cost. depending on age, sex, and smoker or non-smoker. PCIP: Monthly premiums range from $110 to $471 depending on your age.21 Alabama
    • Publicly-Sponsored Programs Demographic Children in Trade Dislocated Moderate Income Women Seniors & Disabled Workers Veterans Families (TAA Recipients) ALL Kids Breast and Cervical Medicare Health Coverage VA Medical 888-373-5437 334-206-5568 Cancer Early 800-633-4227 www.medicare.gov Tax Credit Benefits Package 877-774-9521 Detection Program 866-628-4282 www.irs.gov 877-222-8387 www.va.gov insurealabama.adph.state.al.us (ABCCEDP) Medicare (Search: HCTC) or 877-252-3324 www.adph.org/allkids www.adph.org/earlydetection Prescription Drug Program Program AL Child Caring Plan First 800-633-4227 (Family Planning) Program 888-737-2083 800-726-2289 www.adph.org/planfirst Alabama State insurealabama.adph.state.al.us www.accf.net Health Insurance Assistance Program Note: AL Child Caring Program 800-243-5463 closed on January 1, 2011. The children in the program have been referred to Medicaid and ALL Kids. ALL Kids: Coverage will begin ABCCEDP: Pelvic exam, Pap Medicare offers Part A, Inpatient and outpatient care Comprehensive preventive and on the first day of the month smear, Clinical breast exam, inpatient care in hospitals and (lab tests, x-rays, etc.), Doctor primary care, outpatient and after application is received. Mammogram, and Diagnostic rehabilitative centers; Part B, visits, Preventive and major inpatient services. Benefits include 12 months services, such as an ultrasound, doctor and some preventive medical care (surgery, physical continuous coverage, doctor colonoscopy, or biopsy, if services and outpatient care; therapy, Durable medical Pre-Existing Health visits, check-ups, hospital and needed. Part C allows Medicare benefits equipment, etc.), Mental health Conditions Covered physician care, immunizations, through private insurance and substance abuse care, and prescriptions, dental and vision Plan First: Yearly family planning (Medicare Advantage); Part C Prescription drugs. Coverage care, emergency services, and exams, Care support from a includes Parts A, B, and C not mental health/substance abuse social worker or nurse, Some covered by Medicare. Part D Pre-Existing Health services with dedicated phone types of birth control (such covers prescription drugs. Conditions Covered number available 24 hours a as birth control pills and day, 7 days a week. Depo-Provera shots), Tubal ASHIAP is a Medicare counseling ligation (tube tying) for women service. AL Child Caring Program: 21 years or older, Lab work Outpatient services only. (pregnancy and STD testing), Pre-Existing Health and Family planning help. Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Both: Must be under the age of ABCCEDP: Women without Medicare and ASHIAP: Must be Must be receiving TAA (Trade ”Veteran status” = active duty 19 and an Alabama resident, insurance or who are U.S. citizen or permanent U.S. Adjustment Assistance), or in the U.S. military, naval, or air not be covered by any other underinsured ages 40–64, resident, and: service and a discharge or release health insurance, and be earning up to 200% FPL. Must be 55 years or older and from active military service ineligible for Medicaid. 1) If 65 years or older, you or receiving pension from the under other than dishonorable Women under age 40 who your spouse worked for at least Pension Benefit Guaranty conditions. ALL Kids: Must be a U.S. citizen or have problems with their 10 years in Medicare-covered Corporation (PBGC). eligible immigrant, not be in an breasts can undergo a clinical employment, or Certain veterans must have institution. Children 0–5 years breast exam to determine if Must not be enrolled in certain completed 24 continuous months old must have family incomes they are eligible to receive a 2) You have a disability or end- state plans, or in prison, or of service. of 133%–300% FPL. Children free breast cancer screening stage renal disease (permanent receiving 65% COBRA premium Eligibility 6–18 years old must have family through the program. kidney failure requiring dialysis reduction, or be claimed as a incomes of 100% - 300% FPL. or transplant) at any age. dependent in tax returns. Plan First: Must be a U.S. citizen AL Child Caring Program: Must not or legal alien and an Alabama Must be enrolled in qualified be eligible for ALL Kids and resident. Must be a woman health plans where you pay all other plans; be enrolled in between the ages of 19 and 55 more than 50% of the premiums. school (if of age). with an income limit of 133% FPL and have not had surgery Individuals who are eligible to prevent pregnancy. 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. Both: $0 or small co-pays. ABCCEDP: $0 or minimal share Medicare and ASHIAP: $0 and 20% of the insurance $0 and share of cost and of cost. share of cost for certain premium including COBRA co-pays depending on income ALL Kids: Yearly costs range services; deductibles for premium if employer from $50 to $100 per child up to Plan First: $0 for family certain plans. Part A: $0–$450 level. Monthly Cost contributes less than 50%. the first 3 children (no cost for planning services only. based on length of Medicare- additional children). Small co- covered employment; Part B: pays are required at the time of $96.40–$369.10 depending on service. There are no co-pays for annual income; Part C: Based on preventive services. provider; Part D: Varies in cost and drugs covered. Alabamawww.CoverageForAll.org 2
    • Demographic Private Health Insurance Individuals Individuals with Small Businesses Recently Covered Individuals Pre-Existing, Low-Income Children (2-50 Employees) by an Employer & Families Severe, or Chronic & Families Health Plan Medical Conditions Group Plans COBRA Individual Plans Alaska Medicaid Comprehensive 907-465-3347 800-780-9972 Alaska Association of Health Alaska Association of Health Underwriters Then convert to a plan under: Underwriters Health Insurance www.hss.state.ak.us www.alaskaahu.org www.alaskaahu.org Association (ACHIA) (Search: Medicaid) Program HIPAA 888-290-0616 Health Insurance Portability & www.achia.com Accountability Act 866-487-2365 Pre-Existing www.dol.gov Condition Insurance Plan (PCIP) Federal program run by the ACHIA 877-505-0510 www.PCIP.gov www.achia.com/ACHIA-FED There is a 6-month look- COBRA: Coverage available for Assorted deductible and plan ACHIA: Offers 6 different Inpatient and outpatient hospital back/12-month exclusionary 18–36 months depending on design options for selection. comprehensive PPO plans with services, Mental health and period for pre-existing qualifying events. Benefits are different deductibles. Offers substance abuse care, Rural conditions if enrollee had what you had with your previous There are no limits to look-back one traditional non-PPO plan health clinics, Nurse, Midwife, no prior coverage, or if prior employer. and exclusionary periods for paying 80% of the allowed Dentist, Optometrist, Physician coverage had a break of more pre-existing conditions. charges after the $1,000 annual care, Prescription drugs, Physical than 63 days. HIPAA: Benefits are based on deductible is satisfied. After therapy, Medical equipment and program selected. There is no Limits on Pre-Existing Health deductible and out-of-pocket devices (prosthetics, eyeglasses, Group coverage as selected by expiration of coverage. Conditions May Apply maximum have been satisfied, dentures, etc.), Preventive care employer with a variety of plan ACHIA will pay claims at 100%. and diagnostic services, Family designs available. Pre-Existing Health planning, Labs and x-rays, Home Coverage Conditions Covered PCIP: Inpatient and outpatient health services (such as nursing Pre-Existing Health hospital services, physician services, home health aides). Conditions Covered services, prescription drugs, skilled nursing, home health, Pre-Existing Health Conditions hospice, chemotherapy, Covered anesthesia, prosthesis, durable medical equipment, x-rays and laboratory services, oral surgery, physical therapy, substance abuse treatment, mental health services, ambulance, maternity, PKU formula, Pap smear and mammograms. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size 2–50. COBRA: Available for employees Eligibility is subject to medical ACHIA: Must be a U.S. citizen Must be U.S. citizen or qualified alien who work for businesses with 20 underwriting. or legal resident living in and Alaska resident. Eligible employees must work or more employees. You have 60 Alaska and at least one of the at least 30 hours a week. days from date of termination to If you are denied coverage following: 1) You were rejected Income limits: sign up for COBRA coverage. for a medical condition, you for health insurance in the last 6 Owner can count as an may be eligible for an Alaska months, or received restrictive Family: 185% FPL. employee. Proprietor name on HIPAA: Must have had 18 months Comprehensive Health riders that reduced coverage, Working disabled: 250% FPL. license must draw wages. of continuous coverage and Insurance Association plan, or or 2) You have a qualified completely exhausted COBRA PCIP. See next column. pre-existing condition, or 3) Aged, blind, and disabled: Singles or state continuation coverage. You had exhausted COBRA, are with incomes up to 109% FPL and Must not have lost coverage uninsured, not eligible for any asset limit of $2,000, and couples Eligibility due to fraud or non-payment of group coverage from private or with incomes up to 120% FPL and premiums. You have 63 days to public sources (e.g. Medicaid, asset limit of $3,000. enroll in a HIPAA-eligible plan. Native Health Care, etc.), and you were covered under a For pregnant women and children, group health plan in the prior see “Moderate Income Children & 18 months with no break of Families” column. more than 90 days, or 4) You Contact your local Division of are receiving Trade Adjustment Public Assistance office or your Assistance (TAA). community’s village fee agent for more information. PCIP: Must have been uninsured for at least 6 months prior to applying. Must prove being a U.S. citizen or legal U.S. resident, an Alaska resident, and having problems getting insurance due to a pre-existing condition. Costs depend on employer contribution and ± 35% of the COBRA: Premiums range from 102%-150% of group health rates. Costs vary dependent on age and medical underwriting. ACHIA: Premiums range from $107–$2,950 depending on your $0 for families below 100% FPL. Monthly Cost insurance company’s index There are no rate caps. age and plan chosen. rate. HIPAA: Premiums will depend on $50–$200 per day for hospital plan chosen. PCIP: Monthly premiums range admission (except for mental from $452 to $1,806 . institutions).43 Alaska
    • Publicly-Sponsored Programs Demographic Trade Dislocated Moderate Income Adults with Chronic Native American Seniors & Disabled Workers Children & Families Medical Conditions Indians (TAA Recipients) Denali Kid Care Chronic and Acute Indian Health Medicare Health Coverage Toll Free Outside Anchorage 888-318-8890 Medical Assistance Services (IHS) 800-633-4227 www.medicare.gov Tax Credit (Alaska Area) 866-628-4282 Anchorage Area (CAMA) 907-729-3686 www.irs.gov 907-269-6529 800-780-9972 www.ihs.gov Medicare (Search: HCTC) Program www.hss.state.ak.us www.hss.state.ak.us (Search: Alaska) (Search: Denali Kid Care) (Search: CAMA) Prescription Drug Or contact the Division of Public For eligibility information visit: Program www.ihs.gov 800-633-4227 Assistance office nearest you or (Search: Eligibility) the fee agent in your community. Prevention and treatment Prescription drugs and medical IHS services are provided Medicare offers Part A, Inpatient and outpatient care services such as: Doctors visits, supplies, limited to 3 prescriptions directly and through tribally- inpatient care in hospitals and (lab tests, x-rays, etc.), Doctor Check-ups and screenings, per month and no more than a 30- contracted and operated health rehabilitative centers; Part B, visits, Preventive and major Vision exams and eyeglasses, day supply of any drug. programs. From private care doctor and some preventive medical care (surgery, physical Dental checkups, Cleanings sources, tribal health programs services and outpatient care; therapy, Durable medical and fillings, Hearing tests Physician services which are purchase services for Native Part C allows Medicare benefits equipment, etc.), Mental health and Hearing aids, Speech directly related to the medical American patients in areas through private insurance and substance abuse care, and therapy, Physical and Mental condition that qualifies you for where IHS facilities or services (Medicare Advantage); Part C Prescription drugs. health therapy, Substance CAMA. are not readily available. includes Parts A, B, and C not abuse treatment, Chiropractic covered by Medicare. Part D Pre-Existing Health care, Foot doctor’s services, Chemotherapy and radiation IHS-funded, tribally-managed covers prescription drugs. Conditions Covered Coverage Hospital care, Laboratory tests, services for a recipient with hospitals are located in Prescriptions, and Medical cancer requiring chemotherapy, if Anchorage, Barrow, Bethel, Pre-Existing Health transportation. provided in an outpatient setting. Dillingham, Kotzebue, Nome Conditions Covered and Sitka. There are 37 tribal Pre-Existing Health Outpatient laboratory and x-ray health centers, 166 tribal Conditions Covered services. community health aide clinics and five residential substance Pre-Existing Health abuse treatment centers. Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Must be a U.S. citizen and Alaska Must be a U.S. citizen or legal alien Must exhaust all private, state, Must be U.S. citizen or Must be receiving TAA (Trade resident. and resident of Alaska, and have and other federal programs. permanent U.S. resident, and: Adjustment Assistance), or one of following: a terminal illness; Income limits: cancer requiring chemotherapy; Must be regarded by the local 1) If 65 years or older, you or Must be 55 years or older and chronic diabetes or diabetes community as an Indian; is a your spouse worked for at least receiving pension from the Children 0–18 with health insipidus; chronic seizure disorders; member of an Indian or Alaska 10 years in Medicare-covered Pension Benefit Guaranty insurance: 150% FPL. chronic mental illness; chronic Native Tribe or Group under employment, or Corporation (PBGC). Children 0–18 with no health hypertension. Must have no other Federal supervision; resides insurance: 175% FPL. resources to meet the health care on tax-exempt land or owns 2) You have a disability or end- Must not be enrolled in certain you need. restricted property; actively stage renal disease (permanent state plans, or in prison, or P  regnant with proof of participates in tribal affairs; kidney failure requiring dialysis receiving 65% COBRA premium Eligibility pregnancy from your health Income limit per household: any other reasonable factor or transplant) at any age. reduction, or be claimed as a care provider with or without At or less than $300 a month for indicative of Indian descent; is dependent in tax returns. health insurance: 175% FPL. one person. a non-Indian woman pregnant At or less than $400 a month for with an eligible Indian’s child for Must be enrolled in qualified two people. the duration of her pregnancy health plans where you Add $100 for each additional through post-partum (usually pay more than 50% of the person. 6 weeks); is a non-Indian premiums. member of an eligible Indian’s You must have $500 or less in household and the medical countable resources that could officer in charge determines be used to pay medical bills: cash, that services are necessary to bank/credit union accounts, or control a public health hazard personal property. CAMA does or an acute infectious disease not count your home, one vehicle, which constitutes a public income-producing property, health hazard. property that is used for your job (boat, fishing gear, etc.), or a fishing permit. $0 for eligible children, teens, $0 and $1 per prescription or $0 or minimal share of cost. $0 and share of cost for 20% of the insurance and pregnant women. medical supply. certain services; deductibles for premium including COBRA Monthly Cost certain plans. Part A: $0–$450 premium if employer 18-year-olds may be required to based on length of Medicare- contributes less than 50%. share a limited amount of the cost for some services. covered employment; Part B: $96.40–$369.10 depending on annual income; Part C: Based on provider; Part D: Varies in cost and drugs covered. Alaskawww.CoverageForAll.org 4
    • Demographic Private Health Insurance Individuals with Individuals Recently Low-Income Small Businesses Individuals Pre-Existing, Severe, Covered by an Families (2-50 Employees) & Families or Chronic Medical Employer Health Plan & Adults Conditions Group Plans COBRA Individual Plans Medical Expense AHCCCS National Association National Association Deduction(MED) Arizona Health Care Cost Then convert to a plan under: Containment System of Health Underwriters of Health Underwriters Program (Arizona’s Medicaid) 703-276-0220 703-276-0220 Run by the Arizona Health 602-417-4000 www.nahu.org HIPAA www.nahu.org Care Cost Containment 800-654-8713 Health Insurance Portability & System(AHCCCS) www.ahcccs.state.az.usProgram Health Care Group of Arizona Accountability Act 602-417-4000 (HCG) 866-487-2365 800-352-8401 www.hcgaz.com www.dol.gov www.ahcccs.state.az.us 602-417-6755 (Search: Medical Expense Deduction Program) Pre-Existing Condition Insurance Plan (PCIP) Run by the U.S. Department of Health and Human Services 866-717-5826 www.PCIP.gov There is a 6-month look- COBRA: Coverage available for 18–36 Up to $5M. Assorted MED: Provides medical coverage Some benefits include back/12-month exclusionary months depending on qualifying deductibles depending on for individuals who do not qualify Preventive care, Doctor’s period for pre-existing events. Benefits are what you had with age and ZIP code. for other AHCCCS programs due visits, Hospital services, Lab conditions on enrollees that do your previous employer. to income. May be eligible if and x-rays, Emergency care, not have prior coverage. There are no limits to the they have medical expenses in Family planning, Dialysis, HIPAA: Benefits are based on program look-back and exclusion the month of application (or the Surgery, Behavioral health Benefits will vary depending on selected. There is no expiration of periods on pre-existing previous month) that reduce their services, Podiatry, pregnancy, the chosen plan. coverage. conditions. monthly income to 40% FPL. immunizations, physical exams, annual well-woman exams, Pre-Existing Health Pre-Existing Health Elimination riders are PCIP: Covers broad range of specialist care, PrescriptionCoverage Conditions Covered Conditions Covered allowed. benefits, including primary and drugs for non-Medicare specialty care, hospital care, and recipients. Children under 21 Limits on Pre-Existing prescription drugs. also receive dental, vision, Health Conditions May hearing services, and Early and Apply Pre-Existing Health Periodic Screening Diagnosis Conditions Covered and Treatment (EPSDT). Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size 2–50 employees. COBRA: Available for employees who Eligibility is subject to MED: Must be an Arizona resident. Must be an Arizona resident work for businesses with 20 or more medical underwriting. Must not be eligible for other and a U.S. citizen or permanent Eligible employees must work employees. You have 60 days from AHCCCS programs. Monthly resident. at least 20 hours a week. date of termination to sign up for If you are denied coverage income cannot exceed $735 for COBRA coverage. for a medical condition, a family of four, after deducting Income limits: Owner can count as an you may be eligible for medical expenses, childcare, and employee. HIPAA: Must have had 18 months the Medical Expense each person employed. Resources Children ages 0–5: Family of continuous coverage and Deduction (MED) program cannot exceed $100K. Only $5K income up to 133% FPL. Owner name on business completely exhausted COBRA or run by the AHCCCS, or PCIP. may be liquid assets: cash, bank Children ages 6–19: Family license must draw wages from state continuation coverage. Must To learn more, see next accounts, stocks, bonds, etc. Home income up to 100% FPL. the company. not have lost coverage due to fraud column. equity is counted toward theEligibility or non-payment of premiums. You resource limit, but one vehicle is Pregnant women: Up to 200% have 63 days to enroll in a HIPAA- not counted. FPL. eligible plan. PCIP: Must have been uninsured Childless adults: Up to 100% for at least 6 months prior to FPL. applying. Must prove being a Parents/caretakers living with U.S. citizen or legal U.S. resident, their children ages 0–18: Up to an Arizona resident, and having 100% FPL. problems getting insurance due to a pre-existing condition. Aged, blind, and disabled: Up to 100% FPL. Costs depend on employer COBRA: Premiums range from Costs for individual MED: $0 or minimal share of cost. $0–$5 co-pay for officeMonthly Cost contribution and ± 60% of the 102%–150% of group health rates. coverage vary. There are no insurance company’s index rate visits. based on the health status of HIPAA: Premiums will depend on plan rate caps. PCIP: Monthly premium of $104 to the group. chosen. $450 depending on your age and $30 for non-emergency visits plan chosen. to ER.65 Arizona
    • Publicly-Sponsored Programs Demographic Children in Pregnant Native American Moderate Income Women Women & Seniors & Disabled Indians Families Children KidsCare Well Woman Health Baby Arizona Indian Health Medicare 877- 764-5437 602- 417-5437 Check Program 800-833-4642 Services (IHS) 800-633-4227 www.medicare.gov Run by the Arizona Department www.babyarizona.gov www.kidscare.state.az.us of Health Services Navajo (An enrollment cap is in place 888-257-8502 928-871-4811 Medicare Prescription www.wellwomanhealthcheck.org www.ihs.gov/Navajo for KidsCare due to a lack Drug Program Program of funding. Individuals and Phoenix Area 800-633-4227 families can still apply and be 602-364-5179 placed on a waiting list, and www.ihs.gov/Phoenix they will be contacted when funding becomes available.) Tucson Area 520-295-2405 www.ihs.gov/Tucson A wide array of medical services Cancer screening for women Gives prenatal care to pregnant Available programs vary Medicare offers Part A, inpatient including behavioral health such as clinical breast exams, women while they wait to see depending on health center care in hospitals and rehabilitative services. mammograms, pelvic exams if they are eligible for AHCCCS and may include primary and centers; Part B, doctor and some and Pap smear tests. Health Insurance. Staff will put child care, prenatal and post preventive services and outpatient Pre-Existing Health the woman in touch with a delivery care, family planning care; Part C allows Medicare benefits Conditions Covered Provides financial help to doctor in her area that will help (birth control), minor through private insurance (Medicare women who are diagnosed her apply for AHCCCS Health surgical and orthopedic Advantage); Part C includes Parts A, with breast cancer through Insurance. care, pharmacy, dental and B, and C not covered by Medicare. the program and are unable to orthodontics, optometry, Part D covers prescription drugs. qualify for other assistance or Pre-Existing Health nursing, mental health, Coverage to pay for treatment on their Conditions Covered laboratory and radiology. Pre-Existing Health own. Conditions Covered Pre-Existing Health Pre-Existing Health Conditions Covered Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Must be an Arizona resident Must be a woman with income Must be an Arizona resident Must exhaust all private, Must be U.S. citizen or permanent and U.S. citizen or a qualified at or below 250% FPL. Must and U.S. citizen or qualified state, and other federal U.S. resident, and: immigrant, under age 19, with have no insurance, or have non-citizen. programs. income at or below 200% insurance that does not cover 1) If 65 years or older, you or your FPL, be ineligible for no-cost preventive services or that For pregnant women, the Must be regarded by the spouse worked for at least 10 years in Medicaid or employer-based has a high deductible (as income limit is 150% FPL. local community as an Medicare-covered employment, or coverage, with no health determined by the program). Indian; is a member of an insurance for the last 3 months If the mother ends up NOT Indian or Group under 2) You have a disability or end- at time of application. Parents For breast cancer screening, qualified for AHCCCS due to Federal supervision; resides stage renal disease (permanent with incomes of 200% FPL can patient must be at least 40 on tax-exempt land or kidney failure requiring dialysis or also qualify. years old or any age with income, then it’s possible to get owns restricted property; transplant) at any age. Eligibility qualifying symptoms. coverage from KidsCare (see actively participates in tribal “Children in Moderate Income affairs; any other reasonable For cervical cancer screening, Families” column). factor indicative of Indian patient must be at least 18 descent; is a non-Indian years old. woman pregnant with an eligible Indian’s child for the Women screened by the Well duration of her pregnancy Woman HealthCheck Program through post-partum (usually that are under age 65, who are 6 weeks); is a non-Indian legal residents of the U.S. and member of an eligible do not have credible coverage Indian’s household and the may qualify for treatment medical officer in charge through AHCCCS. determines that services are necessary to control a public health hazard or an acute infectious disease which constitutes a public health hazard. $10 to $50 a month for $0 or minimal share of cost. $0 when women begin $0 or minimal share of cost. $0 and share of cost for certain Monthly Cost one child or $15–$70 a month prenatal care while eligibility is services; deductibles for certain for two or more children. processed. If found ineligible, plans. Part A: $0–$450 based then coverage can be found on length of Medicare-covered from KidsCare (see “Children employment; Part B: $96.40–$369.10 depending on annual income; Part C: in Moderate Income Families” Based on provider; Part D: Varies in column). cost and drugs covered. Arizonawww.CoverageForAll.org 6
    • Demographic Private Health Insurance Small Individuals with Individuals Recently Businesses Individuals Pre-Existing, Low-Income Individuals Covered by an Employer (2-50 & Families Severe, or Chronic & Families Health Plan Employees) Medical Conditions Group Plans COBRA/Mini-COBRA Individual Plans Comprehensive Medicaid National Association of National Association of Health Insurance (Including ARKids First A) 800-482-8988 Health Underwriters Then convert to a plan under: Health Underwriters Pool (CHIP) 800-482-5431 703-276-0220 703-276-0220 800-285-6477 501-682-8233 www.nahu.org www.nahu.org HIPAA www.chiparkansas.org www.medicaid.state.ar.us Health Insurance Portability &Program Accountability Act Pre-Existing ARHealthNetworks 866-487-2365 800-540-7566 www.dol.gov Condition Insurance www.arhealthnetworks.com Plan (PCIP) Federal program run by CHIP Administered by Blue Advantage Administrators 800-285-6477 www.chiparkansas.org/pcip www.PCIP.gov There is a 6-month COBRA: Coverage available for 18–36 Assorted plans CHIP: $1M lifetime benefits Medicaid & ARKids First A: Ambulance look-back/12-month months depending on qualifying events. depending on medical offering: comprehensive service (emergency only), Ambulatory exclusionary period for Benefits are what you had with your needs. coverage of doctor visits, surgical center, Chiropractor, Dental pre-existing conditions previous employer. prescription drugs, outpatient care, Doctor’s services, Emergency on enrollees that do not There is a 12-month and in-hospital care, ambulance, room services, Home health have prior coverage. Mini-COBRA: Coverage available for 4 look-back and 24-month labs and x-rays, skilled nursing services, Hospice care, Hospital care, months. Benefits are what you had with exclusionary period care, home health visits, Immunizations, Lab tests and x-rays, Benefits will vary your previous employer. limit for pre-existing maternity, preventive care, Medical equipment, Medical supplies, depending on the conditions on enrollees transplants, rehabilitation, Non-emergency transportation (net) chosen plan. HIPAA: Benefits are based on program that do not have prior durable medical equipment, program, Nurse-midwife (certified),Coverage selected. There is no expiration of coverage. mental health and substance Podiatrist, Pregnancy termination, Pre-Existing Health coverage. abuse, and physical and Prescription drugs, Rural health clinic, Conditions Covered Limits on Pre-Existing occupational therapy among Therapy (physical, occupational, or Pre-Existing Health Conditions Covered Health Conditions May other services. speech), Vision care. Apply PCIP: Covers broad range of ARHealthNetworks: Limited benefits benefits, including primary and every 12 months including 7 inpatient specialty care, hospital care, and days a year, 2 major outpatient prescription drugs. services (emergency room and major services performed in the office), 6 Pre-Existing Health Conditions physician office visits, 2 prescriptions Covered a month, maximum annual benefit of $100,000. Pre-Existing Health Conditions Covered GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE COBRA: Available for employees who work Eligibility is subject to CHIP: Must be a resident of Medicaid: Company size 2–50 for employers with 20 or more employees. medical underwriting. Arkansas for at least 90 days Pregnant women & children ages 0–18: employees (including You have 60 days from date of termination or for at least 30 days with Income limit of 200% FPL. owner). to sign up for COBRA coverage. If you are denied evidence of coverage under coverage for a medical a Qualified High Risk Pool of Supplemental Security Income Eligible employees must Mini-COBRA: Available for employees condition, you may be another state. Must not be Recipients: Income limit of 74% FPL. work at least 30 hours who work for employers with less than eligible for CHIP or PCIP. enrolled in or eligible for Part A a week. 20 employees. You must have been See next column. or B of Medicare, or the Arkansas ARKids First A: insured continuously under your previous Medical Assistance Program Children ages 0–5: Income limit ofEligibility Owner name on business employer’s group policy for at least 3 (Medicaid and ARKids). Must not 133% FPL. license must draw wages months prior to enrolling in Mini-COBRA, be eligible for group coverage from the company. be ineligible for Medicare, and currently or COBRA, or government Children ages 6 –18: Income limit of uninsured. You have 10 days from date of programs (must have exhausted 100% FPL. termination to sign up for Mini-COBRA this option). May need to prove coverage. denial of coverage or offer of Children with family income of higher premium. May also be 133%–200% FPL who do not meet HIPAA: Must have had 18 months of federally-eligible for CHIP. certain ARKids First B eligibility are also continuous coverage and completely eligible for ARKids First A. exhausted COBRA or state continuation PCIP: Must have been uninsured coverage. Must not have lost coverage for at least 6 months prior to ARHealthNetworks: Must live in Arkansas. due to fraud or non-payment of applying. Must prove being a U.S. Employees must be between the ages premiums. You have 63 days to enroll in citizen or legal U.S. resident, an of 19–64. Must be a U.S. citizen, or a HIPAA-eligible plan. Arkansas resident, and having permanent resident for at least 5 years. problems getting insurance due Income limit of 200% FPL. to a pre-existing condition. Costs depend on COBRA/Mini-COBRA: Premiums range from Costs for individual CHIP: Premiums from $10.42 to Medicaid & ARKids First A: $0 or minimal employer contribution 102%–150% of group health rates. coverage vary. $1,556.94 depending on age, share of cost. and ± 25% of the gender, and tobacco use. insurance company’s HIPAA: Premiums will depend on planMonthly Cost ARHealthNetworks: $100 annual index rate. chosen. PCIP: Monthly premiums range deductible (does not apply to office from $140.47 to $807.20 visits & Rx). After deductible, 15% depending on your age, gender, co-coverage will be required. $1,000 and tobacco use. maximum out-of- pocket annually, including deductible.87 Arkansas
    • Publicly-Sponsored Programs Demographic Children in Trade Dislocated Moderate Income Women Seniors & Disabled Workers Veterans Families (TAA Recipients) ARKids First B Breast Care Medicare Health Coverage VA Medical (Children’s Health Insurance Plan) 877-670-2273 501-661-2513 800-633-4227 www.medicare.gov Tax Credit Benefits Package 866-628-4282 877-222-8387 888-474-8275 www.arbreastcare.com www.irs.gov www.va.gov www.arkidsfirst.com Medicare (Search: HCTC) Mother-Infant Prescription Drug Program Program Program 501-661-2154 800-633-4227 www.adhhomecare.org/ maternal.htm Senior’s Health Maternity Program Insurance 501-661-2480 Information Program 800-462-0599 (SHIIP) 800-224-6330 501-371-2782 insurance.arkansas.gov/seniors/ homepage.htm Ambulance (emergency Breast Care: Mammograms, Medicare offers Part A, Inpatient and outpatient care Comprehensive preventive and only), Chiropractor, Dental clinical breast exams, pelvic inpatient care in hospitals and (lab tests, x-rays, etc.), Doctor primary care, outpatient and care (orthodontia included), exams and Pap tests , and free rehabilitative centers; Part B, visits, Preventive and major inpatient services. Durable medical equipment, follow-up tests or treatment, doctor and some preventive medical care (surgery, physical ER services, EPSDT screens, if needed. services and outpatient care; therapy, Durable medical Pre-Existing Health Family planning, Hearing, Home Part C allows Medicare benefits equipment, etc.), Mental health Conditions Covered health, Hospice, Immunizations, Mother-Infant Program: Skilled through private insurance and substance abuse care, and Inpatient hospital, Lab and x-ray, home nursing visits for new (Medicare Advantage); Part C Prescription drugs. Midwife, Outpatient mental and mothers and infants to meet includes Parts A, B, and C not behavioral health, Physician, their medical, social and covered by Medicare. Part D Pre-Existing Health Coverage Podiatry, Prescription drugs, nutritional needs. covers prescription drugs. Conditions Covered Speech therapy, Transportation, and Vision. Maternity Program: Pregnancy SHIIP is a Medicare counseling testing, prenatal education service. Pre-Existing Health and visits that include medical Conditions Covered history and physical exam, Pre-Existing Health Conditions Pap smear, STD and other Covered lab tests that can harm baby. Postpartum care and birth control. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Children ages 0–18 with family All: Must be resident of Medicare & SHIIP: Must be U.S. Must be receiving TAA (Trade ”Veteran status” = active duty incomes up to 200% FPL. Arkansas. citizen or permanent U.S. Adjustment Assistance), or in the U.S. military, naval, or air resident, and: service and a discharge or release Breast Care: Must be women at Must be 55 years or older and from active military service least age 40, with income at or 1) If 65 years or older, you or receiving pension from the under other than dishonorable below 200% FPL, be uninsured your spouse worked for at least Pension Benefit Guaranty conditions. (including no Medicaid or 10 years in Medicare-covered Corporation (PBGC). Medicare), or have insurance employment, or Certain veterans must have that do not cover services Must not be enrolled in certain completed 24 continuous Eligibility offered by AR Breast Care. 2) You have a disability or end- state plans, or in prison, or months of service. stage renal disease (permanent receiving 65% COBRA premium Mother-Infant Program: Must be kidney failure requiring dialysis reduction, or be claimed as a pregnant women. or transplant) at any age. dependent in tax returns. Maternity Program: Must be Must be enrolled in qualified pregnant women. No one will health plans where you be refused services because pay more than 50% of the they do not have money to pay. premiums. $0–$10 co-payments. Breast Care: $0 Medicare & SHIIP: $0 and share 20% of the insurance $0 and share of cost and co- Exceptions: Durable medical of cost for certain services; premium including COBRA pays depending on income level. equipment and inpatient Mother-Infant Program: Will be deductibles for certain plans. premium if employer Monthly Cost hospital care require a 20% co- covered even if not Medicaid- Part A: $0–$450 based on contributes less than 50%. insurance. eligible. length of Medicare-covered employment; Part B: $96.40– Maternity Program: $0 or $369.10 depending on annual minimal share of cost. income; Part C: Based on provider; Part D: Varies in cost and drugs covered. Arkansaswww.CoverageForAll.org 8
    • Demographic Private Health Insurance Small Individuals with Individuals Recently Businesses Individuals Pre-Existing, Low-Income Families Covered by an Employer (2-50 & Families Severe, or Chronic & Medically-Needy Health Plan Employees) Medical Conditions Group Plans COBRA/Cal-COBRA Individual Plans MRMIP Medi-Cal (Major Risk Medical California’s Medicaid Program California Association California Association Insurance Program) 800-541-5555 of Health Underwriters Then convert to a plan under: of Health Underwriters 800-289-6574 800-786-4346 800-322-5934 800-322-5934 www.mrmib.ca.gov www.medi-cal.ca.gov www.cahu.org/consumers www.cahu.org/ HIPAA consumers Due to changes in the program, Or contact local county Health Insurance Portability & MRMIP has opened up a waitlist. social services agency Program Accountability Act 866-487-2365 www.dhs.ca.gov www.dol.gov Pre-Existing Condition Insurance AIM HIPP Plan (PCIP) Access for Infants & Mothers 800-433-2611 Health Insurance Premium Payment www.dhcs.ca.gov Federal program run by the www.aim.ca.gov Managed Risk Medical Insurance Board(MRMIB) 877-428-5060 www.PCIP.ca.gov Wide selection of plans COBRA: Coverage available for 18–36 months Wide selection of plans MRMIP: Offers a variety of Medi-Cal: Must be a California cover different medical depending on qualifying events. Benefits cover different medical medical services provided by resident. Offers health, dental, services. are what you had with your previous services. HMOs and PPOs and has a 3 vision, and prescription coverage. employer. month exclusion period for Treatment for special health No Lifetime Limits. No Lifetime Limits. pre-existing conditions. There problems, like breast cancer, Cal-COBRA: Coverage available for 36 months is a $75K annual limit, $750K kidney problems, nursing home Guarantee issue depending on qualifying events. Benefits Pre-existing conditions lifetime limit, and $500 annual needs, and AIDS. regardless of pre-existing are what you had with your previous may require increased deductible. The annual out- health conditions. employer. rates or declination. of-pocket max is $2,500/$4000 AIM: Comprehensive medical care for Coverage individual or family. MRMIP mother provided (not just maternity). Maximum exclusion of 6 HIPAA: Benefits are based on program Limits on Pre-Existing enrollees cannot enroll in PCIP. Mothers continue coverage up to 60 months for pre-existing selected. There is no expiration of coverage. Health Conditions May days after delivery. After birth, infant conditions on certain Apply PCIP: Covers broad range of is automatically enrolled in Healthy plans for enrollees with HIPP: Benefits are the same as what you benefits, including primary and Families Program up to age 1. no prior coverage. had with your previous employer. HIPP is a specialty care, hospital care, and premium assistance program. prescription drugs. There is an Pre-Existing Health Employers may allow annual deductible of $15,000 in- Conditions Covered part-time employees Pre-Existing Health Conditions Covered network/$3,000 out-of-network, who work 20 hours to be brand name Rx deductible of eligible. $500/$500, and an annual out- of-pocket max of $2,500. Pre-Existing Health Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE COBRA: Available for employees who work for Eligibility is subject to MRMIP: Must have been a Medi-Cal: Pregnant women and Company size 2–50 businesses with 20 or more employees. You medical underwriting. California resident for at least children ages 0–1: 200% FPL. employees. have 60 days from date of termination to 12 months. Must have a pre- sign up for COBRA coverage. If you are denied existing health condition as Children ages 1–5: 133% FPL. Eligible employees must coverage for a medical evidenced by a declination letter Children ages 6–18: 100% FPL. work at least 30 hours a Cal-COBRA: Available for employees who work condition, you may be within the last 12 months, or week. for businesses with less than 20 employees. eligible for MRMIP or offered coverage with a higher Parents/caretakers with children You have 60 days from date of termination PCIP. See next column. premium than MRMIP. Cannot under 21 in foster care: 107% FPL. Owner can count as an to sign up for Cal-COBRA coverage. be eligible for Medicare, COBRA Elderly or disabled: Income limit of Eligibility employee. or Cal-COBRA. 100 % FPL with asset limit of $2,000 HIPAA: Must have had 18 months of for singles and $3,000 for couples. Owner name on business continuous coverage and completely PCIP: Uninsured for at least 6 license must draw wages exhausted COBRA or state continuation Months. Must have a pre-existing AIM: Income limit of 200%–300% from the company. coverage. Must not have lost coverage due health condition as evidenced FPL. Must be pregnant less than to fraud or non-payment of premiums. You by a declination letter within 31 weeks, be a California resident have 63 days to enroll in a HIPAA-eligible the last 12 months, or offered for at least 6 months, with legal plan. coverage with a higher premium immigration status, must not be than MRMIP. Applicant must be a receiving no-cost Medi-Cal or HIPP: You may be eligible for HIPP if you U.S. citizen, Nationals or Lawfully Medicare Part A and Part B benefits as of the application date, and have a high-cost health condition (e.g., Present. Cannot be eligible for must be uninsured or insurance pregnancy, HIV/AIDS), and are eligible for Medicare, COBRA or Cal-COBRA. has maternity deductible or co- Medi-Cal. payment of $500 or more. Rates are age–banded and COBRA/Cal-COBRA: Premiums range from Costs for individual MRMIP: Monthly premiums Medi-Cal: $0–$1 co-pays. depend on plan, zip code 102%–150% of group health rates. coverage vary. range from $239.20 -$1,850.50 and overall health of the depending on your age, region in $5 for non-emergency visits in ER. Monthly Cost group. HIPAA: Premiums will depend on plan CA, and program. chosen. AIM: 1.5% of family annual income Rates are limited by PCIP: Monthly premiums range for AIM. regulation to ±10% of HIPP: $0 or minimal share of cost. from $107-$557 depending on standard approved rates. your age and location.109 California
    • Publicly-Sponsored Programs Demographic Children in Low- Pregnant Women, Immigrants Adults in Income Families Adults without Infants, & Moderate Awaiting Need of Cancer or Undocumented Dependents Income Children Legal Status Screening Children Healthy Kids IMPACT (County-Based Programs) Medi-Cal County Medical Restricted 800-409-8252 Contact Your County’s Children’s Health www.california-impact.org Initiative California’s Medicaid Program 800-541-5555 Services Program Medi-Cal www.cchi4families.org 800-786-4346 (CMSP) California’s Medicaid Program Breast and www.medi-cal.ca.gov Contact local county social CaliforniaKids services agency 800-952-5253 www.medi-cal.ca.gov Cervical Cancer 818-755-9700 AIM www.cmspcounties.org Treatment www.californiakids.org Program Program Access for Infants & Mothers 800-433-2611 Genetically Family PACT Kaiser Permanente Child (Family planning) (BCCTP) Health Plan (KPCHP) www.aim.ca.gov Handicapped 800-942-1054 800-824-0088 800-464-4000 Persons Program www.familypact.org www.dhs.ca.gov info.kp.org/childhealthplan Healthy Families (Search: BCCTP) 800-880-5305 (GHPP) For local programs Note: Temporarily opened for Southern 888-747-1222 916-327-0470 contact California in select counties (Los www.healthyfamilies.ca.gov 800-639-0597 www.dhs.ca.gov WISEWOMAN Angeles, Orange County, San Diego). www.dhcs.ca.gov/services/ 800-511-2300 ghpp www.cdph.ca.gov Children Health and (Search: WISEWOMAN) Disability Prevention (CHDP) Call your local CHDP provider www.dhs.ca.gov/pcfh/cms/chdp Healthy Kids: Doctors visits, Medi-Cal: Prenatal, pregnancy, and delivery CMSP: Program availability Restricted Medi-Cal: IMPACT: Provides men with Immunizations, Dental & vision care. Mothers are covered up to 60 days after varies by county; medically- Covers emergencies, Radical prostatectomy, care, Prescriptions, Surgery, and delivery. necessary physician and pregnancy- related care External beam radiation Hospitalization. hospital-related services; (prenatal and delivery). therapy, Hormone AIM: Comprehensive medical care for depending on county, may therapy, Watchful CaliforniaKids: Medical (outpatient only), mother provided (not just maternity); preventive, dental, and vision care, provide coverage for other Family PACT: Provides waiting, Brachytherapy, emergency room ($1,000 annual limit), mothers covered up to 60 days after services such as dental and comprehensive family Chemotherapy, Counseling, behavioral health program (requires delivery; after birth, infant is automatically vision; benefits vary by planning services. Prostate cancer treatment approval), and prescription drugs. enrolled in Healthy Families Program up county. Please refer to social for the initial 12 months, to age 1. Coverage KPCHP: Hospital care, Hearing and services agency in county of Pre-Existing Health and more. vision tests, Laboratory and x-ray Healthy Families: Physician, emergency residence. Conditions Covered services for no charge. Doctor office and preventive care; prescription BCCTP: Women can get visits, Prescriptions, Urgent care, drugs; inpatient and outpatient GHPP: Special care center screening and treatment for Emergency visits, and Mental health (medical, mental, and substance abuse) services, hospital stay, breast and cervical cancer. care (outpatient 20 visits/year) for a fee. outpatient medical care, See below for cost. hospital service; family planning and maternity care; medical transportation; pharmaceutical services, WISEWOMAN: Screening CHDP: Immunizations; dental, vision, durable medical equipment; physical, surgeries, nutrition products and intervention for hearing, and nutrition screening; occupational, and speech therapy; x-ray and medical foods, durable cardiovascular diseases and tests for illnesses like anemia, TB and and lab services; home health care and medical equipment, and education about their signs, others as needed; health and tobacco nursing care. other services. symptoms, and prevention. education; WIC referral for children up to age 5. Pre-Existing Health Conditions Covered Pre-Existing Health Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED GUARANTEED COVERAGE COVERAGE Healthy Kids: Eligibility varies by county. Medi-Cal: Must be a California resident. If CMSP: Must be U.S. citizen or IMPACT: Male California Must not be eligible for no-cost, full- you are pregnant, your income can be up Restricted Medi-Cal: residents over 18 years scope Medi-Cal or Healthy Families. to 200% FPL. legal resident between Undocumented children are eligible. ages of 21–64. Must not Income limits for old that are uninsured or AIM: Income limit of 200%–300% FPL. be eligible for Medi-Cal. pregnant women and underinsured. Income up CaliforniaKids: Must be children ages Must be pregnant less than 31 weeks, Must be a resident of children ages 0–1: 200% to 200% FPL, have abnormal 0–18 and going to school, not be be a California resident for at least 6 eligible counties. In CMSP FPL. DRE, PSA or diagnosed with eligible for other government plans months, with legal immigration status, counties, income can be up Children ages 1–5:133% prostate cancer. such as Medi-Cal or Healthy Families must not be receiving no-cost Medi-Cal to 200% FPL. In non-CMSP FPL. Program. or Medicare Part A and Part B benefits Children ages 6–18: counties, eligibility income BCCTP: Female California as of the application date, and must be 100% FPL. Eligibility KPCHP: Must be children ages 0–18 living standards vary. Please refer resident and U.S. citizen uninsured or insurance has maternity Elderly or disabled: or legal resident under 65 at or below 300% FPL, be California deductible or co-payment of $500 or to social services agency residents living near Kaiser or in county in county of residence. 133% FPL. living at or below 200% plan area, uninsured and not be eligible more. Property and vehicle limits, FPL, have been screened for employer-based coverage. Healthy Families: Children ages 0–1: Above and dependents/relatives Family PACT: Must be and found to be in need 200% to 250% FPL. considered. a California resident for breast and/or cervical CHDP: Must be Medi-Cal recipients Children ages 1–5: Above 133% to 250% with income limit of under age 21. Children 0–19 years old 200% FPL. Must be cancer and have no other must have income of 200% FPL or less FPL. GHPP: Must be diagnosed with health insurance. and not be receiving Medi-Cal. Also Children ages 6–18: Above 100% to 250% uninsured, or ineligible a genetic condition that is for Medi-Cal. If insured, eligible are children in Headstart, State FPL. covered by GHPP. Must be WISEWOMAN: Must be Preschool programs, and Foster Care. If income is at or below 100% FPL, your then insurance must not child may be eligible for Medi-Cal. Must resident of California. Must cover family planning or enrolled in BCCTP. be ineligible for no-cost Medi-Cal or be 21 years or older (some birth control methods, employer-based coverage. Must be persons younger than 21 or patient cannot afford California residents and legal immigrants years of age may be eligible); insurance deductible. If or U.S. citizens. No income limit. Applicants Medi-Cal enrollee, then may be required to apply for must not have met share Medi-Cal. of cost. Healthy Kids: $0–$15 per child Medi-Cal: $0 or minimal share of cost. CMSP: Share-of-Cost = Both: $0 or minimal For all: $0 or minimal share monthly; $5 co-pay for most outpatient countable net income AIM: 1.5% of family annual income for minus maintenance need. share of cost. of cost. services. Monthly Cost AIM. CaliforniaKids: Monthly premium of $75 per child. GHPP: For some clients, the Healthy Families: $4–$72 monthly amount of annual enrollment KPCHP: $8-15 per child per month ($45 premium per family based on FPL and fee is based on income and max per family), co-pays range from $5- plan chosen. Up to $15 in co-pays. family size. $35 for some services with a $250 per child or $500 for two or more children maximum. CHDP: $0 or minimal share of cost. www.CoverageForAll.org California 10
    • Demographic Private Health Insurance Small Individuals with Individuals Recently Low-Income Businesses Individuals Pre-Existing, Severe, Covered by an Employer Families & (1-50 & Families or Chronic Medical Health Plan Medically-Needy Employees) Conditions Group Plans COBRA/Colorado Continuation Individual Plans CoverColorado Colorado Colorado State Association Colorado State (Colorado Medical Insurance Pool) Health Plan of Health Underwriters Then convert to a plan under: Association (Medicaid) 888-770-1120 303-866-3513 (Metro 720-733-8000 of Health Underwriters 303-863-1960 (Enrollment) www.csahu.org 720-733-8000 Denver) Colorado Conversion www.covercolorado.org 800-221-3943 (outside www.csahu.org Program Metro Denver) www.dora.state.co.us/insurance 800-930-3745 GettingUSCovered www.chcpf.state.co.us Federal program run by the Rocky 303-894-7490 Mountain Health Maintenance Organization, Inc. Contact your local county 877-779-0387 (Enrollment) offices for Medicaid HIPAA 877-397-1109 (Customer Service) information in your county. Health Insurance Portability & Accountability www.gettinguscovered.org List of numbers can be Act www.PCIP.gov found here: 866-487-2365 www.dol.gov www.cdhs.state.co.us/ servicebycounty.htm Assorted deductibles. COBRA: Coverage available for 18–36 months Different plans will CoverColorado: Covers Hospitalization, Diagnosis, Physician depending on qualifying events. Benefits are cover different medical Physician care, Diagnostic tests, services, check-ups There is a maximum what you had with your previous employer. services. X-rays, Prescription drugs, and (medical and dental), look-back and exclusion Some mental health care services. family planning, maternity, period of 6 months for Colorado Continuation: Benefits are what you had There is a maximum If you have not been insured within prenatal, and newborn pre-existing conditions on with your previous employer. Coverage lasts up look-back and exclusion the past 90 days prior to applying, care, prescriptions, enrollees who do not have to 18 months. period of 12 months for expenses related to any pre-existing hospital services, comfort prior coverage. pre-existing conditions medical condition will not be care, hospice, dental Coverage HIPAA/Colorado Conversion: Benefits are based on enrollees who do not covered for the first 6 months. If services, drug and alcohol Pre-Existing Health on program selected. There is no expiration of have prior coverage. you have been insured for at least 6 treatment, mental health Conditions Covered coverage. continuous months within 90 days services. Limits on Pre-Existing of applying, you will not be subject Pre-Existing Health Conditions Covered Health Conditions May to the 6-month pre-existing waiting Pre-Existing Health Apply period. Conditions Covered GettingUSCovered: Covers broad range of benefits, including primary and specialty care, hospital care, and prescription drugs. Pre-Existing Health Conditions Covered GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE COBRA: Available for employees who work for Eligibility is subject to CoverColorado: Must have resided in Must be a Colorado Company size 1–50. businesses with 20 or more employees. You have medical underwriting. Colorado as a legal resident for at resident and a U.S. citizen 60 days from date of termination to sign up for least 6 months prior to applying. or legal alien. Eligible employees must COBRA coverage. If you are denied You may be HIPAA eligible or work at least 24 hours a Colorado Continuation: Applies to employees of any coverage for a transferring from another state’s Income limits: week. employer group policy where COBRA doesn’t medical condition, high risk pool. Must have a you may be eligible qualifying health condition. Cannot SSI aged or disabled: 75% apply. Must have been covered under employer’s FPL. Owner can count as an group plan for six consecutive months, and sign for CoverColorado, or be eligible for Medicaid, Medicare employee. for continuation coverage within 30 days of GettingUSCovered. See or any other health insurance. Pregnant women and termination. next column. May be eligible through the Trade children ages 0–5: 133% Proprietor-name on license Adjustment Assistance Act (TAA) FPL. Eligibility must draw wages. HIPAA: Must have had 18 months of continuous Coverage/Health Coverage Tax coverage and completely exhausted COBRA Credit (HCTC). Children ages 6–18: 100% or state continuation coverage. Must not have FPL. lost coverage due to fraud or non-payment of GettingUSCovered: Must have been premiums. You have 63 days to enroll in a HIPAA- Parents/caretakers living uninsured for at least 6 months with children ages 0–18: eligible plan. prior to applying. Must prove being 66% FPL. Colorado Conversion: Available for employees a U.S. citizen or legal U.S. resident, who were covered for less than 6 but more than a Colorado resident, and having 3 months by their employer’s group plan, or problems getting insurance due to a Some eligibility at the end of continuation coverage, or upon pre-existing condition. requirements change termination of a small group policy. You have 31 from county to county so days to sign up for a conversion plan with no pre- contact your local county existing health condition exclusion. department. Costs depend on employer COBRA/Colorado Continuation: Premiums range from 102%–150% of group health rates. Costs depend on age CoverColorado: Varies based on the $0 –$3 for children, contribution and +10% and county/zone. plan and deductible you choose and pregnant women, and adults. or –25% of the insurance underwriting guidelines. Monthly Cost HIPAA/Colorado Conversion: Premiums will depend company’s index rate. on plan chosen. If you are self-employed $10/day up to 50% and buy your own GettingUSCovered: Monthly premiums of payment for first insurance you are range from $116.16 to $729.21 day of care for hospital eligible to deduct depending on your age, county of admissions (except for 100% of the cost of the residence and smoking status. mental institutions). premium from your federal income tax. $2/hour for psychological consultation.1211 Colorado
    • Publicly-Sponsored Programs Demographic Trade Dislocated Low-Income Native American Women Workers Veterans Children Indians (TAA Recipients) Child Health Women’s Wellness Indian Health Health Coverage VA Medical Plan Plus (CHP+) Connection Services Tax Credit Benefits Package 800-359-1991 (WCC) 505-248-4500 866-628-4282 877-222-8387 www.cchp.org www.irs.gov www.va.gov 303-692-2581 www.ihs.gov (Search: HCTC) 866-951-9355 (Search: Albuquerque) Program womenswellnessconnection.org www.cdphe.state.co.us (Search: CWCCI) Regular checkups, The program provides breast Health care team includes, Inpatient and outpatient care Comprehensive preventive and Immunizations (shots), and cervical cancer screening Clinical psychologists, Dental (lab tests, x-rays, etc.), Doctor primary care, outpatient and Prescriptions (medicine), (mammograms, clinical breast assistants, Dental hygienists, visits, Preventive and major inpatient services. Hospital services, Eyeglasses, exams, Pap tests and pelvic Dental officers, Dieticians, medical care (surgery, physical Hearing aids, Dental services up exams) and selected diagnostic Environmental health staff, therapy, Durable medical Pre-Existing Health to $600 a year including exams, services. Health educators, Medical equipment, etc.), Mental health Conditions Covered Cleanings, and some other officers, Medical records staff, and substance abuse care, and services. Cancer treatment for some Medical technologists, Mental Prescription drugs. Coverage women qualified through health technicians, Nurses, Pre-Existing Health Medicaid. Nutritionists, Pharmacists, Pre-Existing Health Conditions Covered Radiology technologists, Social Conditions Covered workers. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Must be U.S. citizens or Must live in Colorado, be 40–64 Must exhaust all private, state, Must be receiving TAA (Trade ”Veteran status” = active duty permanent residents and years old, underinsured or and other federal programs. Adjustment Assistance), or in the U.S. military, naval, or air live in Colorado (for at least 5 uninsured, with income at or service and a discharge or release years), be children ages 0–18, below 250% FPL, and must not Must be regarded by the local Must be 55 years or older and from active military service or pregnant women ages 19 have had Pap or mammogram community as an Indian; is a receiving pension from the under other than dishonorable and over, must not be in prison test in last 12 months. member of an Indian or Group Pension Benefit Guaranty conditions. or mental institutions, must under Federal supervision; Corporation (PBGC). be uninsured or ineligible for resides on tax-exempt land Certain veterans must have Medicaid, and earn up to 250% or owns restricted property; Must not be enrolled in certain completed 24 continuous months FPL. actively participates in tribal state plans, or in prison, or of service. affairs; any other reasonable receiving 65% COBRA premium Eligibility factor indicative of Indian reduction, or be claimed as a descent; is a non-Indian woman dependent in tax returns. pregnant with an eligible Indian’s child for the duration Must be enrolled in qualified of her pregnancy through health plans where you post-partum (usually 6 weeks); pay more than 50% of the is a non-Indian member of an premiums. 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. $0 for most members and $0 for most members. $0 or minimal share of cost. 20% of the insurance $0 and share of cost and co-pays Native Americans. premium including COBRA depending on income level. premium if employer Monthly Cost For those who have to pay, contributes less than 50%. enrollment fee is $25 for one child, $35 for 2+children. Co-pays are $2–$15 per visit for routine medical care. www.CoverageForAll.org Colorado 12
    • Demographic Private Health Insurance Individuals Individuals with Low-Income Small Businesses Recently Covered Individuals Pre-Existing, Individuals & (1-50 Employees) by an Employer & Families Severe, or Chronic Families Health Plan Medical Conditions Group Plans COBRA/Mini-COBRA Individual Plans Health Reinsurance Medicaid National Association of Health National Association of Health Association(HRA) 800-842-1508 TDD/TYY: 800-842-4524 Underwriters Then convert to a plan under: Underwriters 800-842-0004 www.hract.org/hra www.dss.state.ct.us 703-276-0220 703-276-0220 www.nahu.org www.nahu.org HIPAA Pre-Existing HUSKY A Health Insurance Portability & Program (Health Care for Accountability Act Condition Insurance Uninsured Kids and Youth) 866-487-2365 Plan (PCIP) Medicaid for Children www.dol.gov Federal program run by the 877-284-8759 CT Dept. of Social Services and 800-656-6684 the HRA www.huskyhealth.com 800-656-6684 www.PCIP.gov www.ct.gov (Search: Pre-Existing Condition) Mostly plans with co-pays, COBRA: Coverage available for Different plans will cover HRA: Choose from 2 individual Medicaid and HUSKY A: Provides full some with deductibles. 18-36 months depending on different medical services. plans: PPO or a Special Health Medicaid health coverage/benefits qualifying events. Benefits are Care Plan (waiting period of package, including long-term care/ There is a maximum look- what you had with your previous There may also be a lifetime 12 months). Choose from 2 skilled nursing facility, home health back period of 6 months and employer. maximum of benefits, for conversion plans: PPO and a care and non-emergency medical maximum exclusion period example $5M. Special Health Care Plan (no transportation. of 12 months for pre-existing Mini-COBRA: Coverage lasts waiting period, if you qualify). conditions on enrollees who do a maximum of 30 months There is a 12-month look-back All benefits are the same Some services may need prior not have any prior coverage. depending on qualifying events. and exclusionary period limit except the Special Plan, which approval. Coverage Benefits are what you had with for pre-existing conditions. does not cover outpatient Pre-Existing Health your previous employer. prescriptions. HUSKY A includes services available Conditions Covered Limits on Pre-Existing Health to Children and Youth with Special HIPAA: Benefits are based on Conditions May Apply PCIP: Covers broad range of Health Care Needs (CYSHCN). program selected. There is no benefits, including primary and expiration of coverage. specialty care, hospital care, Pre-Existing Health and prescription drugs. Conditions Covered Pre-Existing Health Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size 1–50 employees. COBRA: Available for employees Eligibility is subject to medical HRA: Guaranteed to all Medicaid and HUSKY A: Must be who work for businesses with 20 underwriting. Connecticut residents under U.S. citizens or legal permanent If in business 90 days or more, or more employees. You have 60 the age of 65. If HIPAA-eligible residents, and Connecticut can usually qualify. days from date of termination to If you are denied coverage for then no pre-existing exclusion residents. Must be children ages sign up for COBRA coverage. a medical condition, you may period. Eligible if previous 0–18, adults, parents, or caregivers Owner can count as an be eligible for a Connecticut coverage was terminated for living at or below 185% FPL, or employee. Proprietor name on Mini-COBRA: Available for Health Reinsurance Association reasons other than non- pregnant women living at or below license must draw wages. employees who work for Plan or PCIP. See next column. payment of premium or fraud. 250% FPL. businesses with less than 20 Self-employed groups have employees. You have 30 days PCIP: Must have been uninsured Eligibility a guaranteed issue right to a from date of termination to sign for at least 6 months prior specific small employer plan. up for Mini-COBRA coverage. to applying. Must prove being a U.S. citizen or legal Eligible employees must work HIPAA: Must have had 18 months U.S. resident, a Connecticut at least 30 hours a week. of continuous coverage and resident, and having problems completely exhausted COBRA getting insurance due to a or state continuation coverage. pre-existing condition. Must Must not have lost coverage have a qualifying pre-existing due to fraud or non-payment of condition. premiums. You have 63 days to enroll in a HIPAA-eligible plan. Costs depend on employer COBRA/Mini-COBRA: Premiums Costs depend on age and HRA: Premiums vary depending Medicaid and HUSKY A: $0 contribution and the modified range from 102%–150% of group county/zone. on the applicant’s income level, May share in some costs. community rate. health rates. age, sex, family size,and plan No rate caps. chosen. Rates are usually capped Monthly Cost HIPAA: Premiums will depend on by state law at a level between plan chosen. If you are self-employed and 150% and 200% of standard buy your own insurance you are market rates. eligible to deduct 100% of the cost of the premium from your PCIP: Flat rate of $381 per month federal income tax. regardless of age.1413 Connecticut
    • Publicly-Sponsored Programs Demographic Low-Income Children Women Adults Seniors & Disabled Adults Medicaid for Low- HUSKY B and Plus Connecticut Breast Charter Oak Medicare Income Adults 877-284-8759 800-656-6684 and Cervical Cancer Health Plan (Age 65 and up) 800-633-4227 (Medicaid LIA) www.huskyhealth.com Early Detection 877-772-8625 www.ct.gov/coh www.medicare.gov 866-409-8430 860-269-2031 Program (CBCCEDP) www.ct.gov/dph www.ct.gov/dss Medicare Prescription Program (Search: Low-Income Adults) (Search: CBCCEDP) Drug Program 800-633-4227 WISEWOMAN www.ct.gov/dph (Search: WISEWOMAN) Connecticut CHOICES Both programs: Program 860-509-7804 (Medicare advice) www.dph.state.ct.us 800-994-9422 Inpatient and outpatient HUSKY B: Comprehensive CBCCEDP: Office visits, Covers Primary care, Specialist Medicare offers Part A, inpatient hospital services, Physician medical care except long-term Mammograms, Breast biopsies office visits, Preventive care, care in hospitals and rehabilitative services, Laboratory services, care and non-emergency and ultrasounds, Fine needle Ambulance, Emergency room centers; Part B, doctor and some Prescription drugs, Mental medical transportation. aspirations, Pap tests, LEEP, visit, Prescription medication, preventive services and outpatient health services, Immunizations, Surgical consultations, Clinical Durable medical equipment, care; Part C allows Medicare and Emergency services. HUSKY Plus: For HUSKY B breast exams, and colposcopies Lab and x-ray, Behavioral benefits through private insurance recipients with or are at high and colposcopy-directed health services, Inpatient and (Medicare Advantage); Part C Pre-Existing Health risk for chronic physical, biopsies. outpatient services, Pre- and includes Parts A, B, and C not Conditions Covered developmental, behavioral, post-natal care. Lifetime covered by Medicare. Part D covers Coverage or emotional conditions and WISEWOMAN: Cardiovascular maximum benefit of $1 million, prescription drugs. require health and related disease risk assessment and annual maximum benefit of services beyond that are counseling; blood, lipid, and $100,000. Connecticut CHOICES is a Medicare required by children generally. blood glucose screening. counseling service. Services cover severe physical Referral for treatment if Pre-Existing Health health problems not covered screening results are elevated. Conditions Covered Pre-Existing Health under the basic HUSKY B plan. Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Must be U.S. citizens and HUSKY B and Plus: Must CBCCEDP: Income must be at Must be uninsured Connecticut Medicare and Connecticut CHOICES: Must Connecticut residents ages be children ages 0–18, or below 200% FPL. Must residents, ages 19–64 who are be a U.S. citizen or permanent U.S. 19–64, not receiving Medicare U.S. citizens, and live in be 19–64 years of age for U.S. citizens or qualified aliens. resident, and: or Supplemental Security Connecticut. clinical breast exams and There are no income limits. Income (SSI), not be pregnant, Pap tests, or 40–64 years of 1) If 65 years or older, you or your live at or below 56% FPL. For HUSKY B: May not be available age for mammograms. Must spouse worked for at least 10 years those living in Region A (mostly if a child has been covered by be uninsured or have health in Medicare-covered employment, southwestern Connecticut), health insurance through a insurance that excludes or income limit is 68% FPL. There parent’s employer during the routine Pap tests and/or are no asset requirements. past two months; exceptions to mammograms, or insurance 2) You have a disability or end- Eligibility this waiting period include loss deductible of $1,000 or more. stage renal disease (permanent of employment and financial Women ages 65 or older who kidney failure requiring dialysis or hardship. No income limit for are not enrolled in Medicare transplant) at any age. HUSKY B. Families with incomes Part B may be eligible to receive greater than 300% FPL can buy CBCCEDP & WISEWOMAN into a HUSKY plan. services. HUSKY Plus: Income limit of 185% WISEWOMAN: Must be enrolled to 300% FPL. in the CBCCEDP, 40 to 64 years old, have an income at or below 200% FPL, have no health insurance or health insurance that excludes routine blood pressure screening, lipid profile, and blood glucose screenings. $0 or minimal share of cost. HUSKY B: Co-pays $10–$15, Both: No co-pays or premiums. $446 monthly premium per Medicare and Connecticut CHOICES: $0 and share of cost for certain Medicaid will pay for your prescription drugs and individual. benefits only if you bring your services; deductibles for certain contraceptives $5–$10. Primary care office visit: $25 plans. Part A: $0–$450 based gray CONNECT card when Monthly Cost visiting a Medicaid-approved co-pay. Specialist office visit: on length of Medicare-covered provider. If you paid for services HUSKY Plus: No additional $35 co-pay. employment; Part B: $96.40– from Medicaid providers you premiums, no deductible, and $369.10 depending on annual Co-pays, co-insurance and income; Part C: Based on provider; visited on or after April 1, no co-pays. Over 300% FPL deductibles depend on income 2010, you may be eligible for Part D: Varies in cost and drugs buy into the plan at negotiated and family size. covered. reimbursement. group price. Family’s annual cost-sharing less than 5% of income. www.CoverageForAll.org Connecticut 14
    • Demographic Private Health Insurance Individuals Recently Individuals with Low-Income Small Businesses Covered by an Individuals Pre-Existing, Severe, Individuals (1-50 Employees) Employer Health & Families or Chronic Medical & Families Plan Conditions Group Plans COBRA Individual Plans Pre-Existing Condition Medicaid National Association National Association Insurance Plan (PCIP) 302-255-9500 of Health Underwriters Then convert to a plan under: of Health Underwriters Run by the U.S. Department of 800-372-2022 703-276-0220 703-276-0220 Health and Human Services dhss.delaware.gov 866-717-5826 www.nahu.org HIPAA www.nahu.org www.PCIP.gov (Search: Medicaid) Health Insurance Portability & Program Accountability Act 866-487-2365 www.dol.gov All group health insurance COBRA: Coverage available for Assorted plans depending on Covers broad range of benefits, Doctor visits, Hospital care, carriers can impose a 18–36 months depending on medical needs. including primary and specialty Labs, Prescription drugs, 6-month look-back/12-month qualifying events. Benefits are care, hospital care, and prescription Transportation, Routine shots exclusionary period for what you had with your previous There is a maximum look-back drugs. for children, Mental health pre-existing conditions on employer. period of 60 months and no and substance abuse services, enrollees that do not have prior limit to the exclusion period Pre-Existing Health X-rays, Home health care, creditable coverage. HIPAA: Benefits are based on for pre-existing conditions on Conditions Covered Hospice care, Dental care (up program selected. There is no enrollees who have no prior to age 21). Benefits will vary depending on expiration of coverage. coverage. the chosen plan. Pre-Existing Health Coverage Pre-Existing Health Elimination riders are Conditions Covered Pre-Existing Health Conditions Covered permitted. Conditions Covered Limits on Pre-Existing Health Conditions May Apply GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size 1–50 employees COBRA: Available for employees Eligibility is subject to medical Must have been uninsured for at Must be U.S. citizens or (including owner). Owner name who work for businesses with 20 underwriting. least 6 months prior to applying. qualified legal residents living on business license must draw or more employees. You have 60 Must prove being a U.S. citizen in Delaware. wages from the company. days from date of termination to If you are denied coverage for or legal U.S. resident, a Delware sign up for COBRA coverage. a medical condition, you may resident, and having problems Income limits: Must be actively engaged in be eligible for PCIP. See next getting insurance due to a pre- business in at least 50% of HIPAA: Must have had 18 months column. existing condition. Pregnant women and infants its working days during the of continuous coverage and age 0–1: 200% FPL. Eligibility preceding calendar quarter. completely exhausted COBRA Children (ages 1–5): 133% FPL. or state continuation coverage. Eligible employees must work Must not have lost coverage Children ages 6–19, working at least 30 hours a week. due to fraud or non-payment of parents, and aged, blind and premiums. You have 63 days to disabled: 100% FPL. Carriers may impose enroll in a HIPAA-eligible plan. participation requirements on Parents/caretakers living with employees and contribution children ages 0–18: 120% FPL. requirements on employers. Childless Adults: 110% FPL. SSI recipients: For singles 75% FPL with asset limit of $2,000; for couples 83% FPL with asset limit of $3,000. Costs depend on employer contribution or health COBRA: Premiums range from 102%–150% of group health Costs for individual coverage vary. Monthly premiums range from $109 to $467 depending on your $0 premiums or minimal share of cost. condition of self-employed rates. age and plan chosen. and ± 35% of the insurance Prescription drugs cost a Monthly Cost company’s index rate. HIPAA: Premiums will depend on plan chosen. maximum $15/month.1615 Delaware
    • Publicly-Sponsored Programs Demographic Trade Dislocated Parents & Children Children Adults Seniors & Disabled Workers (TAA Recipients) Children & Families Delaware Healthy Delaware Medicare Health Coverage First: Children Program Screening for Life 800-633-4227 Tax Credit 888-822-4530 800-464-4357 www.medicare.gov 866-628-4282 Special Medical, Treatment dhss.delaware.gov www.irs.gov dhss.delaware.gov (Search: HCTC) Foster Care, and Resource (Search: DHCP) (Search: Screening for LIfe) Medicare Mothers Program Prescription Drug Program 800-734-2388 www.cffde.org Program 800-633-4227 Adolescent Resource Center (ARC) ELDER Info www.cffde.org/Services/ supportingteens/arc.aspx 800-336-9500 www.delawareinsurance.gov New Castle County: (Search: ELDER Info) 302-658-6134, Kent County: 800-924-6977 Special Medical Foster parents receive Well-baby and well-child Age limits for women: Ages 18–49: Medicare offers Part A, Inpatient and outpatient care specialized training for skills (e.g. checkups, Drug/alcohol abuse office visits, clinical breast inpatient care in hospitals and (lab tests, x-rays, etc.), Doctor CPR, use of medical equipment) to treatment, Speech/hearing exams, pelvic exams, Pap tests, rehabilitative centers; Part B, visits, Preventive and major care for medically-fragile children. therapy, Immunizations, breast and cervical cancer doctor and some preventive medical care (surgery, physical Physical therapy, Eye education. Ages 40–49: All of services and outpatient care; therapy, Durable medical Treatment Foster Care Program provides exams, Ambulance services, the above and mammograms. Part C allows Medicare benefits equipment, etc.), Mental intensive therapy for adolescents Prescription drugs, Hospital Ages 50-64: All services above, through private insurance health and substance abuse who have mental health or care, Physician services, and digital rectal exam, fecal (Medicare Advantage); Part C care, and Prescription drugs. behavioral issues. X-rays, Lab work, Assistive occult blood test, colonoscopy, includes Parts A, B, and C not Resource Mothers Program helps at-risk technology, Mental health and colorectal cancer covered by Medicare. Part D Pre-Existing Health Coverage pregnant mothers receive the counseling, Limited home education. covers prescription drugs. Conditions Covered appropriate prenatal and pediatric health and nursing care, Case management and Age limits for men: Age 40–49: care to ensure healthy babies. office visits, digital rectal ELDER Info is a Medicare Coordination, Hospice care, ARC offers confidential counseling and Comprehensive dental exams, PSA tests, prostate counseling service that about sexual health and medical service. cancer education. Ages 50–64: educates and assists Medicare services (e.g. STD testing, All of the above and fecal occult beneficiaries, those eligible for contraceptives, etc.) for teens. Pre-Existing Health blood test, colonoscopy and Medicare, and caregivers about Conditions Covered colorectal cancer education. Medicare, Medicaid, Medigap, prescription drug benefits, and other issues related to health For men and women over 65 not insurance benefits. eligible for Medicaid: All benefits. Pre-Existing Health Pre-Existing Health Conditions Covered Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Qualified person willing to learn Must be a U.S. citizen or Must be Delaware adults Both: Must be a U.S. citizen or Must be receiving TAA (Trade about children’s needs and qualified non-citizen, and live ages 18–64, uninsured or permanent U.S. resident, and: Adjustment Assistance), or developmental stages, able to work in Delaware. Must be under underinsured (have high, with birth family and Children and age 19, with family income unmet deductible, or insurance 1) If 65 years or older, you or Must be 55 years or older and Families First on behalf of the child. at or below 200% FPL. Must does not cover Pap tests, your spouse worked for at least receiving pension from the not have other comprehensive mammograms, or screenings 10 years in Medicare-covered Pension Benefit Guaranty Special Medical Foster Care: Foster health insurance coverage or be (breast, cervical, colorectal, employment, or Corporation (PBGC). parents of children ages 0 -18 who a dependent of a permanent prostate). Must not be eligible Eligibility may suffer with chronic or acute State employee. for Medicaid or Medicare. Must 2) You have a disability or end- Must not be enrolled in medical conditions (e.g. AIDS, live between 100% to 250% stage renal disease (permanent certain state plans, or in cerebral palsy, etc.) and may require Waiting period may apply. FPL. kidney failure requiring dialysis prison, or receiving 65% supportive technology. or transplant) at any age. COBRA premium reduction, or Treatment Foster Care: Foster parents be claimed as a dependent in of adolescents ages 12–17 with tax returns. mental health or behavioral issues, or needing strong supervision and Must be enrolled in qualified structure. health plans where you pay more than 50% of the Resource Mothers Program: Delaware premiums. women who are pregnant and not yet receiving prenatal care. ARC: Adolescents ages 12–20. Special Medical and Treatment Foster Care: Foster parents receive a monthly $10 to $25 monthly premium $0 or share of cost. Both: $0 and share of cost for 20% of the insurance and no co-pays depending on certain services; deductibles for premium including COBRA payment to cover the child’s expenses income. For every 3 months you certain plans. Part A: $0–$450 determined by the age and level of premium if employer care. Medical expenses are covered by pay in advance, you get the 4th based on length of Medicare- contributes less than 50%. Monthly Cost Medicaid, the state Of Delaware, or the month free. covered employment; Part B: birth family’s insurance. $96.40–$369.10 depending on Services are free due to funding annual income; Part C: Based by the United Way of Delaware, on provider; Part D: Varies in Resource Mothers Program and ARC: $0 grants from the State as well cost and drugs covered. as private and corporate contributions. www.CoverageForAll.org Delaware 16
    • Demographic Private Health Insurance Individuals Individuals with Low-Income Small Businesses Recently Covered Individuals Pre-existing, Individuals (1-50 Employees) by an Employer & Families Severe, or Chronic & Families Health Plan Medical conditions Group Plans COBRA/Mini-COBRA Individual Plans Pre-Existing Medicaid Florida Association of Health Florida Association of Health Condition Insurance 850-488-3560 www.fdhc.state.fl.us/Medicaid Underwriters Then convert to a plan under: Underwriters Plan (PCIP) 321-244-0427 321-244-0427 Run by the U.S. Department of www.fahu.org www.fahu.org Health and Human Services HIPAA 866-717-5826 Health Insurance Portability & Accountability Act www.PCIP.gov Program 866-487-2365 NOTE: Due to the PCIP, Cover www.dol.gov Florida is no longer being offered.If you are enrolled in Cover Florida, please call your health plan to find out more about your coverage continuation. No Lifetime Limits. COBRA: Coverage available for Assorted plans depending on Covers broad range of benefits, Among some of the services: 18–36 months depending on medical needs. including primary and specialty Ambulatory, Surgical centers, Birth There is a 6-month look- qualifying events. Benefits care, hospital care, and center services, Child health check back/12-month exclusionary are what you had with your There is a 24-month look-back prescription drugs. ups, Chiropractic care, Durable period for pre-existing previous employer. and exclusionary period limit medical equipment and supplies, conditions on enrollees with no for pre-existing conditions Pre-Existing Health Federally qualified health centers, prior coverage or whose prior Mini-COBRA: Coverage lasts up on enrollees with no prior Conditions Covered Home health, Hospital inpatient/ coverage had a break of more to 18months depending on coverage. outpatient care, Laboratory, Coverage than 63 days. qualifying events. Benefits Licensed midwives, Physician, are what you had with your If eligible for HIPAA portability, Podiatry, Prescriptions, Rural health Pre-Existing Health previous employer. pre-existing conditions are clinics, Therapy, and X-rays. Conditions Covered covered. HIPAA: Benefits are based on Pre-Existing Health program selected. There is no Limits on Pre-Existing Health Conditions Covered expiration of coverage. Conditions May Apply Pre-Existing Health Conditions Covered GUARANTEED COVERAGE COBRA: Available for employees Eligibility is subject to medical GUARANTEED COVERAGE GUARANTEED COVERAGE who work for businesses underwriting. Company size 1–50 employees. with 20 or more employees. Must have been uninsured Must be U.S. citizens or legal aliens You have 60 days from date If you are denied coverage for for at least 6 months prior to and Florida residents. Owner can count as an of termination to sign up for a medical condition, you may applying. Must prove being employee. Owner name on COBRA coverage. be eligible for Cover Florida or a U.S. citizen or legal U.S. Income limits: business license must draw PCIP. See next column. resident, a Florida resident, wages from the company. Mini-COBRA: Available for and having problems getting Pregnant women: 185% FPL. employees who work for insurance due to a pre-existing Children ages 0–1: 200% FPL. Groups of one have open businesses with less than 20 condition. enrollment during limited employees. You have 30 days Children ages 1–5: 133% FPL. times during the year. from receiving election notice from insurance carrier to sign Children ages 6–18: 100% FPL. Eligibility Eligible employees must work up for Mini-COBRA coverage. Parents/caretakers: 0-20% FPL. at least 25 hours a week. HIPAA: Must have had 18 months Aged, blind and disabled: 88% FPL. Employers must provide copies of continuous coverage and of their federal income tax completely exhausted COBRA SSI Recipients: 74% FPL. Schedule K or Schedule C forms or state continuation coverage. Parents/caretakers living with for insurance carriers. Also, if Must not have lost coverage children ages 0–18: 53% FPL. there is an employee or owner due to fraud or non-payment of who is not drawing a paycheck, premiums. You have 63 days to Medically-needy: 20% FPL with carriers require a letter from enroll in a HIPAA-eligible plan. asset limits of $5,000 for singles, CPA or Attorney stating when and $6,000 for couples. business was formed and who No asset or resource requirements works for the business and for children or pregnant mothers. number of hours. Costs depend on employer COBRA/Mini-COBRA: Premiums range from 102%–150% of Costs for individual coverage Monthly premiums range from $118-$505 depending on your $0–$3 co-pays per visit. contribution and ± 15% of vary. There are no rate caps. 5% of payment up to $15/visit for Monthly Cost the indexed rate depending group health rates. age and plan chosen. non-emergency services in the ER. on the health, residence HIPAA: Premiums will depend on and number of the group plan chosen. members. Groups with 10 or more employees may use group medical questionnaire. Groups of under 10 employees must answer individual medical questionnaires.1817 Florida
    • Publicly-Sponsored Programs Demographic Trade Dislocated Children Women Seniors & Disabled Workers Veterans (TAA Recipients) Florida KidCare Breast and Medicare Health Coverage VA Medical MediKids, Healthy Kids, Children’s Medical Services and Medicaid Cervical Cancer 800-633-4227 Tax Credit Benefits Package www.medicare.gov 888-540-5437 Prevention 866-628-4282 www.irs.gov 877-222-8387 www.va.gov TTD: 877-316-8748 800-227-2345 (Search: HCTC) www.floridakidcare.org www.doh.state.fl.us/ Medicare Family/cancer/bcc Prescription Drug Program Program 800-633-4227 Comprehensive health insurance Breast and cervical Medicare offers Part A, Inpatient and outpatient care Comprehensive preventive and coverage. cancer screening exams inpatient care in hospitals and (lab tests, x-rays, etc.), Doctor primary care, outpatient and clinical breast exams, rehabilitative centers; Part B, visits, Preventive and major inpatient services. Benefits vary based on the segment mammograms, and Pap doctor and some preventive medical care (surgery, physical of the program in which a child smears. services and outpatient care; therapy, Durable medical Pre-Existing Health participates—MediKids, Healthy Part C allows Medicare benefits equipment, etc.), Mental health Conditions Covered Kids, or the Children’s Medical Some diagnostic exams through private insurance and substance abuse care, and Services (CMS) Network for children are covered and referral to (Medicare Advantage); Part C Prescription drugs. Coverage with special health care needs. treatment as necessary. includes Parts A, B, and C not covered by Medicare. Part D Pre-Existing Health Pre-Existing Health Conditions Outreach, public covers prescription drugs. Conditions Covered Covered education and professional education are Pre-Existing Health Conditions provided. Covered Treatment for eligible women may be paid by Medicaid. GUARANTEED COVERAGE GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE Must be a U.S. citizen or qualified Must be U.S. citizen or Must be receiving TAA (Trade ”Veteran status” = active duty in the non-citizen and live in Florida. Must be women 50 to permanent U.S. resident, and: Adjustment Assistance), or U.S. military, naval, or air service and Must be under age 19 years old, 64 years of age, living a discharge or release from active uninsured, and have an income at at or below 200% FPL. 1) If 65 years or older, you or Must be 55 years or older and military service under other than or below 200% FPL. Must either be uninsured your spouse worked for at least receiving pension from the dishonorable conditions. or have insurance that 10 years in Medicare-covered Pension Benefit Guaranty Must not be eligible for Medicaid, does not cover breast or employment, or Corporation (PBGC). Certain veterans must have or be the dependent of a state cervical cancer screening. completed 24 continuous months employee eligible for health 2) You have a disability or end- Must not be enrolled in certain of service. insurance, or be in a public stage renal disease (permanent state plans, or in prison, or institution. kidney failure requiring dialysis receiving 65% COBRA premium Eligibility or transplant) at any age. reduction, or be claimed as a Families who are not eligible for dependent in tax returns. premium assistance may buy Florida KidCare (MediKids or Must be enrolled in qualified Healthy Kids) at the “full pay” health plans where you premium rate. pay more than 50% of the premiums. Premium is based on household $0 or minimal share of $0 and share of cost for 20% of the insurance $0 and share of cost and size and monthly income. Most cost. certain services; deductibles for premium including COBRA co-pays depending on income level. Monthly Cost families pay either $15 or $20 per premium if employer certain plans. Part A: $0–$450 family per month; some families contributes less than 50%. may pay more. There may be based on length of Medicare- co-payments required based on the covered employment; Part B: service provided. $96.40–$369.10 depending on annual income; Part C: Based on No monthly premiums or co- provider; Part D: Varies in cost payments required from federally- recognized American Indians. and drugs covered. www.CoverageForAll.org Florida 18
    • Demographic Private Health Insurance Small Individuals with Individuals Recently Low-Income Businesses Individuals Pre-Existing, Severe, Covered by an Employer Families & (2-50 & Families or Chronic Medical Health Plan Medically-Needy Employees) Conditions Group Plans COBRA/Mini-COBRA Individual Plans Pre-Existing Condition Medicaid Georgia Association of Then convert to a plan under: Georgia Association of Insurance Plan (PCIP) 404-656-6060 dch.georgia.gov Health Underwriters Health Underwriters Run by the U.S. Department of 770-516-4746 770-516-4746 Health and Human Services HIPAA Program www.gahu.org www.gahu.org 866-717-5826 Health Insurance Portability & Accountability Act www.PCIP.gov 866-487-2365 www.dol.gov HIPP Health Insurance Premium Payment 678-564-1162 ext 131 dch.georgia.gov (Search: HIPP) There is a 6-month COBRA: Coverage available for 18–36 Covers broad range of benefits, Ambulance, Ambulatory look-back/12-month months depending on qualifying events. Elimination riders are including primary and specialty surgical, Nurse anesthetists, exclusionary period for If beneficiary is age 60 or older when group permitted. care, hospital care, and prescription Diagnostic, screening and pre-existing conditions plan is terminated, then COBRA lasts until drugs. preventive services, Dental, on enrollees that do not beneficiary is Medicare-eligible. Benefits are There is no limit to the Dialysis, Durable medical have prior creditable what you had with your previous employer. look-back period and Pre-Existing Health equipment, Family planning, coverage or had a lapse of there is a maximum Conditions Covered Early and periodic screening, more than 90 days in their Mini-COBRA: Benefits are what you had with exclusion period of 24 for diagnosis and treatment prior coverage. your previous employer. Mini-COBRA lasts pre-existing conditions (EPSDT), Health insurance 3 months. on enrollees with no prior premium purchase program, Benefits will vary HIPAA: Benefits are based on program coverage. Home health, Hospice, Inpatient Coverage depending on the chosen selected. There is no expiration of coverage. and outpatient hospital, Care plan. Limits on Pre-Existing for the developmentally- HIPP: Benefits are the same as what you Health Conditions May challenged, Laboratory and Pre-Existing Health had with your previous employer. HIPP is a Apply radiology, Medicare crossovers, Conditions Covered premium assistance program. Mental health, Non-emergency transportation, Maternity, Pre-Existing Health Conditions Covered nurses and nursing facility, Oral surgery, Orthotic and prosthetic, Pharmacy, Physician, Podiatric services, Pre- admission screening/annual resident review, Rural health clinic/community health center, and Vision care. Pre-Existing Health Conditions Covered GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE COBRA: Available for employees who work Eligibility is based on Must have been uninsured for at Must be U.S. citizen or lawful Company size 2–50 for employers with 20 or more employees. medical underwriting. least 6 months prior to applying. alien living in Georgia. employees. Have 60 days from date of termination to Must prove being a U.S. citizen sign up for COBRA coverage. Must be resident of or legal U.S. resident, a Georgia Income limits for the following: Owner can count as an Mini-COBRA: Available for employees who state or documented resident, and having problems Pregnant women: 200% FPL. employee. work for employers with less than 20 immigrant. getting insurance due to a pre- employees. Must be ineligible for Medicare, existing condition. Children ages 0-1: 185% FPL. Proprietor name on have been insured by group plan 6 months license must draw wages. Children ages 1-5 : 133% FPL. prior to date of termination. Qualified individuals must sign up for Mini-COBRA in Children ages 6-19: 100% FPL. Eligible employees must Eligibility 63 days after date of receiving notice of right work at least 30 hours a to continue coverage. Families with dependents: up to week. 30% FPL. HIPAA: Must have had 18 months of continuous coverage and completely Medically-needy: Singles exhausted COBRA or state continuation earning 35% FPL with resource coverage. Must not have lost coverage due limit of $2,000; couples earning to fraud or non-payment of premiums. You 30% FPL with resource limit of have 63 days to enroll in a HIPAA-eligible $4,000. Add $100 for additional plan. member. HIPP: Must be Medicaid members and have Aged, blind, or disabled health insurance through employer. receiving SSI: Singles earning 74% FPL with asset limit of $2,000; couples earning 83% FPL with asset limit of $3,000. Costs depend on employer contribution COBRA/ Mini-COBRA: Premiums range from 102%–150% of group health rates. Various price ranges depending on Monthly premiums range from $147 $0–$3 per office visit. to $633 depending on your age and $12.50 for non-emergency Monthly Cost and ± 25% of the deductible and what insurance company’s HIPAA: Premiums will depend on plan plan you buy. There are plan chosen. admission in hospital other than index rate. Annual rate chosen. no rate caps. in mental institution. increases are limited to 15%. HIPP: $0 or minimal share of cost.2019 Georgia
    • Publicly-Sponsored Programs Demographic Infants & Trade Dislocated Children with Children Women Seniors & Disabled Workers Developmental (TAA Recipients) Delays PeachCare for Kids Babies Can’t Wait Georgia Cancer Medicare Health Coverage 877-427-3224 www.peachcare.org 404-657-2878 888-651-8224 Screening Program 800-633-4227 www.medicare.gov Tax Credit 404-657-6611 866-628-4282 health.state.ga.us www.georgiacancer.org www.irs.gov Women-Infants- (Search: BCW) Medicare Prescription (Search: HCTC) Program Children (WIC) Babies Born Healthy Drug Program 404-657-2900 800-228-9173 404-657-3147 800-633-4227 wic.ga.gov www.health.state.ga.us (Search: Babies Born Healthy) Children 1st Georgia Cares 404-656-6679 (Assistance for seniors) NOTE: Babies Born Healthy has 800-669-8387 health.state.ga.us stopped enrollment effective (Search: Children 1st) www.mygeorgiacares.org June 7, 2010. Please refer to Children 1st program in the “Children” column. PeachCare for Kids: Doctor visits, Evaluation and assessments Georgia Cancer Screening Program: Medicare offers Part A, inpatient Inpatient and outpatient Check-ups, Immunizations, to determine eligibility and Offers clinical breast examinations, care in hospitals and rehabilitative care (lab tests, x-rays, Preventive care, Specialist scope of services needed. mammograms, and pelvic centers; Part B, doctor and some etc.), Doctor visits, care, Dental care, Vision care, examinations and Pap tests. If preventive services and outpatient Preventive and major Hospitalization, Emergency room Service coordination that screened and diagnosed for breast care; Part C allows Medicare medical care (surgery, services, Prescriptions, and Mental assists the family and other or cervical cancer, may be eligible benefits through private insurance physical therapy, Durable health care. professionals in developing for complete health coverage (Medicare Advantage); Part C medical equipment, a plan to enhance the through Medicaid. includes Parts A, B, and C not etc.), Mental health and WIC: Nutrition assessment, health child’s development. covered by Medicare. Part D covers substance abuse care, and screening, medical history, body Babies Born Healthy: Comprehensive, prescription drugs. Prescription drugs. measurement (weight and height), Pre-Existing Health quality, prenatal services as early as Coverage hemoglobin check, nutrition Conditions Covered possible in their pregnancy. Georgia Cares is a Medicare counseling Pre-Existing Health education, breast-feeding support service. Conditions Covered and education, and vouchers for Pre-Existing Health food supplements. Conditions Covered Pre-Existing Health Children 1st: Entry point to Georgia’s Conditions Covered public health programs. Children 1st screens children for poor health, refers them to appropriate programs, (such as Babies Can’t Wait or Medicaid) and monitors children with risky health conditions to ensure their proper development. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE PeachCare for Kids: Must be low- Must be children 0–3 years Georgia Cancer Screening Program: Both: Must be U.S. citizen or Must be receiving TAA income children under age 19, old, of any income, who Must be a woman with income at permanent U.S. resident, and: (Trade Adjustment with family incomes up to 235% meet one of the following: or below 200% FPL, uninsured, and Assistance), or FPL, and must be uninsured, ineligible for Medicaid or Medicare. Must have been one year or more 1) If 65 years or older, you or your ineligible for Medicaid, and be 1) Have a diagnosed since last mammogram and/or Pap spouse worked for at least 10 years Must be 55 years or older U.S. citizens, certain qualified legal physical or mental condition test or have symptoms suspicious of in Medicare-covered employment, and receiving pension residents, refugees or asylees who which is known to result breast or cervical cancer. or from the Pension Benefit reside in Georgia. in a developmental delay, Guaranty Corporation such as blindness, Down Age 40 or older: May be 2) You have a disability or end- (PBGC). WIC: Must be pregnant or syndrome, or Spina Bifida. eligible for clinical breast and pelvic examinations, Pap tests, stage renal disease (permanent postpartum women and children kidney failure requiring dialysis or Must not be enrolled in Eligibility mammograms, and diagnostic up to the age of 5 years with Or, evaluations transplant) at any age. certain state plans, or in family incomes at or below 185% prison, or receiving 65% FPL. Must be a Georgia resident 2) Have a diagnosed Age 35-39: May be eligible for COBRA premium reduction, and be at nutritional or medical developmental delay diagnostic evaluation if they have or be claimed as a risk, as determined by a health confirmed by a qualified symptoms highly suspicious of dependent in tax returns. breast cancer. professional. team of professionals. Age less than 40: May be eligible for Must be enrolled in Children 1st: Must be Georgia diagnostic evaluation services if they qualified health plans children ages 0 to 5, who are have abnormal Pap test results. where you pay more than identified to be at risk for poor 50% of the premiums. health and development. There Under the age of 40: May be are no financial requirements. eligible for clinical breast and pelvic examinations and Pap tests. Babies Born Healthy: Must be pregnant women and newborns with incomes at or below 250% FPL. Must not be eligible for Medicaid. PeachCare for Kids: $0 for children $0 or fees based on a Both: $0 or minimal share of cost. Both: $0 and share of cost for 20% of the insurance under age 6, $10–$35 for one sliding fee scale for families certain services; deductibles for premium including COBRA Monthly Cost unable to pay. certain plans. Part A: $0–$450 premium if employer child, max of $70 for two or more based on length of Medicare- children. contributes less than 50%. covered employment; Part B: WIC & Children 1st: $0 or minimal $96.40–$369.10 depending on annual income; Part C: Based on share of cost. provider; Part D: Varies in cost and drugs covered. Georgiawww.CoverageForAll.org 20
    • Demographic Private Health Insurance Individuals with Individuals Recently Pre-Existing, Small Businesses Individuals Low-Income Individuals Covered by an Employer Severe, or (1-50 Employees) & Families & Families Health Plan Chronic Medical Conditions Group Plans COBRA /Prepaid Health Individual Pre-Existing QUEST National Association of Care Continuation (PHC) Plans Condition 800-316-8005, 808-524-3370 Then convert to a plan under: www.med-quest.us Health Underwriters National Association Insurance Plan hawaii.gov/dhs/health/medquest 703-276-0220 www.nahu.org HIPAA of Health Underwriters (PCIP) There are various plans: QUEST, QUEST-Expanded, Program Health Insurance Portability & 703-276-0220 Run by the U.S. QUEST-ACE, and QUEST-Net. Accountability Act www.nahu.org Prepaid Health 866-487-2365 Department of Health and Human Services QUEST Expanded (QExA) Care Law (PHC) www.dol.gov 866-717-5826 866-928-1959 808-586-9188 www.PCIP.gov www.qexa.org hawaii.gov/labor/dcd/ Hawaii Insurance NOTE: There is a QUEST enrollment cap aboutphc.shtml Continuation Program of 125,000. Single childless adults cannot (H-COBRA) be enrolled, even if they meet all other 808-733-9360 requirements. Cap is lifted when enrollment is hawaii.gov below 125,000 individuals on (Search: H-COBRA) Dec. 31 of any year. Hawaii has no law defining COBRA: Coverage available for Covers broad range All: 1-month waiting period for all services (except size of small group market. 18–36 months depending on qualifying of benefits, including emergency and urgent care) unless under age 21. Most carriers define it as events. Benefits are what you had with Elimination riders are primary and specialty 1–50 employees, others as your previous employer. permitted. care, hospital care, and QUEST: Inpatient and outpatient hospital and 1–100. There’s a maximum prescription drugs. clinical services (including x-rays and lab exams), PHC Continuation: Pays part of There is no limit to the Physician, Nursing facility and home health look-back and exclusion look-back period, but period of zero months. employee‘s premium for 3 months Pre-Existing Health services, Prescription drugs, Biological and in case of employee disability and there is a maximum medical supplies and equipment, Vision and Insurers cannot impose exclusion period of 36 Conditions Covered pre-existing condition inability to work. dental, Family planning and maternity, Psychiatric months. and psychological services, Diagnostic, screening, exclusion. HIPAA: Benefits are based on program Options vary preventive and rehabilitative services, Medical PHC: Requires employers to selected. There is no expiration of transportation, Respiratory and hospice care, coverage. depending on Coverage provide health insurance applicant needs and Emergency and urgent care. Early Periodic that covers hospital, H-COBRA: Benefits are the same as what plan selected. Screening, Diagnosis and Treatment (EPSDT) medical, diagnostic and you had with your previous employer. available for enrollees under age 21. maternity benefits for H-COBRA pays premiums for COBRA- Limits on Pre-Existing QUEST-ACE & QUEST-Net: Limited prescription drugs, eligible employees. If eligible HIV-positive people who Health Conditions Medical, urgery, psychiatric and substance employee has 2 or more cannot afford premiums, or for those May Apply abuse services (cataract and heart surgeries employers, then the ineligible for group coverage (such not covered). 10 inpatient, 12 outpatient, and 6 employer who provides as COBRA) but who can convert from mental health visits. ER for actual emergencies. coverage is the one who 1) group to individual coverage under Preventive and restorative dental care. No pays the most wages or 2) HIPAA. H-COBRA pays only for HIPAA maternity benefits for adults ages 21 or older, employs the employee for plans that cover prescription drugs. unless income of pregnant woman’s family is at or at least 35 hours/week. below 185% FPL. Pre-Existing Health Conditions Pre-Existing Health Covered QeXA: Same as QUEST, plus home/community- Conditions Covered based care, institutional services, and services of health care coordinator and primary care doctor. Pre-Existing Health Conditions Covered Company size: 1–50 GUARANTEED COVERAGE GUARANTEED GUARANTEED COVERAGE employees. Owner can COVERAGE count as an employee. COBRA: Available for employees who Medical underwriting All: Must be U.S. citizen or legal immigrant and Proprietor’s name on work for businesses with 20 or more is allowed without Must have been Hawaii resident and not be in a public institution. license must draw wages. employees. You have 60 days from date restriction. uninsured for at least of termination to sign up for COBRA QUEST: Must not be qualified for health coverage 6 months prior to from employer (except General Assistance and PHC: Employers must coverage. applying. Must prove get approved health AFDC recipients). Must not be blind, disabled, or PHC Continuation: Employee must be being a U.S. citizen or Medicare-eligible, and must be under 65 years plans from authorized legal U.S. resident, a health care contractor. eligible under PHC Law. See “Small old. Income limit of 100% FPL. Asset limits of Businesses (1–50 employees)” column Hawaii resident, and $2,000 for a household of one, $3000 for two, Eligible employees must having problems getting work at least 20 hours a on left. and $250 for each additional family member. Also insurance due to a pre- eligible: Children ages 0–18 living at or below Eligibility week, earn at least 86.67 HIPAA: Must have had 18 months of existing condition. times Hawaii’s minimum continuous coverage and completely 200% FPL and pregnant women at or below 185% wage, have worked for 4 exhausted COBRA or state continuation FPL with no asset limits requirements for either. consecutive weeks, and coverage. Must not have lost coverage QUEST-ACE: Same as QUEST but must be childless must be uninsured at time due to fraud or non-payment of living at or below 200% FPL. of enrollment. premiums. You have 63 days to enroll in a HIPAA-eligible plan. QUEST-Net: Same as QUEST but living at or Not eligible for coverage below 300% FPL with asset limit of $5,000 for a under PHC: Federal, State H-COBRA: Must live in Hawaii. Must be household of one, $7,000 for two, and $500 for and County workers; diagnosed as HIV positive, eligible for each added member. agricultural seasonal COBRA or for converted individual plan workers; real-estate or under HIPAA, and have income up to QeXA: Must be 65 and older, or certified blind insurance sales people 300% FPL. or disabled living at or below 100% FPL with paid only on commission; asset limits of $2,000 for singles, and $3,000 for people working for son, couples. daughter or spouse; children under 21 working for father or mother. Costs depend on employer COBRA: Premiums range from 102%– Various price ranges Monthly premiums QUEST: $0 or $30 if self-employed and earning Monthly Cost contribution. Rates must 150% of group health rates. depending on range from $116 to $500 100% FPL. be approved by the state deductible and what depending on your age Dept. of Insurance. PHC Continuation: Employer must pay at plan you buy. There and plan chosen. QeXA & QUEST-ACE: $0 least 50% of premium. Employees pay PHC: Employer must pay no more than 1.5% of monthly wage. are no rate caps. QUEST-Net: $60 full premium if earning 100% FPL at least 50% of premium. and at least 19 years old. 50% of full premium if HIPAA: Premiums will depend on plan self-employed and earning 100% FPL or below. Employees pay no more chosen. than 1.5% of monthly Full or part of premium if earning 250% FPL or wage. H-COBRA: $0 or minimal share of cost. more and age 18 and younger.2221 Hawaii
    • Publicly-Sponsored Programs Demographic Adults with Trade Dislocated Children Women Substance Abuse Seniors & Disabled Workers Problems (TAA Recipients) Hawaii’s Medical Breast and Cervical Department of Medicare Health Coverage Tax Service Association Cancer Program Health Alcohol and 800-633-4227 www.medicare.gov Credit (HMSA) Children’s 808-692-7460 www.hawaii.gov Drug Abuse Division 866-628-4282 www.irs.gov Plan (Search: BCCCP) 808-692-7506 Medicare Prescription (Search: HCTC) Program www.hawaii.gov 808-948-5555 (Search: ADAD) Drug Program www.hmsa.com 800-633-4227 (Search: Childrens Plan) Sage Plus 888-875-9229 Office visits, Routine Clinical breast and pelvic Comprehensive system of Medicare offers Part A, inpatient Inpatient and outpatient care and preventive care, exams, mammograms, Pap services to meet the treatment care in hospitals and rehabilitative (lab tests, x-rays, etc.), Doctor Gynecological exams, tests, and follow-up diagnostic and recovery needs of centers; Part B, doctor and some visits, Preventive and major Emergency services, care for abnormal results. individuals and families. preventive services and outpatient medical care (surgery, physical Surgeries, Anesthesia, care; Part C allows Medicare therapy, Durable medical Diagnostic lab and x-ray Inpatient and out-patient benefits through private insurance equipment, etc.), Mental health services, Inpatient and programs. (Medicare Advantage); Part C and substance abuse care, and outpatient hospital services, includes Parts A, B, and C not Prescription drugs. Maternity care, Mental health Residential programs, day covered by Medicare. Part D covers and substance abuse services, treatment programs, intensive prescription drugs. Pre-Existing Health and Prescription drugs, and outpatient programs, Conditions Covered more. outpatient treatment, Sage Plus is a Medicare counseling Coverage therapeutic living programs, service. There is a 12-month waiting residential social detoxification period for maternity-related programs, methadone Pre-Existing Health Conditions services. maintenance outpatient Covered programs. Pre-Existing Health Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Must be uninsured children Must be women ages 50 to 64, Treatment services have, Medicare & Sage Plus: Must be U.S. Must be receiving TAA (Trade ages 31 days to 18 years old. uninsured or under-insured, as a requirement, priority citizen or permanent U.S. resident, Adjustment Assistance), or with incomes at or below 250% admission for pregnant women and: Must be a Hawaii resident FPL. and injection drug users. Must be 55 years or older and for at least 6 months (based 1) If 65 years or older, you or your receiving pension from the on the parent’s or guardian’s spouse worked for at least 10 years Pension Benefit Guaranty residency). in Medicare-covered employment, Corporation (PBGC). or There is no household Must not be enrolled in certain income limit or citizenship 2) You have a disability or end- state plans, or in prison, or Eligibility requirement. stage renal disease (permanent receiving 65% COBRA premium kidney failure requiring dialysis or reduction, or be claimed as a transplant) at any age. dependent in tax returns. Must be enrolled in qualified health plans where you pay more than 50% of the premiums. $71.50 per month. $0 or minimal share of cost. $0 or share of cost. Costs vary Medicare: $0 and share of cost 20% of the insurance premium Monthly Cost depending on which program for certain services; deductibles including COBRA premium if you choose. for certain plans. Part A: $0 - $450 employer contributes less than based on length of Medicare- 50%. covered employment; Part B: $96.40 - $369.10 depending on annual income; Part C: Based on provider; Part D: Varies in cost and drugs covered. Sage Plus: $0 www.CoverageForAll.org Hawaii 22
    • Demographic Private Health Insurance Individuals Individuals with Pre- Low-Income Small Businesses Recently Covered Individuals Existing, Severe, Individuals & (2-50 Employees) by an Employer & Families or Chronic Medical Families Health Plan Conditions Group Plans COBRA Individual Plans Idaho Individual High Risk Medicaid Idaho Association of Health Idaho Association of Reinsurance Pool (HRP) 800-926-2588 TDD: 208-332-7205 Underwriters Health Underwriters 208-334-4250 Then convert to a plan 800-721-3272 www.healthandwelfare. 208-323-0611 208-323-0611 idaho.gov under: www.doi.idaho.gov Program www.iahu.org www.iahu.org (Search: Medicaid) Access to Health HIPAA Pre-Existing Condition Or contact the local health or Insurance (AHI) Health Insurance Portability Insurance Plan (PCIP) welfare agency. 866-326-2485 & Accountability Act Run by the U.S. Department of Health www.accesstohealthinsurance. 866-487-2365 and Human Services idaho.gov www.dol.gov 866-717-5826 www.PCIP.gov Up to $5M lifetime maximum, COBRA: Coverage available for Carriers must guarantee HRP: Maternity care, Prescription drugs, Depending on plan chosen assorted deductibles. 18–36 months depending on coverage for at Preventive services, Nursing, Therapies, (Standard, Basic, Enhanced, and qualifying events. Benefits least three products Home health care, Hospice, Ambulance Medicare-Medicaid Coordinated), There is a maximum 6-month are what you had with your (basic, standard and services, Durable medical equipment, services include Primary care, look-back/12-month previous employer. catastrophic) to all Psychiatric and substance abuse services. Hospital services, Lab and x-ray, exclusionary period for pre- individual market All insurers sell the same 5 HRP plans that Physician services, Midwife, existing conditions on enrollees HIPAA: Benefits are based on consumers with 12 cover the same health benefits, but cost Nursing home coverage (over that do not have prior coverage program selected. There is no months of creditable sharing varies age 21), Family planning, Home or whose prior coverage lapsed expiration of coverage. coverage, and health, Emergency, Medical for more than 63 days. elimination riders are PCIP: Covers broad range of benefits, transportation, Preventive Pre-Existing Health not permitted. including primary and specialty care, health, Nutrition, Prescription AHI: AHI is not a health insurance Conditions Covered hospital care, and prescription drugs. drugs, Dental, Vision, Mental Coverage plan but a premium assistance Assorted deductibles health, Therapies, Durable program that makes health depending on age and Pre-Existing Health Conditions Covered medical equipment and supplies, insurance more affordable for ZIP code. Prosthetics/orthotics, School employees of qualified small based services, Nursing facility businesses. Limits on Pre-Existing services, Intermediate care Health Conditions May facilities for developmentally Pre-Existing Health Conditions Apply challenged persons, Psychosocial Covered rehabilitation, Private duty nursing, Home and community- based waiver services, Service coordination. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size is 2–50 COBRA: Available for employees Eligibility is subject to HRP: There are 4 ways to be eligible: 1) Must be a U.S. citizen or legal non- employees (including owner). who work for businesses medical underwriting. You are under age 65, uninsured and citizen and Idaho resident. Owner name on business with 20 or more employees. unqualified for any group insurance license must draw wages You have 60 days from date If you are denied including Medicaid and Medicare, were Income limits: from the company. Eligible of termination to sign up for coverage for a medical turned down for health coverage due employees must work at COBRA coverage. condition, you may be to pre-existing conditions, offered Pregnant women and children least 30 hours a week. Or, eligible for HRP or PCIP. premiums that were unaffordable. Or, 2) ages 0–18 with incomes at or by agreement between the HIPAA: Must have had 18 See next column. You lost your health insurance not due below 133% FPL (co-payments employer and the carrier, an months of continuous to fraud or non-payment of premium, vary depending on the families eligible employe can work coverage and completely and had group coverage for at least 12 qualifying income). 20–30 hours per week. exhausted COBRA or state months prior, had taken and exhausted Eligibility continuation coverage. Must your COBRA benefits, and you are Parents/caretakers living with AHI: Employers must operate an not have lost coverage due ineligible for Medicaid or Medicare. Or, 3) children ages 0–18: 27% FPL Idaho small business, currently to fraud or non-payment of You receive Trade Adjustment Assistance not offer health insurance, premiums. You have 63 days to (TAA). Or, 4) If you are eligible under 1, Aged, blind, and disabled: Singles must pay at least 50% of the enroll in a HIPAA-eligible plan. 2 or 3 above but are insured, then the earning up to 78% FPL with asset employee’s premium, and lifetime benefit maximum of your current limit of $2,000; couples earning have at least one employee policy must be at least $500,000 and there up to 83% FPL with asset limit of eligible for premium assistance. must be reasonable probability that you $3,000. Employees must work for a will exceed your policy’s lifetime benefit participating small business, maximum in 90 days. be at least 18, uninsured, U.S. citizens or legal residents, live PCIP: Must have been uninsured for at least 6 in Idaho with incomes of or less months prior to applying. Must prove being than 185% FPL. a U.S. citizen or legal U.S. resident, an Idaho resident, and having problems getting insurance due to a pre-existing condition. Costs depend on employer contribution and ± 50% of the COBRA: Premiums range from 102%–150% of group health Costs for individual coverage vary. Rates can HRP: Based on plan chosen, age, tobacco use, and gender, premiums range from $0 or minimal share of cost. Monthly Cost insurance company’s index rate. rates. vary no more than ±50% $119 to $1,850. of the base individual AHI: Premium assistance of up HIPAA: Premiums will depend market rate. PCIP: Monthly premiums range from $133 $500 per month, per family. on plan chosen. to $571 depending on your age and plan chosen.2423 Idaho
    • Publicly-Sponsored Programs Demographic Immigrants Trade Dislocated Children Women Awaiting Legal Seniors & Disabled Workers Status (TAA Recipients) Idaho State Women’s Emergency Medicare Health Coverage Health Plan Health Check Medicaid 800-633-4227 www.medicare.gov Tax Credit 800-926-2588 800-926-2588 800-926-2588 866-628-4282 www.healthandwelfare. www.healthandwelfare. TDD 208-332-7205 www.irs.gov idaho.gov idaho.gov 866-326-2485 Medicare Prescription (Search: HCTC) Program (Click: Children, Idaho State Health Plan) (Search: Health Check) (Emergency Processing Center) Drug Program 800-633-4227 Or contact the local health or welfare agency. Regular checkups, Annual clinical breast Emergencies, Deliveries Medicare offers Part A, inpatient Inpatient and outpatient care Immunizations, examinations, (CBE) mammograms, (not prenatal or post- care in hospitals and rehabilitative (lab tests, x-rays, etc.), Doctor Prescription drugs, Lab pelvic examinations, and Pap tests. partum care), Kidney centers; Part B, doctor and some visits, Preventive and major tests and x-rays, Hospital dialysis, and Treatment for preventive services and outpatient medical care (surgery, physical visits, and more. After three consecutive normal breast and cervical cancer. care; Part C allows Medicare benefits therapy, Durable medical Pap tests, Women’s Health Check through private insurance (Medicare equipment, etc.), Mental health Pre-Existing Health will cover one Pap test every three Pre-Existing Health Advantage); Part C includes Parts A, B, and substance abuse care, and Conditions Covered years. Conditions Covered and C not covered by Medicare. Part D Prescription drugs. covers prescription drugs. Diagnostic services, if needed. Pre-Existing Health Conditions Pre-Existing Health Conditions Covered Covered Coverage GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE Must be women living up to 200% U.S. citizenship not Must be U.S. citizen or permanent U.S. Must be receiving TAA (Trade Must be a U.S. citizen or FPL and are uninsured or have required. resident, and: Adjustment Assistance), or legal resident under 19 health insurance that does not yeard old with income limit cover mammograms or Pap tests. Income limits: 1) If 65 years or older, you or your Must be 55 years or older and at or below 185% FPL. spouse worked for at least 10 years in receiving pension from the Women ages 50–65 are eligible for Pregnant women and Medicare-covered employment, or Pension Benefit Guaranty Eligible for premium Pap tests, clinical breast exams and children ages 0–18 with Corporation (PBGC). assistance if income is at or mammograms. incomes at or below 133% 2) You have a disability or end-stage below 185% FPL. FPL (co-payments vary renal disease (permanent kidney Must not be enrolled in certain Women ages 40–49 are eligible for depending on the families failure requiring dialysis or transplant) state plans, or in prison, or Pap tests (women who have not qualifying income). at any age. receiving 65% COBRA premium Eligibility had a Pap test in the last 5 years are reduction, or be claimed as a a priority for enrollment). Adults: 23% FPL. dependent in tax returns. Limited enrollment and services Aged, blind, and disabled: Must be enrolled in qualified for uninsured women ages 30–49 Singles earning up to 78% health plans where you pay more who have confirmed suspicious FPL with asset limit of than 50% of the premiums. symptoms of breast cancer or $2,000; couples earning up cervical cancer. to 83% FPL with asset limit of $3,000. Women 65 or older are also qualified if they are not eligible for Medicare or do not have Medicare Part B. $10 or $15 depending $0 or minimal share of cost $0 or minimal share of cost $0 and share of cost for certain 20% of the insurance premium Monthly Cost on income. services; deductibles for certain plans. including COBRA premium if Part A: $0–$450 based on length employer contributes less than of Medicare-covered employment; 50%. Part B: $96.40–$369.10 depending on annual income; Part C: Based on provider; Part D: Varies in cost and drugs covered. Idahowww.CoverageForAll.org 24
    • Demographic Private Health Insurance Small Individuals with Individuals Recently Low-Income Businesses Individuals Pre-Existing, Severe, Covered by an Employer Families & (2-50 & Families or Chronic Medical Health Plan Individuals Employees) Conditions Group Plans COBRA/Illinois Individual Plans Comprehensive Health Medicaid Illinois Association of Continuation Coverage Illinois Association of Insurance Plan (CHIP) 800-843-6154 www.hfs.illinois.gov/medical/ Health Underwriters Health Underwriters 217-782-6333 (Illinois Residents) (ICC) 800-962-8384 (General Info) apply.html Program www.isahu.com www.isahu.com 866-851-2751 (Eligibility Info) Then convert to a plan under: www.chip.state.il.us FamilyCare HIPAA 866-255-5437 Health Insurance Portability & Pre-Existing Condition www.familycareillinois.com Accountability Act Insurance Plan(IPXP) 866-487-2365 877-210-9167 www.dol.gov TTY: 866-883-8551 www.insurance.illinois.gov/ipxp www.PCIP.gov There is a maximum COBRA: Coverage available for 18–36 There is a maximum look- CHIP: Inpatient and outpatient care, Medicaid: Different program look-back period of 6 months depending on qualifying events. back period and maximum Doctor visits, Surgery, Preventive variations covering Medical, months and a maximum Benefits are what you had with your exclusion period of 24 care, Diagnostic care, X-rays, Home Dental and Vision, Prescriptions, exclusion period of 12 previous employer. months for pre-existing health care, Skilled nursing care, Hospitalization and more months for pre-existing conditions on enrollees Hospice, Transplant coverage, depending on program. conditions on enrollees ICC: Benefits are what you had with your who have no prior Speech, Physical and occupational Programs for people with who have no prior previous employer. Length of coverage coverage. therapy, Mental health and chemical either MS, nursing home needs, coverage. for A) Ex-employees: 12 months, B) dependency, Separate prescription kidney dialysis, breast and Dependents and divorced/widowed Elimination riders are drug card. You can also choose a cervical cancer, AIDS, TB, hyper- Benefits will vary spouses under age 55: 2 years, and C) 55 permitted. High Deductible Health Plan. alimentation, pregnancy. Coverage depending on the chosen years or older divorced/widowed spouses plan. and spouses of retired employees: Until Covers certain state IPXP: Covers broad range of benefits, FamilyCare: Covers doctor eligible for Medicare. mandated items, however including primary and specialty care, visits, dental care, specialty Pre-Existing Health HIPAA: Benefits are based on program Illinois does not require hospital care, and prescription drugs. medical services, hospital Conditions Covered with selected. There is no expiration of standardization. care, emergency services, Some Limitations coverage. Pre-Existing Health Conditions prescription drugs and more. Coverage options vary Covered Pre-Existing Health Conditions Covered by carrier, but most Pre-Existing Health offer plans that are HSA Conditions Covered (Health Savings Account) compatible. Limits on Pre-Existing Health Conditions May Apply GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE COBRA: Available for employees who work Eligibility is based on Both: Must be U.S. citizens or legal Both: Must be U.S. citizens or residents and living in Illinois. Company size 2–50 for employers with 20 or more employees. medical underwriting. qualified aliens and live in Illinois. employees. You have 60 days from date of termination CHIP: Can be covered in 6 ways: to sign up for COBRA coverage. Must be resident of state or 1) Federal Eligibility: Most recent Medicaid: Income limits: Eligible employees must documented immigrant. coverage must have been group work at least 25 hours a ICC: Available for employees who work plan lasting 18+ months with no Children ages 1–18: 133% FPL. for employers of any size. Ex-employees, break of 90+ days, and lost coverage week. If you are denied coverage not due to fraud or non-payment Pregnant women and infants: dependents, spouses, and ex-spouses for a medical condition, must have been covered for 3 continuous of premium, and exhausted all 200% FPL if the mother is Owner can count as an you may be eligible for COBRA coverage. Not eligible for any enrolled in Medicaid at time of employee. months before qualifying event. Must elect CHIP or IPXP. See next group plans; HCTC: are TAA or PBGC Illinois Continuation Coverage in 30 days birth. If not, infants with family column. Certified with at least three months incomes of 133% FPL. Proprietor name on after getting election notice or qualifying of prior creditable coverage; Eligibility license must draw wages. event (whichever is later), but no later than 2) HIPAA Plan: Must be both Federal- Parents/caretakers living with 60 days after job termination. and HIPAA-eligible; children ages 0–18: 185% FPL. 3) HCTC Plan: Must be both Federal- HIPAA: Must have had 18 months of and HCTC- eligible; Aged, blind, disabled: 100% FPL. continuous coverage and completely 4) Traditional Plan: Must be denied exhausted COBRA or state continuation coverage due to pre-existing SSI recipients: 40% FPL. coverage. Must not have lost coverage due conditions or have a similar plan to fraud or non-payment of premiums. You but costs them more than CHIP, has Medically-needy: 100% FPL. one of the covered pre-existing have 63 days to enroll in a HIPAA-eligible conditions; FamilyCare: Offers healthcare plan. 5) Medicare Plan: Must be enrolled coverage to parents living with in Medicare parts A and B; 6) their children 18 years old or Presumptive Condition: Must prove younger. FamilyCare also covers having a qualified medical condition relatives who are caring for and be under 65 years old. children in place of their parents. IPXP: Must have been uninsured for at Must have income up to 200% least 6 months prior to applying. Must FPL. prove being a U.S. citizen or legal U.S. resident, an Illinois resident, and having problems getting insurance due to a pre-existing condition. Costs depend on COBRA: Premiums range from 102%–150% Various price ranges CHIP: Monthly premiums range Medicaid: $0 or minimal share employer contribution of group health rates. depending on deductible from $80-$2,802 depending on of cost. and ± 25% of the and what you buy. age, gender, location, tobacco use, ICC: Premiums are 100% of group health insurance company’s deductible, plan chosen, any other FamilyCare: $2–$3 co-pays for Monthly Cost index rate rate plus administration fee of 2%. option you have chosen. Premiums for dependents must be less doctor visits and prescriptions. than the rate charged to an employee Parents in FamilyCare Premium IPXP: Monthly premiums range from pay a monthly premium from if dependent child were an employee $99-$755 depending on your age, PLUS the amount of employer’s premium $15 to $40 depending on the residence, and tobacco use. number of family members contribution if dependent child were an employee. covered. HIPAA: Premiums will depend on plan chosen.2625 Illinois
    • Publicly-Sponsored Programs Demographic Trade Dislocated Children Women Seniors & Disabled Workers Veterans (TAA Recipients) ALL Kids Illinois Breast & Medicare Health Coverage VA Medical 866-255-5437 www.allkids.com Cervical Cancer 800-633-4227 www.medicare.gov Tax Credit Benefits Package Program (IBCCP) 866-628-4282 www.irs.gov 877-222-8387 Program Womens Health-Line www.va.gov 888-522-1282 Medicare Prescription (Search: HCTC) www.cancerscreening.illinois. Drug Program gov 800-633-4227 Healthy Women Illinois Cares Rx 800-226-0768 (Health Benefits Hotline) 800-226-0768 www.illinoishealthywomen. (Health Benefits Hotline) com www.illinoiscaresrx.com Doctor visits, Hospital stays, IBCCP: Offers mammograms, Medicare offers Part A, inpatient Inpatient and outpatient Comprehensive preventive and Prescription drugs, Vision breast and pelvic exams, and care in hospitals and rehabilitative care (lab tests, x-rays, etc.), primary care, outpatient and care and eyeglasses, Dental Pap tests. If enrolled in the centers; Part B, doctor and some doctor visits, preventive and inpatient services. care, Regular checkups, BCCP and diagnosed with preventive services and outpatient major medical care (surgery, Immunization shots, Medical cancer through the program’s care; Part C allows Medicare benefits physical therapy, durable Pre-Existing Health equipment, Speech and screenings, can be eligible to through private insurance (Medicare medical equipment, etc.), Conditions Covered physical therapy for children receive treatment. Advantage); Part C includes Parts A, B, mental health and substance who need them. and C not covered by Medicare. Part D abuse care, and prescription Healthy Women: Covers family covers prescription drugs. drugs. Pre-Existing Health planning (birth control) and Coverage Conditions Covered patient education. Certain Illinois Cares Rx: Provides state Pre-Existing Health services provided such as prescription drug assistance to people Conditions Covered physical exams, Pap tests, with and without Medicare. lab tests for family planning, testing and medicine for Pre-Existing Health STDs found during a family Conditions Covered planning visit, and sterilization. Also covers mammograms, multivitamins and folic acid if they are ordered by the doctor during the family planning visit. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Must be Illinois resident, IBCCP: Must be women ages 35– Medicare: Must be U.S. citizen or Must be receiving TAA ”Veteran status” = active duty age 18 and uninsured or 64 living in Illinois without health permanent U.S. resident, and: (Trade Adjustment in the U.S. military, naval, or underinsured for 12 months insurance (younger women may Assistance), or air service and a discharge or to be eligible regardless of be eligible in some cases). 1) If 65 years or older, you or your release from active military income. spouse worked for at least 10 years in Must be 55 years or older service under other than Healthy Women: Must be Illinois Medicare-covered employment, or and receiving pension dishonorable conditions. Can qualify even if they had women ages 19–44, U.S. citizens 2) You have a disability or end-stage from the Pension Benefit insurance within the past or legal permanent resident renal disease (permanent kidney Guaranty Corporation Certain veterans must have 12 months, as long as family with a Social Security number, failure requiring dialysis or transplant) (PBGC). completed 24 continuous annual income is below the and earn up to 200% FPL, and at any age. months of service. following: must have lost regular medical Must not be enrolled in 2-person family: $29,000; benefits from the Illinois Illinois Cares Rx: Monthly income up to certain state plans, or Eligibility 3-person family: $37,000; Department of Healthcare and 200% FPL IllinoisCaresRx Plus: U.S. in prison, or receiving 4-person family: $44,000; Family Services (HFS). citizen age 65 or older. 65% COBRA premium 5-person family: $52,000; reduction, or be claimed as a Income limit is higher for Ineligible if pregnant, had tubes May qualify for Illinois Cares Rx Basic dependent in tax returns. larger families. tied, had a hysterectomy or if under age 65 or over age 65 but do have health coverage for birth not meet citizenship requirements. Must be enrolled in qualified Parents and caretaker control. health plans where you relatives with incomes pay more than 50% of the between 150%–185% FPL premiums. may qualify for FamilyCare Premium. Premiums and co-pays depend on family income and $0 or minimal share of cost. Medicare: $0 and share of cost for 20% of the insurance $0 and share of cost and some services; deductibles for some premium including COBRA co-pays depending on income number of children. plans. Part A: $0–$450 based on length premium if employer level. of Medicare-covered employment; Monthly Cost contributes less than 50%. Part B: $96.40–$369.10 based on annual income; Part C: Based on provider; Part D: Varies in cost and drugs covered. Illinois Cares Rx: $2.50–$6.30 for prescription drugs. Additional costs vary based whether one is a Medicare enrollee or not. Illinoiswww.CoverageForAll.org 26
    • Demographic Private Health Insurance Individuals Individuals with Pre- Low-Income Small Businesses Recently Covered Individuals Existing, Severe, Individuals (2-50 Employees) by an Employer & Families or Chronic Medical & Families Health Plan Conditions Group Plans COBRA Individual Plans Indiana Comprehensive Medicaid Health Insurance (Indiana Family and Social Indiana Association of Indiana Association of Services Administration) Health Underwriters Then convert to a plan under: Health Underwriters Association (ICHIA) 800-403-0864 www.inahu.org www.inahu.org 800-552-7921 www.in.gov/fssa www.ichia.org HIPAA Program Health Insurance Portability & (Choose: Guest) Accountability Act 866-487-2365 Pre-Existing Condition www.dol.gov Insurance Plan (PCIP) Run by the U.S. Department of Health and Human Services 866-717-5826 www.PCIP.gov Different plans cover COBRA: Coverage available for Covers certain state- ICHIA: Covered services include Some of the benefits include different medical services. 18–36 months depending on mandated items. However Inpatient hospital services, Mental Preventive services, Behavior and qualifying events. Benefits Indiana does not require illness/substance abuse, Prescription mental health services, Eye care, There is a maximum are what you had with your standardization. drugs, Professional services, Skilled Diabetes self care management 6-month look-back and previous employer. home health care, Skilled nursing training, Inpatient/outpatient a maximum 9-month Coverage options vary by facility, Surgical expenses, Transplant hospital care, Home health care & exclusionary period for HIPAA: Benefits are based on carrier, but most offer plans services. Coverage for spouse and services; transportation, Dental, pre-existing conditions on program selected. There is no that are HSA (Health Savings dependents also available. Pregnancy care, and Emergency enrollees that do not have expiration of coverage. Account) compatible. care. prior coverage. PCIP: Covers broad range of benefits, Pre-Existing Health There is a maximum including primary and specialty care, Pre-Existing Health Pre-Existing Health Conditions Covered 12-month look-back hospital care, and prescription drugs. Conditions Covered Coverage Conditions Covered and a maximum 10-year exclusionary period limit for Pre-Existing Health pre-existing conditions on Conditions Covered enrollees who have no prior coverage. Elimination riders are not allowed. Pre-Existing Health Conditions Covered with Some Limitations GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size 2–50 COBRA: Available for employees Eligibility is based on medical ICHIA: Must live in Indiana, be ineligible Must be U.S. citizens or employees. who work for businesses underwriting. for Medicaid and private insurance permanent legal residents for with 20 or more employees. that provide coverages equal to that at least five years, and Indiana Owner can count as an You have 60 days from date Must be resident of state or of ICHIA’s. Must first apply to Medicaid, residents. employee. of termination to sign up for documented immigrant. PCIP, and HIP no more than 60 days COBRA coverage. prior to applying to ICHIA. Other Income limits: Proprietor-name on license If you are denied coverage eligibility requirements: A) Must have must draw wages. HIPAA: Must have had 18 for a medical condition, prior coverage under a group plan for at Pregnant women: 200% FPL. months of continuous you may be eligible for an least 18 months with no lapse of more Eligibility Eligible employees must coverage and completely ICHIA or PCIP plan. See next than 63 days, did not lose your health Aged, blind, and disabled: 100% work at least 30 hours a exhausted COBRA or state column. insurance due to fraud or non-payment FPL with asset limit of $2,000 for week. continuation coverage. Must of premiums, and you’re ineligible any singles, and $3,000 for couples. not have lost coverage due public health insurance. Or B) You can to fraud or non-payment of prove you were denied coverage due to Infants ages 0–1: 133% FPL. premiums. You have 63 days to pre-existing health conditions. enroll in a HIPAA-eligible plan. Children ages 1–5 133% FPL. PCIP: Must have been uninsured for at least 6 months prior to applying. Must Children ages 6-19 100% FPL. prove being a U.S. citizen or legal U.S. resident, Indiana resident, and having Adults: 25% FPL. problems getting insurance due to a pre-existing condition. Costs depend on employer contribution and ± 35% of COBRA: Premiums range from 102%–150% of group health No rate caps. Various price ranges depending on ICHIA: Monthly premiums range from $144-$1,687. Premiums based on age, $0 or minimal share of cost. the insurance company’s rates. deductible and what plan gender, geographic area, and plan Monthly Cost index rate. At renewal, you buy. chosen. increases are limited to 15% HIPAA: Premiums will depend per year from the original on plan chosen. PCIP: Monthly premiums range from rate. $124 to $532 depending on your age and plan chosen.2827 Indiana
    • Publicly-Sponsored Programs Demographic Children with Pregnant Women & Chronic Medical Women Adults Seniors & Disabled Children Conditions Children’s Special Hoosier Healthwise Indiana Breast and Healthy Indiana Plan Medicare Health Care 800-889-9949 www.in.gov Cervical Cancer (HIP) (Age 65 and up) 800-633-4227 Services (Search: Hoosier Healthwise) Early Detection 877-438-4479 www.hip.in.gov www.medicare.gov (CSHCS) Program There are 3 plans or Program 800-475-1355 www.in.gov “packages” available: (BCCP) NOTE: 8,000 HIP enrollment Medicare Prescription slots were opened to childless (Search: CSHCS) A, B and C. 800-433-0746 317-233-7405 adults on August 1, 2011. Drug Program www.in.gov 800-633-4227 (Search: BCCP) Treatment for chronic Packages A & C: Cover Hospital care, Colonoscopies (with or Services include: Physician Medicare offers Part A, inpatient medical conditions such Doctor visits, Check ups , Well-child without biopsies), Liquid- services, Prescription drugs, care in hospitals and rehabilitative as severe asthma, autism, visits, Clinic services, Prescription based cytology tests Diagnostic exams, Home centers; Part B, doctor and some cerebral palsy, arthritis, drugs, Lab and x-ray, Mental health every other year, High risk Health services, Outpatient preventive services and outpatient congenital heart disease, and substance abuse services, panel, HPV testing, Office hospital, Inpatient hospital, care; Part C allows Medicare cystic fibrosis, chromosomal Medical supplies and equipment, visits, Pelvic exams/tests, Hospice, Preventive services, benefits through private insurance disorders, renal disease Home health care, Dental and Clinical breast exams (CBEs) Family planning, Case and (Medicare Advantage); Part C seizures and more. vision care, Therapies, Hospice care, Mammograms (screening disease management, Mental includes Parts A, B, and C not Transportation, Family planning and diagnostic) Diagnostic health coverage, and Substance covered by Medicare. Part D covers Diagnostic evaluations, services, Nurse practitioner and breast ultrasounds, Breast abuse treatment. prescription drugs. comprehensive well child nurse midwife services, Foot care, biopsies, and Consultations and sick child care, specialty and Chiropractors. Free preventive services Pre-Existing Health Coverage care and other services Pre-Existing Health including annual exams, Conditions Covered related to the eligible medical Package A: Also covers nursing facility Conditions Covered smoking cessation, and conditions, immunizations, services and over-the-counter drugs. mammograms. prescription drugs, routine Package B: Pregnancy-related dental care, community care only, such as prenatal care, Does not cover vision, dental or referrals and information. conditions that may complicate maternity services. pregnancy, delivery, and 60 days after Pre-Existing Health delivery. Pre-Existing Health Conditions Covered Conditions Covered Package C: Does not cover nursing facility services or over-the-counter drugs, and only covers insulin and surgery, x-rays, labs and hospital stays involving the foot. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Must be Indiana resident ages All: Must be U.S. citizens or qualified Must be U.S. citizens Must be a U.S. citizen or legal Must be U.S. citizen or permanent 0–21 years old, with income aliens and Indiana residents. or be legal immigrants resident and live in Indiana. U.S. resident, and: limit of 250% FPL and a and residents of Indiana, qualifying medical condition. Package A: Pregnant women and uninsured or underinsured, Must not be eligible for 1) If 65 years or older, you or your parents/caretaker relatives living with and earn up to 200% FPL. spouse worked for at least 10 years Applicant does not have to children under the age of 18. Adults Medicaid or Medicare. Must be in Medicare-covered employment, be a U.S. citizen to apply, but ages 18 to 20 living with caretaker Age limits: ages 19 to 64. or the child and/or the family relative who meets the financial cannot be in the country on requirements can be covered but Ages 40–49, and ages 65 Must earn income of 22% FPL to 2) You have a disability or end- Eligibility a visa. their caretaker relative is not eligible. and older not enrolled in 200% FPL. stage renal disease (permanent Income limit of 19% FPL and asset Medicare: Office visits and kidney failure requiring dialysis or Applicant must apply for limit of $1,000 for pregnant women Pap tests. transplant) at any age. Indiana Hoosier Healthwise/ and 150% FPL for children up to Must have been uninsured for Medicaid. Must have severe age 19. Ages 50–64: All of the above at least six months and have chronic illnesses that have and mammograms. no access to employer-offered lasted or will last two years Package B: Pregnant women living health insurance. or conditions that require 20%–200% FPL. special devices or would produce disabling physical Package C: Children ages 0–18. Income conditions if untreated. limit of 250% FPL. Cystic fibrosis patients can apply at any age and stay on the program for life as long as they remain financially eligible. $0 or minimal share of cost. Packages A & B: $0 $0 2%–5% of the family’s gross $0 and share of cost for certain income. services; deductibles for certain Package C: $0 if income is 150% FPL plans. Part A: $0–$450 based Monthly Cost or below. No co-pays except for ER use on length of Medicare-covered which will cost below $25 a employment; Part B: $96.40– If child living 151%–250% FPL, visit. $369.10 depending on annual premiums are required. income; Part C: Based on provider; Part D: Varies in cost and drugs Premiums are $22–$33 for one covered. child, and $33–$50 for two or more children. Indianawww.CoverageForAll.org 28
    • Demographic Private Health Insurance Small Individuals with Individuals Recently Businesses Individuals Pre-Existing, Severe, Low-Income Families Covered by an (2-50 & Families or Chronic Medical & Individuals Employer Health Plan Employees) Conditions Group Plans COBRA/Mini-COBRA Individual Plans Health Insurance Medicaid Iowa Association of Iowa Association of Health Plan of Iowa 515-281-6899 www.ime.state.ia.us/Members Then convert to a plan under: Health Underwriters Underwriters (HIPIOWA) www.eiahu.org www.eiahu.org 877-793-6880 HIPAA Medicaid for Employed Program www.hipiowa.com Health Insurance Portability & People with Disabilities Accountability Act HIPIOWA-FED (MEPD) 866-487-2365 Federal program run by the www.dol.gov www.ime.state.ia.us Iowa Comprehensive Health (Search: MEPD) Association HIPP 877-505-0513 Both: 800-338-8366, Health Insurance Premium Payment hipiowafed.com 800-972-2017 888-346-9562 www.PCIP.gov Or contact local county Department of Human Services. Up to $5M lifetime COBRA: Coverage available for 18–36 Up to $5M lifetime maximum, HIPIOWA: Offers five comprehensive All: Inpatient and outpatient maximum, assorted months depending on qualifying assorted deductibles. preferred provider plans each hospital services, physician services, deductibles. events. Benefits are what you had with a pharmacy benefit to medical and surgical dental with your previous employer. Elimination riders are choose from and a Medicare services, nursing facility services There is a maximum permitted. carveout plan. Will not pay for any for persons aged 21+, family look-back period Mini-COBRA: Benefits are what you pre-existing injury or sickness for planning services, nurse/midwife of 6 months and a had with your previous employer. There is a 12-month look-back the first six months of coverage. services, chiropractors, podiatrists, maximum exclusion Coverage lasts 9 months. and exclusionary period optometrists, psychologists, dental period of 12 months limit on pre-existing health HIPIOWA-FED: Covers broad range services, physical therapy, therapies HIPAA: Benefits are based on program Coverage for pre-existing conditions for standardized of benefits, including primary and for speech hearing and language conditions on selected. There is no expiration of guarantee issue policies. specialty care, hospital care, and disorders, occupational therapy, enrollees with no coverage. prescription drugs. prescribed drugs, prosthetic prior coverage or For all other individual policies, devices, vision, mental health, whose coverage had HIPP: Benefits are the same as what you there is a maximum 60-month Pre-Existing Health Conditions hospice care and more. a break of more than had with your previous employer. HIPP look-back and a maximum Covered with Some Limitations 63 days. is a premium assistance program. 12-month exclusionary period Pre-Existing Health limit on pre-existing health Conditions Covered Pre-Existing Health Pre-Existing Health conditions. Conditions Covered Conditions Covered Limits on Pre-Existing Health Conditions May Apply GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE COBRA: Available for employees who Eligibility is based on medical HIPIOWA: 1) Must live in Iowa and All: Must be a U.S. citizen or legal alien Company size 2–50 work for businesses with 20 or more underwriting. prove residency of at least 60 and resident of Iowa. employees. employees. You have 60 days from days in Iowa, denial of insurance date of termination to sign up for Must be resident of state or coverage in the last 9 months Medicaid: Owner can count as COBRA coverage. documented immigrant. due to qualified pre-existing Pregnant women: 300% FPL. an employee. conditions, or offer of insurance Parents/caretakers living with children Mini-COBRA: Available for employees If you are denied coverage for with substantially reduced ages 0–18: 83% FPL. Proprietor name on who work for businesses with less a medical condition, you may benefits (e.g. elimination riders) license must draw than 20 employees. Must have be eligible for HIPIOWA or PCIP. or premiums higher than that Children ages 0–5: 133% FPL. wages. had group coverage for at least 3 See next column. of HIPIOWA’s, or loss of health continuous months before date of insurance not due to non- Children ages 6–19: 100% FPL. Eligibility Eligible employees termination. Must elect coverage payment of premium. Or 2) if Aged, blind, and disabled: Singles must work at least 30 within 31 days of termination. living in Iowa (not required to earning 75% FPL with asset limit hours a week. prove length of residency), can $2,000, and couples earning 83% HIPAA: Must have had 18 months be qualified if one is a beneficiary FPL with asset limit of $3,000. of continuous coverage and of Trade Adjustment Assistance, completely exhausted COBRA or state HIPAA-eligible, or current holder MEPD: Must be disabled (as determined continuation coverage. Must not have of Basic and Standard Policy. by Department of Human Services), lost coverage due to fraud or non- be under 65 years old, employed or payment of premiums. You have 63 HIPIOWA-FED: Must have been self-employed, with income limit of days to enroll in a HIPAA-eligible plan. uninsured for at least 6 months prior 250% FPL and asset limits of $12,000 to applying. Must prove being a for singles and $13,000 for couples. HIPP: You may be eligible for HIPP if you U.S. citizen or legal U.S. resident, an have a high-cost health condition. Iowa resident, and having problems getting insurance due to a pre- existing condition. Costs depend COBRA/Mini-COBRA: Premiums range Costs for individual coverage HIPIOWA: Monthly premiums range Medicaid: $0 or minimal share of cost. on employer from 102%–150% of group health vary. from $55.32-$1,257.26 depending contribution and ± rates. on age, gender, tobacco use, and MEPD: $0 unless income is above Monthly Cost 25% of the insurance plan chosen. company’s index rate. HIPAA: Premiums will depend on plan 150% FPL. Otherwise, premiums chosen. HIPIOWA-FED: Monthly premiums range from $34 to $660 based on range from $155.62 to $765.61 income. depending on your age and HIPP: $0 or minimal share of cost. tobacco use.3029 Iowa
    • Publicly-Sponsored Programs Demographic Individuals & Children in Immigrants Trade Dislocated Native American Families with Moderate Income Awaiting Legal Workers Indians Moderate Income Families Status (TAA Recipients) IowaCare Healthy and Well Emergency Indian Health Services Health Coverage 800-338-8366 515-256-4606 Kids in Iowa Medicaid 605-226-7582 www.ihs.gov Tax Credit 800-338-8366 866-628-4282 www.ime.state.ia.us (Hawk-i) www.ime.state.ia.us/ (Search: Aberdeen) www.irs.gov (Search: IowaCare) 800-257-8563 Members (Search: HCTC) Program TDD: 888-422-2319 Or contact local county www.hawk-i.org Or contact local county Department of Human Department of Human Services. Services. Inpatient and outpatient Qualified children receive Up to 3 days of Medicaid is The Aberdeen Area Office in Inpatient and outpatient care (lab hospital, physician or advanced services through a health plan available to pay for the cost of Aberdeen, South Dakota, works tests, x-rays, etc.), Doctor visits, registered nurse practitioner, participating in the program: emergency services for aliens together with its 13 Service Preventive and major medical care and dental services. doctor visits, outpatient who do not meet citizenship, Units to provide health care to (surgery, physical therapy, Durable hospital services, vaccines alien status, or social security approximately 94,000 Indians medical equipment, etc.), Mental Polk County residents may and shots (immunizations) number requirements. The on reservations located in North health and substance abuse care, receive services at either emergency care, inpatient emergency services must be Dakota, South Dakota, Nebraska, and Prescription drugs. Broadlawns Hospital or hospital services, prescriptions, provided in a facility such as and Iowa. The Area Office’s service University Hospitals in Iowa vision, dental, hospice, speech a hospital, clinic, or office that units include nine hospitals, eight Can use credit to purchase plan City. Residents in other and physical therapy, nursing can provide the required care health centers, two school health through HIPIOWA. Coverage counties must receive services care services, chiropractic after the emergency medical stations, and several smaller at University Hospitals in Iowa care mental health/substance condition has occurred. health stations and satellite clinics. Pre-Existing Health City. The state’s four mental abuse. Beginning 3/1/2010, Conditions Covered health institutes will offer dental-only coverage for Pre-Existing Health mental health services. children who have health Conditions Covered insurance but may not have Unlike Medicaid, IowaCare is dental coverage will be not an entitlement, meaning available. that it depends on specific appropriations. Each county has one or more health plans. Pre-Existing Health Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Must be Iowa adults ages 19– 64 Must be a U.S. citizen or a U.S. citizenship not required. Must exhaust all private, state, and Must be receiving TAA (Trade with income limit of 200% FPL, qualified alien and live in Iowa, other federal programs. Adjustment Assistance), or not be eligible for Medicaid, and be under 19 years old, with an Income limits: be uninsured. income up to 300% FPL. Pregnant women: 300% FPL. Must be regarded by the local Must be 55 years or older and community as an Indian or Alaska receiving pension from the Also eligible: Must have no other health Parents/caretakers living with Native; is a member of an Indian Pension Benefit Guaranty insurance. Must not be a children ages 0–18: 83% FPL. or Alaska Native Tribe or Group Corporation (PBGC). Pregnant women with incomes dependent of a State of Iowa under Federal supervision; at or below 300% FPL, if their employee. Children ages 0–5: 133% FPL. resides on tax-exempt land or Must not be enrolled in certain medical costs can bring their Children ages 6–19: 100% FPL. owns restricted property; actively state plans, or in prison, or monthly incomes to 200% FPL. Children who qualify for participates in tribal affairs; receiving 65% COBRA premium Aged, blind, and disabled: Eligibility Medicaid cannot get Hawk-i. any other reasonable factor reduction, or be claimed as a Patients who do not meet the Singles earning 75% FPL with indicative of Indian descent; is dependent in tax returns. 200% FPL test but who receive asset limit $2,000, and couples a non-Indian woman pregnant State Papers services for chronic earning 83% FPL with asset with an eligible Indian’s child for Must be enrolled in qualified health problems are also limit of $3,000. the duration of her pregnancy health plans where you pay more eligible. through post-partum (usually than 50% of the premiums. 6 weeks); is a non-Indian One can apply for a part of member of an eligible Indian’s a household even if some household and the medical members do not have legal officer in charge determines that immigrant status. Proof of services are necessary to control immigration status is required for a public health hazard or an non-U.S. citizens. acute infectious disease which constitutes a public health hazard. $0-$75 for those earning $0 or minimal share of cost $0 or minimal share of cost. $0 or minimal share of cost. 20% of the insurance premium 150% FPL or less. Otherwise depending on your income. including COBRA premium if premiums for: Monthly Cost Maximum payment of $40. No employer contributes less than cost for Native Americans. 50%. 1 member: $47 to $60. 2+ members: $63 to $80 for each member. Iowawww.CoverageForAll.org 30
    • Demographic Private Health Insurance Small Individuals with Individuals Recently Businesses Individuals Pre-Existing, Severe, Low-Income Covered by an (2-50 & Families or Chronic Medical Families & Children Employer Health Plan Employees) Conditions Group Plans COBRA/Mini-COBRA Individual Plans Kansas Health Medicaid National Association of National Association of Insurance Association 800-766-9012 www.kmap-state-ks.us Health Underwriters Then convert to a plan under: Health Underwriters (KHIA) 703-276-0220 703-276-0220 800-362-9290 www.nahu.org www.nahu.org www.khiastatepool.com Women-Infant-Children HIPAA (WIC) Program Health Insurance Portability & Accountability Act Pre-Existing 800-332-6262 785-296-1320 866-487-2365 Condition Insurance www.kdheks.gov/nws-wic www.dol.gov Plan (PCIP-KS) Federal program run by KHIA HIPP 877-505-0511 www.khiastatepool.com/KHIA- Health Insurance Premium Payment 800-967-4660 FED content.srs.ks.gov/ees/keesm/ www.PCIP.gov keesm2912.htm Up to $5M lifetime COBRA: Coverage available for Up to $5M, assorted KHIA: Prevention services, Inpatient Medicaid: Office visits, Checkups, maximum, assorted 18–36 months depending on qualifying deductibles depending hospital care, Therapies (physical, Immunizations, Inpatient and deductibles. events. Benefits are what you had with on age and ZIP code. speech, occupational), outpatient hospital services, Lab your previous employer. oral surgery, Spinal manipulation, and x-ray, Prescription drugs, Eye There is a maximum There is a no limit to Maternity, Emergency room and doctor exams and glasses, Hearing 3-month look-back and Mini-COBRA: Coverage available for 18 the look-back period ambulatory services, Durable services and speech, Physical and exclusionary period for months. Benefits are what you had with and there is a 24-month medical equipment, Mental health occupational therapy, Dental services people with no prior your previous employer. limit on exclusionary and substance abuse, Nursing, for children (checkups, cleanings, coverage or whose prior period limit for pre- Home health, and Prescription sealants, x-rays and fillings), Inpatient coverage lapsed for more HIPAA: Benefits are based on program existing conditions on drugs. If prior health coverage and outpatient mental health services, Coverage than 63 days. selected. There is no expiration of enrollees with no prior had a lapse of 31 days or more, and substance abuse services, Medical coverage. coverage. there will be a 90-day pre-existing transportation. Carriers must provide condition exclusion in KHIA immunizations for HIPP: Benefits are the same as what Elimination riders are coverage. WIC: Immunization screening and children ages 0–6 , you had with your previous employer. permitted. breastfeeding support, as well as mammograms, Pap HIPP is a premium assistance program. PCIP-KS: Covers broad range of Nutrition education and supplemental smears, prostate Pre-Existing Health benefits, including primary and foods to infants, children and women screenings, osteoporosis Pre-Existing Health Conditions Conditions Covered specialty care, hospital care, and who are pregnant, postpartum or are testing and diabetic Covered with Some Limitations prescription drugs. breastfeeding. supplies, minimum mental health/substance Pre-Existing Health Conditions Pre-Existing Health abuse services. Covered Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE COBRA: Available for employees who Eligibility is subject to KHIA: 1) Must be ineligible for All: Must be Kansas resident. Company size 2–50 work for businesses with 20 or more medical underwriting. Medicare or Medicaid, prove employees. You have 60 days from date Medicaid: Must be a U.S. citizen or a employees. residency in Kansas for at least 6 qualifying alien. Income limits for the of termination to sign up for COBRA If you are denied months prior to enrollment, and coverage. following: Owner can count as an coverage for a medical one of the following: denial of employee. Mini-COBRA: You must have been insured condition, you may be health coverage by 2 insurance Children ages 1–5: 133% FPL. continuously under your previous eligible for KHIA or PCIP. carriers due to pre-existing Owner name on business See next column. conditions; offer of insurance with Children ages 6–18: 100% FPL. employer’s group policy for at least 3 license must draw wages months prior to termination. You have rates higher than KHIA’s or with no Pregnant women and infants ages 0–1: from the company. 31 days from date of termination or coverage for pre-existing condition 150% FPL. from date of receiving election notice (elimination rider); insurance Eligible full-time from insurance company to sign up for involuntarily terminated not due Parents/caregivers living with children Eligibility employees must work at Mini-COBRA coverage. to non-payment of premium. Or ages 0–18: 30% FPL (if more than 4 least 30 hours per week 2) Must live in Kansas (not required household members, add $61 for each and must not be temporary HIPAA: Must have had 18 months of to prove length of residency) and added member). or substitute employees. continuous coverage and completely be eligible for HIPAA plans or Trade exhausted COBRA or state continuation Adjustment Assistance (TAA). Medically-needy: $495/month with coverage. Must not have lost coverage asset limit of $2,000 for singles and due to fraud or non-payment of PCIP-KS: Must be a U.S. citizen or $3,000 for couples. premiums. You have 63 days to enroll in lawfully present in the U.S. and have been uninsured for at least Aged, blind, and disabled: 75% FPL a HIPAA-eligible plan. with asset of limit of $2,000 for singles, 6 months prior to applying. Must HIPP: Must be Medicaid recipients, have had a problem getting and 83% FPL with asset limit of $3,000 at least 18 years old, employed with insurance due to a pre-existing for couples. insurance or COBRA. Enrollees in condition. WIC: Must be women who are pregnant, HealthWave or SOBRA are not eligible. or breastfeeding up to baby’s first birthday, non-breastfeeding mothers with babies up to six months old, or children under 5 years old. Income limit of 185% FPL. Costs depend on COBRA/Mini-COBRA: Premiums range from Costs for individual KHIA: Monthly premiums range Medicaid & WIC: $0 or minimal share Monthly Cost employer contribution 102%-150% of group health rates. coverage vary. There from $157.70 to $1,974.59 of cost. and ± 25% of the are no rate caps. depending on your age, gender, insurance company’s HIPAA: Premiums will depend on plan tobacco use and deductible. index rate. chosen. PCIP-KS: Premiums based on age HIPP: $0 or minimal share of cost. and tobacco use, and must be at or less than 100% of the average market rate for similar insurance policies.3231 Kansas
    • Publicly-Sponsored Programs Demographic Children with Low-Income Children Women Seniors & Disabled Special Needs Individuals Medicare HealthWave Children and Youth with Women’s MediKan 800-633-4227 www.medicare.gov 800-792-4884 TTY: 800-792-4292 Special Health Care Health Care and 800-766-9012 888-369-4777 www.kdheks.gov/hcf/ Needs (CYSHCN) Family Planning www.srs.ks.gov Medicare Prescription healthwave 800-332-6262 785-296-1313 Services Drug Program 800-332-6262 Or contact local social services 800-633-4227 Program www.kdheks.gov/cyshcn 785-296-1307 agency. www.kdheks.gov (Search: Family Planning) Senior Health Insurance Counseling Early Detection of Kansas (SHICK) Works 800-860-5260 877-277-1368 www.agingkansas.org 785-296-1207 www.kdheks.gov/edw All applications will be Helps those at risk for disabilities or Women’s Health Care and Limited benefits to adults whose Medicare offers Part A, inpatient screened for Medicaid- chronic disease. Planning Services: Pap smears, applications for federal disability care in hospitals and rehabilitative eligibility first. Services Urinalysis, Screening for are being reviewed by the Social centers; Part B, doctor and include Office visits, Diagnostic services limited to anemia, Hypertension, and Security Administration. Average some preventive services and Checkups, Immunizations, one-time evaluation to determine if abnormal conditions of the monthly benefit from General outpatient care; Part C allows Inpatient and outpatient medically eligible, with no income breast and cervix, Pregnancy Assistance is $100. Medicare benefits through private hospital services, Lab requirement, for youth under 22 testing and counseling, insurance (Medicare Advantage); and x-ray, Prescription years old. Services also include Contraceptive methods The program is time-limited to Part C includes Parts A, B, and C drugs, Eye doctor exams Outpatient medical specialty care, including abstinence, 24 months per person; however, not covered by Medicare. Part D and glasses, Hearing Hospitalizations, Surgery, Durable Screening and treatment for assistance is continued for those covers prescription drugs. Coverage services and speech, medical equipment and medications, sexually transmitted diseases. who have an ongoing pending Physical and occupational Limited therapy (physical and If problems are discovered application for Social Security SCHICK is a Medicare counseling therapy, Dental services occupational), Case management which are beyond the scope benefits (including the appeal service. for children (checkups, that develops health care plan for of the clinics, appropriate process). cleanings, sealants, x-rays each patient. referrals will be made by the Pre-Existing Health Conditions The scope of MediKan’s services and fillings), Inpatient and Outreach clinics do specialty diagnosis, health care provider. Clients is similar to that of Medicaid’s, Covered outpatient mental health consultation, and follow-along care as are seen by appointments. but some restrictions and and substance abuse close to the childs home as possible. limitations apply. Health services, and Medical Services cover hearing loss, orthopedic Early Detection Works: Services benefits include medical care transportation. conditions, neurological impairment, include breast and cervical in acute situations and during cardiac diseases, and genetic diseases, cancer screenings, treatment catastrophic illness. Pre-Existing Health counseling and planning. and possibly other services. Conditions Covered Pre-Existing Health Pre-Existing Health Conditions Pre-Existing Health Conditions Covered Covered Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Must be a U.S. citizen or Household income limits: Women’s Health Care and Planning The MediKan health program Both: Must be U.S. citizen or qualifying resident and live Services: Kansas residency is covers adults with disabilities permanent U.S. resident, and: in Kansas. Must be children 185% FPL and asset limit of 15% of required. who do not qualify for Medicaid, ages 0–18 living at or income. but are eligible for services 1) If 65 years or older, you or below 241% FPL. Early Detection Works: Must be under the State’s General your spouse worked for at least For PKU (Phenylketonuria) food: 300% Assistance program. FPL and asset limit of 25% of income. Kansas women ages 40–64, 10 years in Medicare-covered Must not already be not have insurance or have Applicants for general assistance employment, or covered by comprehensive Must be a Kansas resident who is 1) insurance policies that have and MediKan are screened by and reasonably accessible Under 22 years old with a medical high deductibles or do not Kansas Health Policy Authority 2) You have a disability or end- health insurance, or be condition covered by the program, pay for these services covered for potential enrollment in stage renal disease (permanent eligible for Medicaid. or 2) Of any age who has a metabolic Early Detection Works. Must Medicaid if they appear to kidney failure requiring dialysis or condition. be ineligible for Medicare meet federal requirements for transplant) at any age. Eligibility Children whose parents Part B or Medicaid/MediKan. disability. have access to the State Conditions include spina bifida, Income limit of to 225% FPL. group health insurance cleft palate/cleft lip; acquired or To be qualified for General plan are not eligible. congenital heart disease; burns Assistance, patient must meet requiring surgery; major orthopedic disability criteria as determined problems requiring surgery; limited through the state’s disability gastrointestinal or genitourinary determination process. conditions requiring surgery; hearing Recipients must pursue federal loss; vision disorders (limited); Social Security disability selected craniofacial anomalies; benefits. seizures (outpatient care and drugs only); juvenile rheumatoid arthritis; Must be a Kansas resident and genetic and metabolic conditions. U.S. citizen or a qualified non- citizen. HealthWave: Families with $0 CYSHCN will pay after private Women’s Health Care and Planning $0 or minimal share of cost. Both: $0 and share of cost for Monthly Cost incomes above 150% insurance and Medicaid are billed. Services: Sliding fee scale certain services; deductibles for FPL must pay premiums based on income and number certain plans. Part A: $0–$450 between $20 and $75. For metabolic formula, CYSHCN will of household members. based on length of Medicare- pay for all or part of charges based on income: Early Detection Works: $0 or covered employment; Part B: minimal share of cost. $96.40–$369.10 depending on 100% if 0–300% FPL income. annual income; Part C: Based on provider; Part D: Varies in cost and 50% if 301–500% FPL income. drugs covered. 25% if 501–700% FPL income. www.CoverageForAll.org Kansas 32
    • Demographic Private Health Insurance Small Individuals with Individuals Recently Low-Income Businesses Individuals Pre-Existing, Severe, Covered by an Families & (2-50 & Families or Chronic Medical Employer Health Plan Medically-Needy Employees) Conditions Group Plans COBRA/Mini-COBRA Individual Plans Kentucky Access Medicaid 866-405-6145 800-635-2570 Kentucky Office of Then convert to a plan under: Kentucky Office of www.kentuckyaccess.com 502-564-4321 Insurance Insurance www.chfs.ky.gov/dms 502-564-3630 HIPAA 502-564-3630 800-595-6053 800-595-6053 Pre-Existing Condition Program Health Insurance Portability & 800-462-2081 TDD 800-462-2081 TDD insurance.ky.gov Accountability Act insurance.ky.gov Insurance Plan (PCIP) 866-487-2365 Run by the U.S. Department of Health National Association of www.dol.gov National Association of and Human Services Health Underwriters Health Underwriters 866-717-5826 703-276-0220 HIPP 703-276-0220 www.PCIP.gov ww.nahu.org Health Insurance Premium Payment ww.nahu.org 855-695-4477 mykhipp.com Benefits will vary COBRA: Coverage available for 18–36 All insurers are required Kentucky Access: Offers 3 health plans: Some of services include depending on the months depending on qualifying to offer a “standard plan” Traditional Access (indemnity), Premier Hospital care (inpatient and chosen plan. events. Benefits are what you had with which offers the same Access (PPO), and Preferred Access outpatient), Nursing home your previous employer. benefits regardless of the (PPO). Benefits include Inpatient care, Physician services, There is a maximum insurer. care, ambulatory/hospital outpatient Laboratory and x-ray services, 6-month look-back Mini-COBRA: Coverage available for 18 surgery, Transplants, Office visit, Immunizations and other period and a maximum months. Benefits are what you had with Insurers are required to Diagnostic services, Allergy testing and early and periodic screening, 12-month exclusionary your previous employer. offer certain benefits such treatments, Maternity care emergency Diagnostic and treatment period for pre-existing as maternity stay and services, Ambulance, Urgent care (EPSDT) services for children, conditions on enrollees HIPAA: Benefits are based on program mammograms. services, Preventive services, Well- Health center (FQHC) and Rural Coverage that do not have prior selected. There is no expiration of child and adolescent care, Well-adult health clinic (RHC) services, creditable coverage or coverage. There is a maximum care, Mental health, Autism substance Nurse midwife and nurse whose prior coverage 6-month look-back and abuse, Prescription drugs and oral practitioner services. had a lapse of more HIPP: Benefits are the same as what maximum 12-month contraceptives, Manipulative treatment than 63 days. you had with your previous employer. exclusionary period limit home health care, Skilled nursing facility, Benefits also include HIPP is a premium assistance for pre-existing conditions Medical supplies, Durable medical Chiropractor, Dental, Durable Pre-Existing Health program. on enrollees that do not equipment, Prosthetic devices, Orthotic medical equipment (DME), Conditions Covered have prior coverage. devices, Services, Hospice services. Family planning, Hearing, Pre-Existing Health Conditions Hospice, Medical transportation, Covered Pre-Existing Health PCIP: Covers broad range of benefits, Organ transplant, Pharmacy, Conditions Covered with including primary and specialty care, Podiatry, Renal dialysis and Some Limitations hospital care, and prescription drugs. Vision. Pre-Existing Health Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE COBRA: Available for employees who Medical underwriting Kentucky Access: One of the following 1) Must be U.S. citizens or qualified Company size 2–50 work for employers with 20 or more determines eligibility. Must be Kentucky resident for at least aliens and residents of Kentucky: employees. employees. You have 60 days from date 12 months and rejected for health Income limits: of termination to sign up for COBRA If you are denied coverage coverage due to pre-existing condition, Owner can count as an coverage. for a medical condition, or were offered coverage with premiums Pregnant women and infants employee. you may be eligible for higher than rates in Kentucky Access, or ages 0–1: 185% FPL. Mini-COBRA: Available for employees who work for employers with less Kentucky Access or PCIP. have a qualified high-cost pre-existing Children ages 1–18: 200% FPL. Proprietor name on than 20 employees. You must have See next column. conditions. Or, 2) You participate in the license must draw state’s GAP (Guaranteed Acceptance Parents/caretakers living been insured continuously under your with children ages 0–18 (after wages. previous employer’s group policy for Program). Or 3) You are HIPAA-eligible. Coverage extends to dependents of deducting expenses for work at least 3 months prior to enrolling and child care): $217 for one “Eligible employee” in Mini-COBRA. You must sign up for Kentucky Access enrollees. means any full- or part- household member, $267 for 2, Mini-COBRA within 31 days from date $308 for 3, $383 for 4, $450 for 5, Eligibility time employee actively of receiving notice of your right to PCIP: Must have been uninsured for at engaged in employer’s least 6 months prior to applying. Must $508 for 6, $567 for 7, $627 for 8. continue coverage. Add $60 per added household business, has satisfied prove being a U.S. citizen or legal U.S. employer’s waiting HIPAA: Must have had 18 months of resident, a Kentucky resident, and member. period requirements, continuous coverage and completely having problems getting insurance due Aged, blind and disabled: Singles and has received a exhausted COBRA or state continuation to a pre-existing condition. earning 75% FPL with asset limit voucher from employer coverage. Must not have lost coverage of $2,000; couples earning 83% to buy health benefit due to fraud or non-payment of FPL with asset limit of $4,000. plan. premiums. You have 63 days to enroll in a HIPAA-eligible plan. Working disabled: Must be ages 16 to 64, meet the Social HIPP: Enrollee or at least one member of Security definition of disabled, enrollee’s family must receive Medicaid earn up to 250% FPL, have asset and have employer-based insurance limit of $5,000, and prove to be or COBRA. employed or self-employed (e.g. pay stubs). Costs depend on COBRA/Mini-COBRA: Premiums range from Rates are ± 35% of the Kentucky Access: Monthly premiums range $0 or nominal co-payment. Monthly Cost employer contribution 102%–150% of group health rates. base individual market from $178.05 to $1,577.38 depending on and ± 35% of the rate. your age, gender, and plan chosen. No insurance company’s HIPAA: Premiums will depend on plan family rates. index rate. chosen. PCIP: Monthly premiums range from $98 HIPP: $0 or minimal share of cost. to $424 depending on your age and plan chosen.3433 Kentucky
    • Publicly-Sponsored Programs Demographic Children with Children Women Seniors & Disabled Veterans Chronic Illnesses Children’s Health Commission for Kentucky Women’s Medicare VA Medical Insurance Program Children with Cancer Screening 800-633-4227 www.medicare.gov Benefits Package (KCHIP) Special Health Care Program 877-222-8387 www.va.gov 877-524-4718 877-524-4719 TTY Needs 502-564-3236 chfs.ky.gov Medicare Prescription Program www.kidshealth.ky.gov (CCSHCN) (Search: Cancer Screening) Drug Program 502-429-4430 chfs.ky.gov/ccshcn 800-633-4227 Women-Infant- Children (WIC) State Health 800-462-6122 Insurance Assistance 502-564-3827 800-648-6056 TTY Program (SHIP) chfs.ky.gov chfs.ky.gov (Search: WIC) (Search: SHIP) KCHIP: Covers Doctor visits, Dental Benefits include CCSHCN If screened and diagnosed for Medicare offers Part A, inpatient Comprehensive care, Hospitalization, Outpatient offices in 12 locations, satellite breast or cervical cancer, may care in hospitals and rehabilitative preventive and primary hospital services, Psychiatrists, clinics in physician offices be eligible for complete health centers; Part B, doctor and some care, outpatient and Laboratory tests and x-rays, Vision and other settings, office coverage through Medicaid, preventive services and outpatient inpatient services. exams, Hearing services, Mental visits, therapy (physical, including dental, prescriptions care; Part C allows Medicare benefits health services, Prescription drugs, occupational, speech), etc. through private insurance (Medicare Pre-Existing Health Glasses, Immunizations, Well- audiology services, related lab Advantage); Part C includes Parts A, Conditions Covered child checkups, Physical therapy, and follow-up services, X-rays Pre-Existing Health B, and C not covered by Medicare. Speech therapy, and many other and lab tests, medication, Conditions Covered Part D covers prescription drugs. services. durable medical equipment. Coverage SHIP is a Medicare counseling and WIC: Nutrition education and Primary medical care is not application service. services, breastfeeding promotion covered. and education, monthly food Pre-Existing Health Conditions prescription of nutritious foods, Pre-Existing Health Covered and access to maternal, prenatal Conditions Covered and pediatric health-care services. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE KCHIP: Must be U.S. citizens Must be a Kentucky resident Must be women residing in Both: Must be U.S. citizen or or qualified aliens and live in under 21 years old, with Kentucky ages 40–64. Must be permanent U.S. resident, and: ”Veteran status” = active Kentucky. Must not be eligible a medical condition that uninsured or underinsured, duty in the U.S. military, for any other insurance, including usually responds to treatment ineligible for Medicaid, and living 1) If 65 years or older, you or your naval, or air service and individual, group or public. Must provided by the program. at or below 100%% FPL. spouse worked for at least 10 years in a discharge or release be children under age 19, with Income limit is 200% FPL. Medicare-covered employment, or from active military incomes at or below 200% FPL. Women younger than 40 are service under other than Also provided are free eye eligible to receive screening 2) You have a disability or end- dishonorable conditions. examinations to all school age services only if they have a family stage renal disease (permanent WIC: Must live in Kentucky and children who fall between history of breast cancer. kidney failure requiring dialysis or Certain veterans must be pregnant or have a pregnant 200%–250% of the Federal transplant) at any age. have completed 24 woman or infant in the family Poverty Line and are without Pap tests are provided to continuous months of who receives Medicaid, or have insurance coverage for vision. uninsured women living at or service. a member of your family who Eligibility below 250% FPL. receives KTAP, or have a household income at or below 185 FPL%. KCHIP: $0 premium depending Sliding-scale fee based on $0 or nominal co-payment. Both: $0 and share of cost for $0 or share of cost and Monthly Cost on income. $1 to $3 co-pays income. certain services; deductibles for co-pays depending on for prescriptions, $6 for non- certain plans. Part A: $0–$450 based on length of Medicare-covered income level. emergency ER admissions, $2 for employment; Part B: $96.40–$369.10 allergy testing. Annual out-of- depending on annual income; Part C: pocket maximum of $450. Based on provider; Part D: Varies in cost and drugs covered. WIC: $0 to minimal share of cost. www.CoverageForAll.org Kentucky 34
    • Demographic Private Health Insurance Small Individuals with Low-Income Businesses Individuals Recently Covered Individuals Pre-Existing, Severe, Individuals (2-50 by an Employer Health Plan & Families or Chronic Medical & Families Employees) Conditions Group Plans COBRA/Mini-COBRA Individual Lousiana Health Medicaid Louisiana Association Then convert to a plan under: Plans Plan(LHP) 888-342-6207 new.dhh.louisiana.gov of Health Underwriters 800-736-0947 Louisiana Association 225-926-6245 (Baton Rouge) (Search: Medicaid) www.la-ahu.org HIPAA Program of Health Underwriters Health Insurance Portability & www.la-ahu.org www.lahealthplan.org Accountability Act 866-487-2365 Pre-Existing Condition www.dol.gov Insurance Plan (PCIP) Run by the U.S. Department of LaHIPP Health and Human Services 888-695-2447 866-717-5826 www.lahipp.dhh.louisiana.gov www.PCIP.gov There is a maximum COBRA: Coverage available for 18–36 months Assorted plans LHP: High Risk and HIPAA Pools that Some of the services include 6-month look-back depending on qualifying events. Benefits are depending on medical provide comprehensive coverage. Audiological, Chemotherapy, and a maximum what you had with your previous employer. needs. Services include Physician visits and chiropractic care, Dental, 12-month exclusionary and services, Prescription drugs, EPSDT (children under age 21), period for pre-existing Mini-COBRA: Coverage available for 12 months. There is a 12-month Inpatient and outpatient hospital Durable medical equipment, conditions on enrollees Benefits are what you had with your previous look-back and care, Inpatient and outpatient Family planning, Hearing aids, who do not have prior employer. exclusionary period mental health and substance abuse Hemodialysis, Home health, creditable coverage or limit for pre-existing services, Skilled nursing care, Home Hospice, Hospital inpatient whose prior coverage HIPAA: Benefits are based on program selected. conditions on health, Hospice, Lab, X-rays and and outpatient services, lapsed more than 63 There is no expiration of coverage. enrollees with no prior chemotherapy, Durable medical Immunizations, Long-term days. coverage. equipment, Therapy (physical, and community care, Medical Coverage LaHIPP: Benefits are the same as what you speech and occupational), Preventive transportation, Mental health, Benefits will vary had with your previous employer. LaHIPP is a Limits on Pre-Existing and wellness care. High Risk Pool Midwife services, Therapy depending on the premium assistance program Health Conditions May has 6-month waiting period for (multi-systemic, occupational, chosen plan. Apply pre-existing conditions. HIPAA physical, speech therapy Pre-Existing Health Conditions Covered Pool has 12-month pre-existing and language evaluation), Pre-Existing Health condition waiting period for spouse Optical and orthodontic Conditions Covered or dependents of enrollee, but none services, Nurses, Elderly care, for enrollee, or for child enrolled in Prescription drugs, Physician HIPAA Pool less than 63 days after services, Podiatry, Prenatal birth or adoption. care, Rehabilitation services, Rural health clinics, STD clinics, PCIP: Covers broad range of benefits, Substance abuse services, including primary and specialty Tuberculosis clinics, Lab and care, hospital care, and prescription x-rays. drugs. Pre-Existing Health Conditions Pre-Existing Health Conditions Covered Covered GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE COBRA: Available for employees who work for Eligibility is subject to LHP: High Risk Pool: Must prove Must be U.S. citizens or Company size 2–50 businesses with 20 or more employees. You have medical underwriting. 6-month residency in Louisiana, denial qualified aliens and live in employees. 60 days from date of termination to sign up for of health coverage by 2 insurance Louisiana. COBRA coverage. Elimination riders are companies due to pre-existing Owner can count as an Income limit: Mini-COBRA: Available for employees who work permitted. conditions within one year. Must not employee. be eligible for or covered by any private Parents/caretakers living with for employers with less than 20 employees. Owner name on Must have been covered by group insurance If you are denied or public health insurance (including children ages 0–18: 25% FPL. business license must continuously for 3 months prior to enrolling coverage for a medical COBRA). Must not be in public condition, you may be institution. Medically-needy: Monthly draw wages from the in Mini-COBRA. Surviving spouse at least age income limit for singles: in company. 55 and covered by deceased spouse’s policy is eligible for LHP or PCIP. See next column. HIPAA Pool: Must be a Louisiana urban counties is $100, in rural eligible until qualified for other group insurance. resident, HIPAA-eligible, and not be in a is $921, with asset limit to both “Eligible employee” is Surviving spouse can cover dependents who defined by insurance public institution. of $2,000; monthly income were insured by deceased spouse’s policy as Eligibility carrier. limit for couples in urban long as they remain eligible under that policy. Also qualified are those eligible for counties is $192, and in rural is You must sign up for Mini-COBRA and pay for Trade Adjustment Assistance (TAA), $1,671 with asset limit for both it on or before the date of termination of group or pensions from the Pension Benefit of $3,000. insurance. Surviving spouses have 90 days after Guarantee Corporation (PBGC). date of death to sign up for Mini-COBRA. Pregnant women and children PCIP: Must have been uninsured for at ages 0–18: 200% FPL. HIPAA: Must have had 18 months of continuous least 6 months prior to applying. Must coverage and completely exhausted COBRA prove being a U.S. citizen or legal U.S. Aged, blind, and disabled: or state continuation coverage. Must not have resident, a Louisiana resident, and Singles earning up to 75% lost coverage due to fraud or non-payment of having problems getting insurance FPL with asset limit of $2,000; premiums. You have 63 days to enroll in a HIPAA- due to a pre-existing condition. couples earning up to 83% FPL eligible plan. with asset limit of $3,000 LaHIPP: You (or one of your family member) must have full-coverage Medicaid and employer- based health insurance or COBRA. Costs depend on COBRA/Mini-COBRA: Premiums range from Costs for individual LHP: Monthly premiums are $107.34 $0 or minimal share of cost. Monthly Cost employer contribution. 102%–150% of group health rates. coverage vary. There to $1,517.41 based on age, gender, Rates vary ± 35% of the are no rate caps. region, tobacco use and deductible. insurance company’s HIPAA: Premiums will depend on plan chosen. PCIP: Monthly premiums are $129 to index rate but only for LaHIPP: $0 or minimal share of cost. $553 based on age and plan chosen. employers with 3–35 eligible employees.3635 Louisiana
    • Publicly-Sponsored Programs Demographic Children in Children with Moderate Income Special Health Women Seniors & Disabled Veterans Families Care Needs Breast and Cervical Cancer LaCHIP Louisiana Children’s Prevention (BCCP) Medicare VA Medical Children’s Health Insurance Plan Special Health 888-342-6207, 888-599-1073 800-633-4227 www.medicare.gov Benefits labchp.lsuhsc.edu 877-252-2447 Services (CSHS) Package Program 504-896-1340 877-222-8387 www.lachip.org new.dhh.louisiana.gov LaMOMS Medicare www.va.gov Women-Infant- 888-342-6207, TTD: 800-220-5404 new.dhh.louisiana.gov Prescription Drug Note: CSHS is now a family Children (WIC) resource center. (Search: LaMOMS) Program 800-251-2229 800-633-4227 new.dhh.louisiana.gov Take Charge (Search: WIC) 888-342-6207 new.dhh.louisiana.gov (Search: Take Charge) LaCHIP: Provides Medicaid Health care services, Medical BCCP: The program provides full Medicaid Medicare offers Part A, Comprehensive coverage for Doctor visits tests and procedures, coverage like doctor and hospital inpatient care in hospitals and preventive and for primary care as well as Hospitalization, Therapies, visits, lab work, and prescriptions. rehabilitative centers; Part B, primary care, preventive and emergency Home health services, Medical doctor and some preventive outpatient and care, Immunizations, equipment and supplies, p LaMOMS: Pregnancy-related services, delivery services and outpatient care; inpatient services. Prescription medications, Parent/family support services and care up to 60 days after the pregnancy Part C allows Medicare benefits Hospitalization, Home health (parent liaisons), Medications ends including doctor visits, lab work/tests, through private insurance Pre-Existing Health care and many other health and special diets, Nursing, prescription medicines and hospital care. (Medicare Advantage); Part C Conditions Covered services. Nutrition and social services includes Parts A, B, and C not follow-up, Care coordination, Take Charge: 4 office visits per year on services covered by Medicare. Part D WIC: Nutrition education Case management, and for family planning (e.g. contraceptives). covers prescription drugs. Coverage and services, breastfeeding Resource development, or over promotion and education, 21 years of age for the Cystic Pre-Existing Health monthly food prescription Fibrosis program. Conditions Covered 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 LaCHIP: Must be a U.S. citizen Children ages 0-21, living in BCCP: U.S. citizens or qualified aliens under 65 Must be U.S. citizen or or qualified alien and live in Louisiana, have a condition years old; uninsured and screened for breast permanent U.S. resident, and: ”Veteran status” = Louisiana. Must be under covered by CSHS, would or cervical cancer under the CDC. Income up active duty in the 19 years old, not covered by benefit from rehabilitation to 250% FPL. Eligibility continues until the 1) If 65 years or older, you or U.S. military, naval, health insurance (including services, have a long-term course of treatment ends or the criteria for the your spouse worked for at least or air service and a Medicaid). Income limit of condition that requires program are no longer met and may begin up 10 years in Medicare-covered discharge or release 200% FPL. specialty care and a multi- to three months before the month a woman employment, from active military disciplinary treatment team. applies for Medicaid. A woman may be or service under other WIC: Must live in Louisiana. eligible to be paid back for services received than dishonorable Must be pregnant or Any child in Medicaid meets up to three months before she applied if she 2) You have a disability or end- conditions. postpartum women, or the financial criteria. Income used a Medicaid provider and if the service is stage renal disease (permanent children under age 5, living limit of 200% FPL. Children covered by Medicaid. kidney failure requiring dialysis Certain veterans must up to 185% FPL. who do not qualify for or transplant) at any age. have completed 24 Eligibility Medicaid may be financially LaMOMS: Income up to 200% FPL continuous months of eligible for CSHS as determined service. by a CSHS eligibility counselor. Take Charge: Women ages 19–44 residing in Louisiana with incomes below 200% FPL, without health insurance or whose insurance policies do not cover family planning services. LaCHIP: $0–$50 monthly $0 or minimal share of cost. All: $0 or minimal share of cost. $0 and share of cost for $0 and share of Monthly Cost premium depending on certain services; deductibles for cost and co-pays income. certain plans. Part A: $0–$450 depending on income based on length of Medicare- level. WIC: $0 or minimal share covered employment; Part B: of cost. $96.40–$369.10 depending on annual income; Part C: Based on provider; Part D: Varies in cost and drugs covered.www.CoverageForAll.org Louisiana 36
    • Demographic Private Health Insurance Small Individuals with Individuals Recently Low-Income Businesses Individuals Pre-Existing, Covered by an Employer Families & (1-50 & Families Severe, or Chronic Health Plan Medically -Needy Employees) Medical Conditions Group Plans COBRA/ Individual Plans Pre-Existing MaineCare 207-624-8475 Mini-COBRA 207-624-8475 Condition Insurance (Medicaid) 866-690-5585 800-300-5000 Then convert to a plan under: 800-300-5000 Plan (PCIP) 800-977-6740 888-577-6690 (TTY) 888-577-6690 (TTY) Run by the Dirigo Health (Member Services) Maine Bureau of Insurance Maine Bureau of Insurance Agency Maine Continuity Law 207-287-3707 (TTY) Program www.maine.gov/pfr/ www.maine.gov/pfr/ 877-892-8391 www.maine.gov/bms insurance www.maine.gov/pfr/insurance/consumer/ insurance www.dirigohealth.maine.gov lostgrouphealth_2009.htm www.PCIP.gov Maine Association of Maine Association of Health Underwriters HIPAA Health Underwriters www.meahu.org Health Insurance Portability & www.meahu.org Accountability Act 866-487-2365 www.dol.gov Medical underwriting is COBRA: Coverage available for 18 to 36 Depends on plan chosen. Covers broad range of benefits, Services include Adult family prohibited. months depending on qualifying events, including primary and specialty care services, Ambulatory benefits are the same as what you had with Carriers are required care, hospital care, and care and surgery, Ambulance Pre-existing conditions your previous employer. to offer standardized prescription drugs. services, Dialysis, Case can be excluded for a plans and to offer management, Nursing services, limited time depending Mini-COBRA: Coverage lasts up to 12 months. certain benefits such as Pre-Existing Health Chiropractic, Community upon the type of group Benefits are what you had with your mammograms, childhood Conditions Covered support, Benefits for the elderly plan you are joining. previous employer. immunizations and and for members with mental automatic coverage for and physical disabilities, Dental, There is a maximum HIPAA/Maine Continuity Law: Benefits are based newborns or adopted Family planning, Hearing look-back/exclusion on the program selected and there is no children. aids, Home health, Hospice, period of 6–12 months for expiration of coverage. Inpatient and outpatient Coverage pre-existing conditions There is a maximum Hospital services, Laboratory for enrollees with no Pre-Existing Health Conditions Covered look-back and exclusion and x-ray services, Medical prior coverage or whose period of 12 months for supplies and durable medical coverage lapsed 90 days pre-existing conditions. equipment, Behavioral health, or more. nursing, Therapy (occupational, Pre-Existing Health physical), Vision, Physician Benefits will vary Conditions Covered services, Preventive health depending on the chosen services, Podiatry, medical plan. imaging services, Rehabilitation services, Rural health clinics, Pre-Existing Health Speech and hearing services, Conditions Covered Transportation services, STD screening, and more. Pre-Existing Health Conditions Covered GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE COBRA: Available for employees who work for In Maine, no medical Must be uninsured for the Must be U.S. citizen or qualified Company size 1–50 businesses with 20 or more employees. Have underwriting is allowed. last 6 months, prove having alien and resident of Maine. employees 60 days from date of termination to sign up for a qualified pre-existing COBRA coverage. Elimination riders are not condition, and be a U.S. citizen Pregnant women and their Owner can count as an permitted. or legal resident. infants living up to 200% FPL. Mini-COBRA: Available for employees who work Infants living up to 185% FPL if employee. for businesses with less than 20 employees. not born to Medicaid-enrolled Must elect coverage within 31 days of Dirigo Health Agency patients mothers. Proprietor-name on termination of employment. If eligible due may be eligible for discounts license must draw wages. to layoff, must have at least 6 months of of 20% to 80% if patients live 19-20 year olds living up to employment before layoff. up to 300% FPL and have 150% FPL and with an asset limit Employees must work at Eligibility least 30 hours a week, and HIPAA: Must have had 18 months of continuous an asset limit of $60,000 for of $2,000. must not be employees coverage and completely exhausted COBRA one household member, or state continuation coverage. Must not have Aged, blind, and disabled, and who work on a temporary or $120,000 for 2 or more medically-needy singles and or substitute basis. lost coverage due to fraud or non-payment household members. of premiums. You have 63 days to enroll in a couples living up to 100% FPL, HIPAA-eligible plan. with asset limit of $2,000 for Carrier’s minimum singles and $3,000 for couples. participation requirements may not Maine Continuity Law: Must be a Maine resident. Depending on qualifying event, Parents and caregivers living exceed 75% of all eligible with children 0–18 with income employees. you must apply for new coverage between 30–90 days of previous coverage to enroll in 150%–200% FPL and with asset a plan with no pre-existing health condition limit of $2,000. exclusion. For children, see “Pregnant Women & Children” column. Costs depend on COBRA/Mini-COBRA: Premiums range from Premiums vary by Monthly premiums range from $0 or minimal share of cost. Monthly Cost employer contribution 100%–150% of group health rates (plus 2% 20% above and below $438–$658 depending on your and ± 20% of the modified administrative cost). community rating. community rate. age and region. There are two HIPAA/Maine Continuity Law: Premiums depend Annual deductibles range deductible choices: a)$1,750 or on plan chosen. from $250–$1,500. b)$2,500. Out-of-Pocket limit for a)$3,500 and for b)$5,600.3837 Maine
    • Publicly-Sponsored Programs Demographic Moderate Income Children with Pregnant Women Individuals, Families, Women Seniors & Disabled Special Needs & Children & Employees Dirigo Choice Maine Children CubCare Maine Breast Medicare (State-Sponsored Plan) 877-892-8391 with Special Needs 800-442-6382 877-543-7669 and Cervical 800-633-4227 www.medicare.gov 207-287-9900(TTY) Program www.maine.gov Health Program www.dirigohealth.maine.gov 800-698-3624 (Search: CubCare) 800-350-5180 TTD: 800-438-5514 207-287-8068 Medicare Prescription Program DirigoChoice is open to new maine.gov/dhhs/boh/cshn Women-Infant- 800-438-5514 (TTY) Drug Program enrollment effective August 2010. www.maine.gov 800-633-4227 As of March 1, 2008, CSHN has Children (WIC) (Search: MBCHP) capped program enrollment 800-437-9300 and will no longer be 207-287-3991 accepting applications for 800-438-5514 (TTY) payment of services. www.maine.gov (Search: WIC) Coverage for qualified individuals, Medical treatment, including CubCare: Doctors visits, Breast exams, Pap Medicare offers Part A, inpatient care in sole proprietors, and small diagnostic, medical, surgical, Hospital care, Immunizations, tests, pelvic exams, hospitals and rehabilitative centers; Part businesses. Voucher program that corrective and other Prescriptions, Surgery, Lab mammograms, limited B, doctor and some preventive services pays for insurance on behalf of therapeutic interventions for: and x-ray, Dental, Medical diagnostic or follow-up and outpatient care; Part C allows part-time/seasonal workers. equipment and supplies, services. Uninsured Medicare benefits through private Blood disorders, Cardiac Chiropractic services, women undergoing insurance (Medicare Advantage); Part C Some services include Preventive defects, Childhood oncology Therapies (speech, physical, treatment for breast includes Parts A, B, and C not covered care, Inpatient/outpatient, Craniofacial anomalies, occupational), Vision, Hearing, or cervical cancer may by Medicare. Part D covers prescription Prescription drugs, Maternity Gastrointestinal, Metabolic Ambulance, Case qualify for MaineCare. drugs. and well-child care, Childhood ophthalmologic, Orthopedic, management, Mental Immunizations, Emergency care, neurological, Neurosensory, health and substance abuse Pre-Existing Health Pre-Existing Health Conditions Covered Mental health, Smoking cessation neuromuscular, and treatment, Family planning Conditions Covered Coverage and education programs, respiratory conditions. services, Prenatal care, and Domestic partner coverage, Transportation. Extensive provider network and Assistance with coordination out-of-network coverage, and of care and referral services to WIC: Screening for growth and No referral required to see a families of infants, children, anemia, healthy advice for specialist. and adolescents with special families, nutrition & healthy health needs regardless of foods, breastfeeding support, Pre-Existing Health income. other referrals to other Conditions Covered services. Pre-Existing Health Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED GUARANTEED COVERAGE COVERAGE HCTC-eligible members are Must be Maine resident. CubCare: Low-income children Must be U.S. citizen or permanent U.S. qualified. ages 0–18. Must be Maine resident. resident, and: Small employers: Must be Maine Infants, children, and residents, have 2–50 employees, adolescents who are at or No citizenship requirements Ages 40 and older. 1) If 65 years or older, you or your spouse contribute 60% of the cost of below 250% FPL. for pregnant women and worked for at least 10 years in Medicare- employees’ coverage. Employees’ children. Under 250% FPL. covered employment, or dependents not covered. Ages 21 and under. Maine residents. Must be uninsured or 2) You have a disability or end-stage Sole proprietors: Must be Maine underinsured, ineligible renal disease (permanent kidney failure residents, pay 60% of cost for Income must be equal to or for Medicaid, MaineCare, requiring dialysis or transplant) at any single coverage before discount is less than 180% FPL. and Medicare Part B. age. Eligibility applied, are not required to give minimum contribution. WIC: Pregnant or postpartum Limited openings for women and children up to the women age 35–39 who Individuals and sole proprietors: age of 5 years with a family Must complete a Certification have seen a doctor and income at or below 185% FPL. Statement. Must be a state resident; and need additional tests Part-Time Worker Coverage Voucher: be at nutritional or medical for a possible breast or Must be Maine residents, work risk, as determined by a health cervical cancer or if they 10–35 hours a week, be uninsured professional. have not had a Pap in 5 or for the last 90 days, living up more years. to 300% FPL with asset of $60K (for singles) or $120K (for 2+ household members). Discounts of 10% – 80% on monthly $0 or nominal co-payment. CubCare: $0-$64 or small $0 or nominal co- $0 and share of cost for certain Monthly Cost premiums, deductibles and annual out-of-pocket expenses based on monthly premium. payment. services; deductibles for certain plans. income, household size, and assets. Part A: $0–$450 based on length of WIC: $0 Medicare-covered employment; Part B: $96.40–$369.10 depending on annual income; Part C: Based on provider; Part D: Varies in cost and drugs covered. Mainewww.CoverageForAll.org 38
    • Demographic Private Health Insurance Individuals with Individuals Recently Low-Income Small Businesses Individuals Pre-Existing, Severe, Covered by an Families & (2-50 Employees) & Families or Chronic Medical Employer Health Plan Medically-Needy Conditions Group Plans COBRA/Mini-COBRA Individual Plans Maryland Health Medicaid Maryland Association of Health Maryland Association of Insurance Plan (MHIP) 410-767-5800 800-492-5231 Underwriters Then convert to a plan under: Health Underwriters 888-444-9016 800-735-2258 (TDD) www.marylandahu.com www.marylandahu.com www. www.dhmh.state.md.us/ marylandhealthinsuranceplan. Comprehensive Standard HIPAA state.md.us mma/mmahome.html Program Health Insurance Portability & Health Benefit Plan (CSHBP) Accountability Act Medical Assistance 410-764-3460 877-245-1762 866-487-2365 MHIP Federal Plan for Families www.dol.gov 443-738-0667 mhcc.maryland.gov www. 800-456-8900 (Search: Health Benefit Plan) marylandhealthinsuranceplan.net www.dhmh.state.md.us/ www.PCIP.gov ma4families/ Health Insurance Partnership (HIP) 410-764-3460 mhcc.maryland.gov/partnership CSHBP: Insurance carriers are COBRA: Coverage available for 18–36 Assorted plans MHIP: Four plans offering Medicaid: Doctor visits, required by law to sell CSHBP to months depending on qualifying depending on medical comprehensive coverage of Prescriptions, Hospital any small employer who applies events. Benefits are what you had needs Doctor visits, Prescription drugs, care (including emergency for it. CSHBP offers comprehensive with your previous employer. Outpatient and in-hospital care, care), Tests, X-rays, Family standardized benefits such as There is a 12-month Maternity, Ambulance, Labs planning, Mental health primary and specialty care, inpatient Mini-COBRA: Coverage lasts up to 18 look-back and 12-month and x-rays, Skilled nursing care, services, Substance abuse and outpatient hospital services, months. Benefits are what you had exclusionary period Hospice, Home health visits, services, Home health care, physician services, prescription with your previous employer. limit for pre-existing Transplants, Rehabilitation, Dental care, Eye care, Therapy Coverage drugs, lab and diagnostic services. conditions. Durable medical equipment, (occupational, physical and HIPAA: Benefits are based on program Mental health and substance speech), and more. Some carriers can impose 6-month selected. There is no expiration of Elimination riders are abuse, Physical, Speech and look-back and 12-month exclusion coverage. permitted. occupational therapy, and Medical Assistance for Families: periods for pre-existing conditions Preventive care. Low-cost or free prescriptions, on new employees joining an Pre-Existing Health Conditions Limits on Pre-Existing Doctor visits, Emergency existing non-HMO group policy. Covered Health Conditions May MHIP Federal Plan: Covers broad room visits,Hospital stays, Carriers cannot impose this on Apply range of benefits, including X-ray and lab services, and enrollees under 19 years old. primary and specialty care, many other services. HIP: Premium subsidy program for hospital care, and prescription small employers. drugs. Pre-Existing Health Conditions Covered Pre-Existing Health Conditions Pre-Existing Health Conditions Covered Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE CSHBP: Must conduct business in COBRA: Available for employees who Eligibility is subject to MHIP: Eligible if previous coverage Both: Must be U.S. citizens or Maryland in the preceding calendar work for businesses with 20 or more medical underwriting. was terminated for reasons other qualified non-citizens and quarter, employ 2–50 workers on employees. You have 60 days from than non-payment of premium or Maryland residents. at least 50% of its working days. date of termination to sign up for If you are denied fraud, you were denied coverage Eligible employees (including Medicaid: Income limits: COBRA coverage. coverage for a medical due to a medical condition, or proprietor) must work at least 30 condition, you may be were offered health insurance Parents/caretakers living with hours per week. Carrier may deny Mini-COBRA: Available for employees eligible for MHIP or MHIP that provides limited coverage or children ages 0–18: 116% FPL. coverage if less than 75% of eligible who work for employers of any size. Federal Plan. See next excludes coverage for a specific employees, who are not covered by Must be resident of Maryland, have column. medical condition. Cannot be Pregnant women: 150% FPL. spouse or another employer, sign up been covered by group insurance eligible for group plan, COBRA, for CSHBP. Aged, blind or disabled: for 3 months before termination. or government programs. Also Singles earning 75% FPL with For non-profits, groups of one Must elect coverage within 45 days eligible if beneficiary of Trade asset limit $2,500, and couples currently uninsured working at of termination. In case of divorce, Adjustment Assistance (TAA). earning up to 83% FPL with Eligibility least 20 hours a week are eligible. insured employee or his/her divorced Families with incomes at or asset limit of $3,000. Employers do not have to offer or spouse must elect coverage within below 300% FPL can qualify for pay for group health benefits for 60 days after change in status. discounted premiums (MHIP+). Medically-needy: Singles their employees. earning $350 per month HIPAA: Must have had 18 months MHIP Federal Plan: Must be a U.S. with asset limit of $2,500, HIP: Employers with 2–9 eligible of continuous coverage and citizen or lawfully present in the and couples earning $392 employees and have not offered completely exhausted COBRA or U.S. and have been uninsured for per month with asset limit of health insurance to employees in state continuation coverage. Must at least 6 months prior to applying. $3,000. last 12 months. Eligible employees not have lost coverage due to fraud Must have had a problem getting must work at least 30 hours a week, or non-payment of premiums. You insurance due to a pre-existing Children: See” Children & earning up to $50,000 ($75,000 for have 63 days to enroll in a HIPAA- condition. Pregnant Women” column. coverage for dependent). Part-time, eligible plan. Medical Assistance for Families: temporary, and seasonal employees Must be living up to 121% FPL. do not qualify. CSHBP: At or less than 10% of COBRA/Mini-COBRA: Premiums range Costs for individual MHIP: 150% or less of the Both: $0 or minimal share of Maryland’s average annual wage. from 102%–150% of group health coverage vary. Monthly Cost standard premium rate charged cost. Carriers must price CSHBP separate rates. by commercial carriers. from riders. HIPAA: Premiums will depend on MHIP Federal Plan: Monthly HIP: Subsidy per employee depends plan chosen. on health plan chosen and premiums range from $141 to employee wage. Subsidy is up to $354 depending on your age. 50% of employee premium.4039 Maryland
    • Publicly-Sponsored Programs Demographic Trade Dislocated Children & Pregnant Women Seniors & Disabled Workers Veterans Women (TAA Recipients) Maryland Children’s Breast Cancer Medicare Health Coverage VA Medical Health Program (MCHP) Screening Program 800-633-4227 www.medicare.gov Tax Credit Benefits Package 800-456-8900 800-477-9774 866-628-4282 877-222-8387 800-735-2258 TTD fha.maryland.gov www.irs.gov www.va.gov www.dhmh.state.md.us/ (Search: Breast Cancer Medicare Prescription (keyword: HCTC) mma/mchp Drug Program Program Screening) MCHP Premium 800-633-4227 410-767-6883 Breast and Cervical 800-456-8900 Cancer Diagnosis 800-735-2258 (TDD) and Treatment Women-Infant-Children Program 410-767-6787 (WIC) 800-477-9774 800-242-4942 www.fha.maryland.gov www.dhmh.state.md.us (Search: Breast and Cervical (Search: WIC) Cancer Diagnosis) MCHP: Doctor Visits, Hospital Care, Screening mammogram, Medicare offers Part A, Inpatient and outpatient Comprehensive preventive Lab Work and Tests, Dental, Vision, Clinical breast exam, Pap inpatient care in hospitals and care (lab tests, x-rays, etc.), and primary care, outpatient Immunizations, Prescription Drugs, test and pelvic exam rehabilitative centers; Part B, Doctor visits, Preventive and inpatient services. Transportation, Mental Health and cervical biopsy, Diagnostic doctor and some preventive and major medical care Substance Abuse treatment, maternity mammogram, Colonoscopies, services and outpatient care; (surgery, physical therapy, Pre-Existing Health services Surgical consultation, Breast Part C allows Medicare benefits Durable medical equipment, Conditions Covered ultrasound, Breast biopsy, through private insurance etc.), Mental health and MCHP Premium: Access to health coverage Colposcopy surgery, Adjuvant (Medicare Advantage); Part C substance abuse care, and Coverage through Healthchoice, the Maryland therapy (chemotherapy, includes Parts A, B, and C not Prescription drugs. Managed Care Program. radiation therapy), Home covered by Medicare. Part D health, Pharmacy, Durable covers prescription drugs. Pre-Existing Health WIC: Nutrition education, Breastfeeding Medical Equipment (including Conditions Covered Support, Free healthy food, Referral to prosthesis and bras), Physical Pre-Existing Health Conditions other health and social agencies. therapy, Occupational Covered therapy, Wigs and breast Pre-Existing Health Conditions Covered reconstruction. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE MCHP and MCHP Premium: Must be U.S. Must be a woman, a Maryland Must be U.S. citizen or permanent Must be receiving TAA ”Veteran status” = active citizens or qualified aliens and live in resident, 40–64 years old, or U.S. resident, and: (Trade Adjustment duty in the U.S. military, Maryland. Must be currently uninsured if over 65 must be without Assistance), or naval, or air service and a or not have voluntarily dropped Medicare, or with Medicare 1) If 65 years or older, you or discharge or release from employer-sponsored group health plan Part A only. Must either be your spouse worked for at least Must be 55 years or older active military service under within last 6 months. uninsured or have health 10 years in Medicare-covered and receiving pension other than dishonorable insurance which does employment, or from the Pension Benefit conditions. Even if you are insured, apply and let not cover the screening Guaranty Corporation the case manager determine whether procedures. 2) You have a disability or end- (PBGC). Certain veterans must have your health insurance will affect your Income must be at or below stage renal disease (permanent completed 24 continuous eligibility. 250% FPL. kidney failure requiring dialysis or Must not be enrolled in months of service. transplant) at any age. certain state plans, or MCHP: Must be children ages 0–19, Not eligible for this program in prison, or receiving Eligibility with incomes up to 200%, or pregnant are women on medical 65% COBRA premium women with incomes up to 250% FPL. assistance or enrolled in reduction, or be claimed as a Must not be eligible for Medicaid. Medicare Part B, HMOs or dependent in tax returns. PPOs . MCHP Premium: Must be children ages Must be enrolled in qualified 0–19 with incomes 201% to 300% FPL. health plans where you pay more than 50% of the WIC: Must live in Maryland, be pregnant premiums. or postpartum women, infants, or children up to 5. Income limit of 185% FPL. MCHP: $0 or monthly premium $0 $0 and share of cost for 20% of the insurance $0 and share of cost and Monthly Cost payment depending on family income. certain services; deductibles for premium including COBRA co-pays depending on certain plans. Part A: $0–$450 MCHP Premium: $48–$60 per month based on length of Medicare- premium if employer income level. per family depending on family contributes less than 50%. covered employment; Part B: income. $96.40–$369.10 depending on WIC: $0 to minimal share of cost. annual income; Part C: Based on provider; Part D: Varies in cost and drugs covered.www.CoverageForAll.org Maryland 40
    • Private/Public Demographic Private Health Insurance Programs Individuals Recently Covered by an Individuals & Families Small Businesses (1-50 Employees) Employer Health Plan Above 300% FPL COBRA/Mini-COBRA Individual Plans Group Plans Then convert to a plan under: MA Division of Insurance 617-521-7794 MA Association of Health Commonwealth Connector www.mass.gov/doi Underwriters 508-634-7373 877-623-6765 www.mahealthconnector.org HIPAA MA Association of Health Health Insurance Portability & Underwriters Program www.massahu.org Accountability Act 508-634-7373 MA Division of Insurance 866-487-2365 www.massahu.org 617-521-7794 www.dol.gov www.mass.gov/doi Commonwealth Connector Medical Security Program (MSP) 877-623-6765 www.mahealthconnector.org The Insurance Partnership Premium Assistance and Medical Coverage 800-399-8285, 508-698-2070 800-908-8801 www.mass.gov Employers can purchase health www.insurancepartnership.org plans either directly from the (Search: Medical Security Program) insurance carrier or through the Employers can purchase health plans either directly from the insurance carrier Commonwealth Connector. or through the Commonwealth Connector Employers may choose one or more employer-sponsored plans for their COBRA/Mini-COBRA: Coverage available for 18–36 Commonwealth Choice plans (Gold, eligible full-time employees among several carriers and plans including months depending on qualifying events. Benefits Silver, or Bronze) are lower-cost Health Savings Accounts plans. Employers may also offer non-employer are what you had with your previous employer. private plans available through sponsored plans through the Connector for their part-time and ineligible Commonwealth Connector and employees, and establish a Section 125 plan enabling employees to use HIPAA: Benefits are based on program selected. There directly through different insurance pre-tax dollars to pay health insurance premiums. Each employee can then is no expiration of coverage. carriers. The companies offering the choose among any of the carriers and plans offered through the Connector. MSP: MSP will pay some of the premiums of the plans include Blue Cross Blue Shield Coverage employer-based health plan you are continuing, of Massachusetts, Fallon Community The Insurance Partnership: Offers premium assistance to employers with 50 or Health Plan, Harvard Pilgrim fewer eligible employees. so your benefits will stay the same. If you cannot continue your employer-based health plan or Health Care, Health New England, Pre-Existing Health Conditions Covered have none, you will get the Network Blue Options Neighborhood Health Plan, and Tufts Deductible plan from Blue Cross Blue Shield. The Health Plan. coverage is comprehensive (inpatient and outpatient Young Adults Plans (YAP) are hospital care, doctor visits, etc.) but does not include available to people ages 18–26 and dental benefits. can only be purchased through the Pre-Existing Health Conditions Covered 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 COBRA: Available for employees who work for There is no medical underwriting. employer contributions so long as the premium contribution towards full-time employers with 20 or more employees. You have 60 non-bargaining employees (defined by the state as working 30 hours or more) days from date of termination to sign up for COBRA You are a resident of Massachusetts is not discriminatory. An employer may also establish a Section 125 plan for coverage. or are employed by a Massachusetts- employees who are not eligible for their group plan and allow them to purchase based employer, you are age 18 insurance through the Commonwealth Connector. Mini-COBRA: Available for employees who work for or older, you are not eligible for employers with less than 20 employees. Must sign Commonwealth Care products A full-time employee must work at least 30 hours per week in Massachusetts (even up for Mini-COBRA within 60 days from the later of because family’s income before taxes if they live in another state). Full-time employees do not include: 1) Independent either A) Date of termination of group coverage; or is above 300% FPL. contractors; 2) Seasonal employees; 3) Temporary employees; 4) Workers from B) Date the notice to elect Mini-COBRA coverage is temp agencies (they are the temp agency’s employees). sent. Young Adults Plan (YAP) is available to people ages 18–26. Employers with 11 or more full-time equivalent employees have four requirements: HIPAA: Must have had 18 months of continuous Eligibility 1) Must offer a Section 125 cafeteria plan that meets Commonwealth Connector coverage and completely exhausted COBRA or state regulations. If it’s not offered, employer must pay the Free Rider Surcharge if the continuation coverage. Must not have lost coverage employees or their dependents get medical care that is paid by the state’s Free due to fraud or non-payment of premiums. You have Care Pool (now called the Health Safety Net ) for the uninsured; 2) Must make a 63 days to enroll in a HIPAA-eligible plan. “fair and reasonable” contribution to employees’ health insurance or pay a Fair Share Contribution or fine of up to $295 per employee per year (see below); 3) Must MSP: Must be a Massachusetts resident, receiving complete an Employer Health Insurance Responsibility Disclosure (HIRD) Form/ unemployment benefits, have worked for a Report which must be filed on-line, to report if you offer a Section 125 Plan that Massachusetts employer, and not have access to complies with Commonwealth Connector regulations; 4) Must collect an HIRD health insurance through spouse. Premium assistance: Employee Form from employees who decline your employer-sponsored health Income limit is 400% FPL. Medical coverage: Must earn insurance and/or your employer-sponsored Section 125 Plan. up to 150% FPL. But, if you earn more than 150% FPL, you must submit proof of your high monthly The Insurance Partnership: Company size 2-50 employees or self employed. Employers expenses and a copy of your group health insurance must offer (or plan to offer) comprehensive health insurance to its employees coverage (COBRA) letter from your former employer. and contribute (or be willing to contribute) at least 50% of the cost of the insurance purchased by the employee. Eligible employees must have incomes up to 300% FPL, and be ages of 19 to 64. In the past six months, they must not have been offered health insurance by their current employer or must not have been eligible for health insurance through their spouse’s employer. Employers must make a “fair and reasonable” contribution to employees’ health COBRA/Mini-COBRA: Premiums range from 102%–150% Premiums will depend on the health insurance or pay a Fair Share Contribution or fine of up to $295 per employee per of group health rates. plan and benefit package chosen. A year. co-payment for each service is required. Monthly Cost HIPAA: Premiums will depend on plan chosen. There may be a deductible amount that A “fair and reasonable” contribution by an employer is: (i) 25% of an employer’s the member must pay for before the full-time employees are participating in the employer’s group health plan or (ii) an MSP: Premium assistance: 80% of premium will be health plan begins paying. Deductibles employer’s contribution of at least 33% toward a health plan premium for all full- subsidized, or up to $1,200 per month for a family vary by plan chosen. time employees who are employed more than 90 days. An employer who meets plan and up to $500 per month for an individual either (i) OR (ii) will not be subject to the Fair Share Contribution of up to $295 per plan. employee Medical coverage: $0 monthly premium. Service The Insurance Partnership: Program will pay up to $1,000 a year toward health insurance costs for each qualified employee. The amount depends on the tier of providers are divided into tiers, and the amount of coverage chosen by the employee. co-pays and deductibles vary based on the service providers used.4241 Massachusetts
    • Publicly-Sponsored Programs Demographic Individuals & Families Women Children Seniors MassHealth Breast Cervical Cancer Children’s Medical Medicare Enrollment Center: 888-665-9993, 888-665-9997 TTY Treatment Program 800-633-4227 Customer Service: 800-841-2900, 800-497-4648 TTY Security Plan (CMSP) www.medicare.gov www.ma.gov/masshealth (BCCTP) 888-665-9993 877-414-4447 800-909-2677 Mass Health offers these programs for: 617-624-5992 TTY www.cmspkids.com Medicare (Search: BCCTP) Prescription Drug Families & Children: Unemployed Adults: Women-Infant- Program Program MassHealth Standard, MassHealth Family Assistance, Children’s MassHealth Essential, Medical Security Plan, MassHealth Basic Healthy Start Children (WIC) 800-633-4227 888-665-9993 (Eligibility) 800-942-1007 Medical Security Plan 800-841-2900 (Customer www.mass.gov Service) (Search: WIC) Pregnant Women: Disabled: (Search: Healthy Start) MassHealth Prenatal MassHealth, CommonHealth Healthy Start Both: www.massresources.org Commonwealth Care Pre-Existing Condition 877-623-6765 www.mahealthconnector.org Insurance Plan (PCIP) 866-717-5826 www.PCIP.gov MassHealth members get similar benefits depending for which MassHealth BCCTP: Screening will be done CMSP: Necessary medical, Medicare offers Part A, plan they qualify. There are similar plans with different names for children, through the Women’s Health behavioral-health, dental, inpatient care in hospitals adults, families, pregnant women, undocumented immigrants, the Network. Insurance coverage and pharmacy services, and and rehabilitative centers; disabled and other groups. by MassHealth Standard. only two outpatient surgical Part B, doctor and some Coverage includes cancer procedures. Pre-existing preventive services and CommonWealth Care benefits include your own health care provider; treatment and comprehensive health conditions are outpatient care; Part C allows Preventive care Checkups, Medical care, Prescriptions at your local medical care. You will get your covered. Medicare benefits through Coverage pharmacy, Treatment for alcohol, drug abuse, and mental health benefits through the Primary private insurance (Medicare problems, Vision care, Dental care (available to some members only). Care Clinician (PCC) plan. You WIC: Nutrition education Advantage); Part C includes CommonWealth Care offers four types of plans: Plan Type 1, 2, 3 or 4.  A cannot get benefits through a and services; breastfeeding Parts A, B, and C not covered Plan Type is a list of health benefits and co-payments that are available to managed care MCO plan. promotion and education; by Medicare. Part D covers members based on their incomes. monthly food prescription of prescription drugs. Healthy Start: Offers early, nutritious foods; maternal, PCIP: Covers broad range of benefits, including primary and specialty care, complete prenatal care to prenatal and pediatric health- hospital care, and prescription drugs. In Massachusetts, PCIP offers 3 Pre-Existing Health pregnant women and children. care services. Conditions Covered plans: Standard, Extended and HSA Option. Pre-Existing Health Conditions Pre-Existing Health Pre-Existing Health Conditions Covered Covered Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Note: Those who are self-employed, are seasonal workers and/or have BCCTP: You are under 65 CMSP: Children under 19, Must be U.S. citizen or income not solely from W-2 income sources with regular pay stubs, should not otherwise eligible for of any income, living in permanent U.S. resident, and: contact an enrollment specialist to determine what their gross incomes are MassHealth Standard. You have Massachusetts, unqualified and to determine for what programs they are eligible. been screened for breast or for any other MassHealth 1) If 65 years or older, you or cervical cancer at a Women’s coverage type (except your spouse worked for at MassHealth: You must be a Massachusetts resident and a U.S. citizen or Health Network site and found qualified alien, and one of the following: a parent living with your children MassHealth Limited), least 10 years in Medicare- in need of treatment and . Your uninsured or whose covered employment, or under age 19; an adult caretaker relative living with children under age 19 income is up to 250% FPL. Your to whom you are related by blood, adoption, or marriage, or are a spouse or insurance do not have insurance does not cover the physician and hospital 2) You have a disability or former spouse of one of those relatives, and you are the primary caretaker treatment you need. You meet of these children when neither parent is living in the home; you are under health-care coverage. end-stage renal disease the residency and citizenship (permanent kidney failure age 19, whether or not you live with your family; you are pregnant, with or requirements for MassHealth. without children; or you have been out of work for a long time; or disabled WIC: Must live in requiring dialysis or Eligibility or HIV positive, or you are a woman under 65 with breast cancer or cervical Healthy Start: Must be pregnant, Massachusetts, have transplant) at any age. cancer. be a resident of Massachusetts, a nutritional need as have little or no health determined by WIC staff. CommonWealth Care: Must be at least 19 years old with an income below 300% coverage for pregnancy, be Must be a child under 5, a FPL; must be uninsured and eligible as defined by the Commonwealth ineligible for MassHealth new mother, or a pregnant Connector’s regulations; and must be a U.S. citizen/national or legal alien. (except MassHealth Limited), or breastfeeding woman. You are considered uninsured if you are currently insured under COBRA; are Income must be no greater Income must be at or below paying a full premium for your health insurance in the-non group insurance than 200% FPL. 185% FPL. 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). Note: Massachusetts residents 18 and older are required by the Individual Mandate law PCIP: Must have been uninsured for at least 6 months prior to applying. Must to have health insurance that is deemed by the state to be affordable to them at their prove being a U.S. citizen or legal U.S. resident, a Massachusetts resident, income level or they risk being fiscally penalized on their personal state income taxes. and having problems getting insurance due to a pre-existing condition. 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. MassHealth and CommonWealth Care: Costs vary depending on which program BCCTP: $0 for those earning CMSP: $0-$64 depending on $0 and share of cost for suits you best. The costs of each plan are based on a sliding scale. below 150% FPL. Monthly income. Co-pays are up to $8, certain services; deductibles PCIP: Monthly premiums range from $181 to $778 depending on your age premium required for pharmacy is up to $4. for certain plans. Part A: Monthly Cost and plan chosen. participants earning 150%- WIC: $0 to minimal share $0–$450 based on length 250% FPL. of cost. of Medicare-covered employment; Part B: $96.40– Healthy Start: $0 $369.10 depending on annual income; Part C: Based on provider; Part D: Varies in cost and drugs covered.www.CoverageForAll.org Massachusetts 42
    • Demographic Private Health Insurance Individuals Individuals with Low-Income Small Businesses Recently Covered Individuals Pre-Existing, Individuals & (2-50 Employees) by an Employer & Families Severe, or Chronic Families Health Plan Medical Conditions Group Plans COBRA Individual Plans Blue Cross/ Medicaid and Michigan Association of Health Michigan Association of Health Blue Shield of Healthy Kids Underwriters Then convert to a plan under: Underwriters Michigan (BCBSM) 517-373-3740 www.mahu.org www.mahu.org 888-642-2276 DHS: 855-275-6424 HIPAA www.bcbsm.org www.michigan.gov/mdch Health Insurance Portability & (Click: Health Care Coverage) Accountability Act Health Insurance Program 866-487-2365 www.dol.gov Program for Michigan (HIP) Federal program established by the United States Department of Health and Human Services 877-459-3113 www.hipmichigan.com www.PCIP.gov There is a maximum look- COBRA: Coverage available for Assorted plans depending on BCBSM: Plans vary depending on Ambulance, Dental, Doctor visits, back period of 6 months and 18–36 months depending on medical needs. applicant’s needs. Family planning, Health checkups, maximum exclusion period qualifying events. Benefits Hearing and speech, Home health of 12 months for enrollees are what you had with your There is a 6-month look-back HIP: Covers broad range of care, Hospice, Hospitalization, without prior creditable previous employer. and 12-month exclusionary benefits, including primary and Lab and x-rays, Immunizations, coverage or whose coverage period limit for pre-existing specialty care, hospital care, Medical supplies, Nursing home lapsed for more than 63 days. HIPAA: Benefits are based on conditions. and prescription drugs. care, Medicine, Mental health care, program selected. There is no Personal care services, Prenatal Benefits will vary depending on expiration of coverage. Limits on Pre-Existing Health Pre-Existing Health care, Surgery, Vision, Substance the chosen plan. Conditions May Apply Conditions Covered abuse treatment, Physical therapy. Coverage Pre-Existing Health Pre-Existing Health Pre-Existing Health Conditions Covered Conditions Covered Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size 2–50 employees. COBRA: Available for employees Eligibility is subject to medical BCBSM: Must be Michigan Must be U.S. citizens or qualified who work for businesses underwriting. resident. Cannot be eligible aliens living in Michigan. Participation requirements for with 20 or more employees. for COBRA, or government Income limits: 10 or fewer eligible employees You have 60 days from date If you are denied coverage for a programs (must have is 100%, for 11 to 25 employees of termination to sign up for medical condition, you may be exhausted this option). Pregnant women and infants ages up to 75%, for 26 to 50 COBRA coverage. eligible for BCBSM or HIP. See HMOs in the state must offer 0–1: 185% FPL. employees up to 50%. next column. guarantee issue coverage to HIPAA: Must have had 18 months residents during annual open Children ages 1–18: 150% FPL. An “eligible” employee is a full- of continuous coverage and enrollment periods. Parents/caretakers living with Eligibility time employee who works 30 completely exhausted COBRA children ages 0–18: 64% FPL. or more hours. or state continuation coverage. HIP: Must be a U.S. citizen or Must not have lost coverage lawfully present in the U.S. and Childless adults: 45% FPL. Owner can count as an due to fraud or non-payment of have been uninsured for at least employee. premiums. You have 63 days to 6 months prior to applying. Aged, blind, and disabled: 100% FPL enroll in a HIPAA-eligible plan. Must have had a problem with asset limit of $2,000 for singles Owner name on business getting insurance due to a pre- and $3,000 for couples. license must draw wages from existing condition. Medically-needy: Monthly income the company. limit varies by region, from $341 to $408 for singles, and $458 to $5,41 for couples. Asset limit of $2,000 for singles and $3,000 for couples. Costs depend on employer contribution and ± 45% of the COBRA: Premiums range from 102%–150% of group health Costs for individual coverage vary. BCBSM: Rates are not restricted and will depend on plan $0 or minimal share of cost. Monthly Cost insurance company’s index rate. rates. (BCBSM does community rating). $5 for non-emergency visit in ER. HIPAA: Premiums will depend on plan chosen. HIP: Monthly premiums range from $103.83 to $514.89 depending on age and plan chosen.4443 Michigan
    • Publicly-Sponsored Programs Demographic Children in Trade Dislocated Adults without Moderate Income Women Seniors & Disabled Workers Dependents Families (TAA Recipients) MIChild Breast and Adult Medical Medicare Health Coverage 888-988-6300 www.michigan.gov/mdch Cervical Cancer Control Program 800-633-4227 www.medicare.gov Tax Credit Program (BCCP) Adult Benefits Waiver 866-628-4282 (Listed under “Health Care 800-642-3195 www.irs.gov Coverage” and “Children & 800-922-6266 Teens”) www.michigan.gov/mdch www.michigan.gov/mdch Medicare (Search: HCTC) Contact local Department (Click: Prevention) of Human Services Prescription Drug Healthy Kids Women-Infant-Children Program Program 888-988-6300 800-633-4227 www.michigan.gov/mdch (WIC) 800-262-4784 www.michigan.gov/mdch Medicare/Medicaid (Listed under “Pregnant Women, Children & Families”) Assistance Program 800-803-7174 Plan First! www.mmapinc.org 800-642-3195 www.michigan.gov/mdch (Search: Plan First) MIChild: Regular checkups, BCCP: Clinical breast exams, Pap Offers limited medical Medicare offers Part A, Inpatient and outpatient care (lab shots, Emergency care, Dental, tests, Pelvic exams, and Screening care: Ambulance for inpatient care in hospitals and tests, x-rays, etc.), Doctor visits, Hospital, Pharmacy, Prenatal mammograms. emergencies, Family rehabilitative centers; Part B, Preventive and major medical care and delivery, Vision and planning, Lab and doctor and some preventive care (surgery, physical therapy, hearing, Mental health and WIC: Nutrition education and services; x-ray, Durable medical services and outpatient care; Durable medical equipment, etc.), substance abuse services. breastfeeding promotion and equipment and medical Part C allows Medicare benefits Mental health and substance education; monthly food prescription supplies, Mental health, through private insurance abuse care, and Prescription Healthy Kids: Ambulance, dental, of nutritious foods; access to diagnostic and treatment (Medicare Advantage); Part C drugs. doctor visits, family planning, maternal, prenatal and pediatric services in outpatient includes Parts A, B, and C not health checkups, hearing and health-care services. hospitals, Pharmacy, covered by Medicare. Part D Coverage speech, home health care, Physician and nurse covers prescription drugs. Pre-Existing Health hospice, hospitalization, lab Plan First!: Offers family planning practitioner, Oral- Conditions Covered and x-rays, immunizations, services only. Covers physical exams, maxillofacial surgery, Medicare/Medicaid Assistance medical supplies, nursing home education and counseling, testing for Medical clinic, Substance Program is a counseling service care, medicine, mental health STDs, contraceptives, sterilization, abuse, Urgent care. for seniors and disabled. care, personal care services, medications. Does not cover prenatal care, surgery, vision, abortions or infertility treatments. No inpatient hospital care. Pre-Existing Health substance abuse treatment, Conditions Covered physical therapy. Pre-Existing Health Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE MIChild: Must be Michigan BCCP: Income limit of 250% FPL. Must All: Must be U.S. citizen or Must be receiving TAA (Trade residents and U.S. citizens or be uninsured or underinsured and Must be uninsured permanent U.S. resident, and: Adjustment Assistance), or qualified immigrants. Must be live in Michigan. Breast/cervical Michigan residents, under age 19. Income must be cancer screening and for diagnostic ineligible for Medicaid. 1) If 65 years or older, you or Must be 55 years or older and above 150% but below 200% follow-up of breast/cervical Income limit is 35% FPL. your spouse worked for at least receiving pension from the FPL. Must be uninsured and abnormalities for women ages 10 years in Medicare-covered Pension Benefit Guaranty ineligible for Medicaid. Families 40–64, or for women ages 18–39 who employment, or Corporation (PBGC). who voluntarily drop employer- have been identified with a cervical based comprehensive abnormality through the Family 2) You have a disability or end- Must not be enrolled in certain Eligibility insurance must wait six months Planning program (Title X). stage renal disease (permanent state plans, or in prison, or to enroll. If families drop kidney failure requiring dialysis receiving 65% COBRA premium private insurance, they may Not eligible: Women who are enrolled or transplant) at any age. reduction, or be claimed as a immediately enroll in MIChild. in a managed care program, a dependent in tax returns. health maintenance organization, or Healthy Kids: Must be U.S. citizens Medicare Part B. Must be enrolled in qualified or qualified immigrants and WIC: Must live in Michigan and have a health plans where you pay more Michigan residents. nutritional need determined by WIC than 50% of the premiums. staff. Must be a child under 5, a new Must either be pregnant mom, or a pregnant or breastfeeding Also see BCBSM. women of any age, or children woman. Income limit is 185% FPL. under age 19. Income must be at or below 150% FPL. Plan First!: Must be U.S. citizens or qualified aliens living in Michigan. Must be women ages 19 to 44, not Medicaid-eligible. Income limit is 185% FPL. MIChild: $10 monthly premium BCCP & Plan First!: $0 $0 or small share of cost. All: $0 and share of cost for 20% of the insurance premium Monthly Cost and no co-pays. certain services; deductibles including COBRA premium if for certain plans. Part A: employer contributes less than Healthy Kids: $0 WIC: $0 to minimal share of cost. $0–$450 based on length 50%. of Medicare-covered Pregnant women over 21 years employment; Part B: old pay small co-pays for some $96.40–$369.10 depending on services. annual income; Part C: Based on provider; Part D: Varies in cost and drugs covered.www.CoverageForAll.org Michigan 44
    • Demographic Private Health Insurance Individuals Recently Individuals with Small Businesses Covered by an Individuals Pre-Existing, Low-Income (2-50 Employees) Employer Health & Families Severe, or Chronic Individuals & Families Plan Medical Conditions Group Plans COBRA/Mini-COBRA Individual Plans Minnesota Medical Assistance Minnesota Association of Minnesota Association of Comprehensive (Medicaid) Twin-Cities Metro Area Health Underwriters Then convert to a plan under: Health Underwriters Health Association 651-431-2670 651-917-6253 651-917-6253 www.emahu.org www.emahu.org (MCHA) Outside Twin-Cities Metro Area HIPAA 952-593-9609 800-657-3739 Program Health Insurance Portability & 866-894-8053 www.dhs.state.mn.us Accountability Act www.mchamn.com www.bridgetobenefits.org 866-487-2365 www.dol.gov Pre-Existing Condition Insurance Plan (PCIP) Run by the U.S. Department of Health and Human Services 866-717-5826 www.PCIP.gov Pre-existing conditions can COBRA/Mini-COBRA: Coverage Options vary depending on MCHA: Professional service, Clinic and physician, immunizations, be excluded for a limited time available for 18–36 months applicant needs and plan prescription drugs and pharmacy ambulance, emergency room services depending upon the type of depending on qualifying events. selected. services, mail service, hospital when used for emergency care, group plan you are joining. Benefits are what you had with and ambulance services, inpatient and outpatient hospital care, your previous employer. There is a maximum look- home health care, outpatient, lab, x-ray, family planning, pregnancy There is a maximum 6-month back period of 6 months rehabilitation, mental health related services, nurse midwife, look-back/12-month HIPAA: Benefits are based on and maximum exclusion substance abuse, durable medical medical equipment and supplies, exclusionary period for program selected. There is no period of 18 months for equipment and prosthetics, hearing aids, physical, occupational, pre-existing conditions on expiration of coverage. pre-existing condition for organ and bone marrow speech, respiratory and rehabilitative Coverage enrollees that do not have enrollees with no prior transplant, dental, infertility therapy, transportation, mental health prior creditable coverage or Pre-Existing Health Conditions coverage. services, hospice, reconstructive services, alcohol and drug treatment, whose prior coverage lapsed Covered and restorative surgery, skilled prosthetics, nursing facilities, home for more than 63 days. Elimination riders are not nursing, emergency and more. health services, hospice, and more. permitted. Benefits will vary depending PCIP: Covers broad range of Pre-Existing Health Conditions on the chosen plan. Pre-Existing Health benefits, including primary and Covered Conditions Covered with specialty care, hospital care, and Pre-Existing Health Some Limitations prescription drugs. Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size 2–50 COBRA: Available for employees If you are denied coverage MCHA: You live in Minnesota and Must be U.S. citizens or qualified aliens employees. who work for employers with 20 or for a medical condition, are eligible for Trade Adjustment and live in Minnesota. Income limits more employees. You have 60 days you may be eligible for an Assistance (TAA) or you are for the following: Owner can count as an from date of termination to sign MCHA plan or PCIP. See HIPAA-eligible. Or you have employee. Proprietor-name up for COBRA coverage. next column been a Minnesota resident for Pregnant women: 175% FPL. on license must draw wages. the last 6 months, and are at Children ages 0–1: 280% FPL. Mini-COBRA: Available for employees least 65 years old and ineligible Eligible employees must work who work for employers with less for the Federal Medicare Children ages 2–18: 150% FPL. at least 20 hours a week. than 20 employees. Must elect program. Or, you can prove that coverage within 60 days from date you have been denied health Children ages 19–20: 100% FPL. of termination or date of receiving coverage in the last 6 months Parents & relative caretakers with notice of right to continue due to a pre-existing condition. children under 19: 100% FPL. Eligibility coverage, whichever is later. Or, you can prove you have been treated in the last 3 years for Parents, legal guardians, foster HIPAA: Must have had 18 months special medical “presumptive parents and relative caretakers with of continuous coverage and condition.” children under 21: 275% FPL. completely exhausted COBRA or state continuation coverage. PCIP: Must have been uninsured Adults without children: 75% FPL. Must not have lost coverage for at least 6 months prior to Aged, blind and disabled: 100% FPL. due to fraud or non-payment of applying. Must prove being premiums. You have 63 days to a U.S. citizen or legal U.S. Medically-needy singles: $677 enroll in a HIPAA-eligible plan. resident, a Minnesota resident, monthly income with asset limit and having problems getting of $3,000; couples with monthly insurance due to a pre-existing income of $911 with asset limit of condition. $6,000. Limited assets such as cash, savings, stocks and bonds (except for pregnant women and children). Disabled are allowed to “spend down” for eligibility. Costs depend on employer contribution and ± 25% of the COBRA/Mini-COBRA: Premiums range from 102%–150% of group health Rates are ±25% of the base individual market rate for MCHA: Monthly premiums range from $107.98 to $2,837.82 $0 premiums. $3 co-pay per office visit. $6 per non-emergency visit insurance company’s index rates. health status, ±50% for age depending on your age, gender Monthly Cost in ER. rate. and ±20%for geography. and deductible. HIPAA: Premiums will depend on plan chosen. PCIP: Monthly premiums range from $96 to $414 depending on your age and plan chosen.4645 Minnesota
    • Publicly-Sponsored Programs Demographic Trade Dislocated Lower-Income Women Seniors & Disabled Workers Veterans Individuals (TAA Recipients) Sage MinnesotaCare Medicare Health Coverage VA Medical Screening Program 651-297-3862 Outside Twin-Cities Metro Area 800-633-4227 www.medicare.gov Tax Credit Benefits Package 888-643-2584 866-628-4282 877-222-8387 888-6-HEALTH 800-657-3672 www.irs.gov www.va.gov TTY: 800-627-3529 www.health.state.mn.us www.bridgetobenefits.org Medicare (keyword: HCTC) (Search: Sage) Program Prescription Drug Women-Infant- Program 800-633-4227 Children (WIC) 800-942-4030 State offices: 651-201-4404 or MinnesotaHelp.info 800-657-3942, 800-333-2433 www.health.state.mn.us TTD: 800-627-3529 (Search: WIC) minnesotahelp.info Sage Screening Program: Dental services, doctor Medicare offers Part A, Inpatient and outpatient care Comprehensive preventive and Breast and cervical exams, and health clinic visits for inpatient care in hospitals and (lab tests, x-rays, etc.), Doctor primary care, outpatient and Mammogram screenings, Pap preventive and non-preventive rehabilitative centers; Part B, visits, Preventive and major inpatient services. smears and diagnostic services. care, emergency room visits, doctor and some preventive medical care (surgery, physical inpatient hospital coverage. services and outpatient care; therapy, Durable medical Pre-Existing Health WIC: Nutrition education Part C allows Medicare benefits equipment, etc.), Mental health Conditions Covered and services; breastfeeding Pre-Existing Health Conditions through private insurance and substance abuse care, and promotion and education; Covered (Medicare Advantage); Part C Prescription drugs. monthly food prescription includes Parts A, B, and C not Coverage of nutritious foods; access covered by Medicare. Part D to maternal, prenatal and covers prescription drugs. Pre-Existing Health Conditions pediatric health care services. Covered MinnesotaHelp.info is a Medicare counseling service. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Sage Screening Program: Must be U.S. citizens or qualified Both: Must be U.S. citizen or Must be receiving TAA (Trade ”Veteran status” = active duty Minnesota women with no aliens and live in Minnesota. permanent U.S. resident, and: Adjustment Assistance), or in the U.S. military, naval, or air insurance or whose insurance Must have been uninsured service and a discharge or release does not cover what Sage in the last 4 months unless 1) If 65 years or older, you or Must be 55 years or older and from active military service Screening provides. Income the insurance was Medical your spouse worked for at least receiving pension from the under other than dishonorable limit: 250% FPL. Must be age 40 Assistance or paid for more 10 years in Medicare-covered Pension Benefit Guaranty conditions. or older. than 50% of premium of employment, or Corporation (PBGC). employer-based insurance. Certain veterans must have If younger than 40 and is 2) You have a disability or end- Must not be enrolled in certain completed 24 continuous months determined by a clinician to Income limits for the following: stage renal disease (permanent state plans, or in prison, or of service. be at elevated risk for breast Adults without children: 250% kidney failure requiring dialysis receiving 65% COBRA premium cancer, Sage will cover her FPL. or transplant) at any age. reduction, or be claimed as a Eligibility office visit and mammogram. dependent in tax returns. If further follow-up is needed, Parents of children under 21, the woman could also have pregnant women, and children Must be enrolled in qualified a diagnostic mammogram, under 21: 275% FPL. health plans where you breast ultrasound, or pay more than 50% of the outpatient breast biopsy. premiums. WIC: Must live in Minnesota, Also see MCHA. have a nutritional need as determined by WIC staff, be a child under 5, a new mom, or a pregnant or breastfeeding woman. Income limit of 185% FPL. Sage Screening Program: $0 $4–$179 per person, Medicare: $0 and share of 20% of the insurance $0 and share of cost and depending on income. cost for certain services; premium including COBRA co-pays depending on income WIC: $0 to minimal share of cost. Monthly Cost deductibles for certain plans. premium if employer Part A: $0 - $450 based on level. contributes less than 50%. length of Medicare-covered employment; Part B: $96.40 - $369.10 depending on annual income; Part C: Based on provider; Part D: Varies in cost and drugs covered. MinnesotaHelp.info: $0www.CoverageForAll.org Minnesota 46
    • Demographic Private Health Insurance Small Individuals with Individuals Recently Low-Income Businesses Individuals Pre-Existing, Severe, Covered by an Employer Individuals & (1-50 & Families or Chronic Medical Health Plan Families Employees) Conditions Group Plans COBRA/Mini-COBRA Individual Plans Mississippi Medicaid National Association of National Association of Comprehensive Health 601-359-6050 800-421-2408 Health Underwriters Then convert to a plan under: Health Underwriters Insurance Risk Pool www.medicaid.ms.gov 703-276-0220 703-276-0220 www.nahu.org www.nahu.org Association (MCHIRPA) HIPAA 601-899 9967 Program Health Insurance Portability & 888-820 9400 Accountability Act www.mississippihealthpool.org 866-487-2365 www.dol.gov Pre-Existing Condition Insurance Plan (PCIP) Run by the U.S. Department of Health and Human Services 866-717-5826 www.PCIP.gov There is a maximum look- COBRA: Coverage available for 18–36 months Assorted plans depending MCHIRPA: Includes Hospital Among some of the services: back period of 6 months depending on qualifying events. Benefits on medical needs. services, Physician care, Office visits and family and a maximum exclusion are what you had with your previous Limited mental health care, planning services, Hospital period 12 months for employer. There is a maximum Prescription drugs, and other care, Outpatient services, enrollees with no prior 12-month look-back and services. Benefits for nervous Prescription drugs eyeglasses, creditable coverage or Mini-COBRA: Coverage lasts up to 12 months. exclusionary period limit and mental conditions, Alcohol Home health services, Long whose prior coverage Benefits are what you had with your for pre-existing conditions and drug services (and certain term care services, Inpatient lapsed for more than 63 previous employer. on enrollees with no prior other treatment and services) psychiatric care, Non- Coverage days. coverage. are provided with substantial emergency transportation HIPAA: Benefits are based on program limitations. Prescription coverage services, Chiropractic services, Pre-Existing Health selected. There is no expiration of Elimination riders are does not begin until you have Dialysis services, Dental Conditions Covered coverage. permitted. been enrolled in MCHIRPA for extractions and related 6 months. Lifetime maximum treatment, Durable medical Pre-Existing Health Conditions Covered Pre-Existing Health benefit of $1,000,000. equipment and medical Conditions Covered with supplies, Hospice services. Some Limitations PCIP: Covers broad range of benefits, including primary and Pre-Existing Health specialty care, hospital care, and Conditions Covered prescription drugs. Pre-Existing Health Conditions Covered GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE COBRA: Available for employees who work Eligibility is subject to MCHIRPA: Must be a legal Mississippi Must be a U.S. citizen or Company size 1–50 for businesses with 20 or more employees. medical underwriting. resident under age 65 years old. qualified alien and a resident of employees. You have 60 days from date of termination Must have been turned down Mississippi. to sign up for COBRA coverage. If you are denied coverage for coverage by an insurance Income limits: Owner can count as an for a medical condition, you company in the last 12 months or employee. Mini-COBRA: Available for employees who may be eligible for MCHIRPA diagnosed with a health condition Pregnant women and infants work for businesses with less than 20 or PCIP. See next column that causes insurance companies 0–1: 185% FPL. Owner name on business employees. Must have been covered by to automatically reject you; or license must draw wages group insurance for 3 months continuously you were offered coverage by an Children ages 1–5: 133% FPL. from the company. before date of termination. Ex-employee insurance company, but the policy Children ages 6–18: 100% FPL. must make a written election and pay contained a material underwriting Eligible employees must premium to insurer on or before the date restriction (such as an elimination Aged, blind, and disabled: For work at least 32 hours a of termination of group insurance. In case rider); or offered coverage costing singles, 80% FPL with asset Eligibility week. of death of employee, divorce, or when more than an MCHIRPA policy and limit of $4,000; for couples, dependent child ceases to be eligible for cannot be eligible for or have other, 87% FPL with asset limit of Insurers are required to group coverage, beneficiary who wants similar coverage from a private or $6,000. guarantee issue small Mini-COBRA coverage must sign up for it government health plan (including group plans to the self- within 30 days of receiving notice of right Medicare and Medicaid) in order Parents/caretakers living with employed, except those to continue coverage. to get MCHIRPA coverage. May be children ages 0–18: 44% FPL. covered by, or eligible eligible for MCHIRPA with HIPAA. for a health benefit plan HIPAA: Must have had 18 months of offered by an employer. continuous coverage and completely PCIP: Must have been uninsured for exhausted COBRA or state continuation at least 6 months prior to applying. coverage. Must not have lost coverage due Must prove being a U.S. citizen or . to fraud or non-payment of premiums. You legal U.S. resident, a Mississippi have 63 days to enroll in a HIPAA-eligible resident, and having problems plan. getting insurance due to a pre- existing condition. Costs depend on employer contribution COBRA/Mini-COBRA: Premiums range from 102%–150% of group health rates. Costs for individual coverage vary. There are no MCHIRPA: Montly premiums range from $116-$1024 depending on $0 to $10 co-pays. Monthly Cost and ± 25% of the rate caps. age, gender, plan chosen, and the insurance company’s HIPAA: Premiums will depend on plan experience of the plan. index rate. chosen. PCIP: Monthly premiums range from $146 to $628 depending on your age and plan chosen.4847 Mississippi
    • Publicly-Sponsored Programs Demographic Children in Moderate Income Infants Women Seniors & Disabled Veterans Families Mississippi CHIP First Steps Breast and Cervical Medicare VA Medical Children’s Health Insurance Plan 800-451-3903 Cancer Prevention 800-633-4227 Benefits Package 601-576-7427 (Jackson Area) 601-576-7466 www.medicare.gov 877-222-8387 877-543-7669 www.msdh.state.ms.us 800-721-7222 www.va.gov 601-359-6050 www.msdh.state.ms.us 800-421-2408 (Search: First Steps) (Search: Breast & Cervical Medicare Prescription Program www.medicaid.ms.gov/Chip. Cancer) Drug Program aspx Women-Infant-Children 800-633-4227 (WIC) 601-991-6000 www.msdh.state.ms.us Mississippi (Search: WIC) Seniorxms.org 800-948-3090 www.seniorxms.org Health screenings (including First Steps: Provides family training and Screening and/or diagnostic Medicare offers Part A, Comprehensive preventive vision and hearing exams); counseling, nursing care, Nutritional mammograms annually for inpatient care in hospitals and and primary care, outpatient Preventive health care such counseling and planning, Psychological women 50 years of age and rehabilitative centers; Part B, and inpatient services. as immunizations; Inpatient services in behavior management, older, ultrasound, fine needle doctor and some preventive and outpatient hospital care; Learning and mental health, Physical aspiration of the breast and services and outpatient care; Pre-Existing Health Doctors or clinic visits for therapy to help teach body movement, breast biopsy, colonoscopy Part C allows Medicare benefits Conditions Covered well-child check ups and crawling, walking, Occupational and biopsy, if indicated. through private insurance sick-child care; Lab services; therapy to help teach self-help, playing (Medicare Advantage); Part C Coverage Prescription medications; and eating skills, Speech pathologist Follow-up and referral for includes Parts A, B, and C not Eyeglasses and hearing aids; services to help develop language abnormal Pap exams and/or covered by Medicare. Part D Dental care; and Mental health skills, Transportation assistance to and mammograms. covers prescription drugs. services. from appointments. Mississippi Seniorxms.org offers Pre-Existing Health Conditions WIC: Nutrition education and services; assistance and advice to seniors Covered breastfeeding promotion and in need. education; monthly food prescription of nutritious foods; access to maternal, Pre-Existing Health Conditions prenatal and pediatric health care Covered services. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Must be a Mississippi resident First Steps: Must be a resident of Must be Mississippi women Both: Must be U.S. citizen or ”Veteran status” = active duty and a U.S. citizen or eligible Mississippi and a child 0-3 years who do not have Medicaid, permanent U.S. resident, and: in the U.S. military, naval, or immigrant. old who has a 25% or greater Medicare or other insurance air service and a discharge or developmental delay in any one or method of reimbursement. 1) If 65 years or older, you or release from active military Must be children up to age developmental area. your spouse worked for at least service under other than 19, uninsured, ineligible for Services available depending 10 years in Medicare-covered dishonorable conditions. Medicaid, with family incomes WIC: Must live in Mississippi, have a on age: employment, or up to 200% FPL. nutritional need, and be child 0-5 Certain veterans must have years old, a new mom, or a pregnant or Ages 40–49: Mammograms 2) You have a disability or end- completed 24 continuous Proof of most recent full breastfeeding woman. Income must be while funds are available stage renal disease (permanent months of service. months family income, (such at or below 185% FPL. and only if patients have kidney failure requiring dialysis or as a paycheck stub) must abnormal clinical breast transplant) at any age. accompany the application. exams. Eligibility Ages 40–64: Pap exams. Each adult or child applying must provide his or her Social Ages 50–64: Mammograms. Security number on the Ages 19–39: May be specially application. approved for enrollment in the BCCP at the discretion of the program director if patient meets all other program criteria other than the age category, has an abnormality of the breast and/or cervix. $0 premiums or deductibles, First Steps & WIC: $0 or minimal share $0 or minimal share of cost. Both: $0 and share of cost for $0 and share of cost and co- although there may be a small certain services; deductibles for Monthly Cost of cost. pays depending on income co-payment for some services certain plans. Part A: $0–$450 for higher-income families based on length of Medicare- level. on CHIP. covered employment; Part B: $96.40–$369.10 depending on annual income; Part C: Based on provider; Part D: Varies in cost and drugs covered.www.CoverageForAll.org Mississippi 48
    • Demographic Private Health Insurance Individuals with Individuals Recently Low-Income Small Businesses Individuals Pre-Existing, Covered by an Employer Individuals & (2-50 Employees) & Families Severe, or Chronic Health Plan Families Medical Conditions Group Plans COBRA/Mini-COBRA Individual Plans Missouri Health MO Healthnet National Association of Health National Association of Insurance Pool (Medicaid) 888-275-5908 Then convert to a plan under: Underwriters Health Underwriters (MHIP) 573-731-3425 703-276-0220 703-276-0220 800-821-2231 www.dss.mo.gov/mhd HIPAA Program www.nahu.org www.nahu.org www.mhip.org Health Insurance Portability & Accountability Act 866-487-2365 Pre-Existing www.dol.gov Condition Insurance Plan (PCIP) HIPP Federal program run by MHIP Health Insurance Premium Payment 800-821-2231 573-751-2005 www.mhip.org www.dss.mo.gov www.PCIP.gov (Search: HIPP) Pre-existing conditions can COBRA: Coverage available for 18–36 Covers certain state MHIP & PCIP: Hospital, physician Inpatient and outpatient be excluded for a limited time months depending on qualifying mandated services. care, maternity, prescription hospital care, Laboratory and depending upon the type of events. Benefits are what you had with drugs, some limitations on x-rays, Physician’s services, group plan you are joining. your previous employer. If beneficiary There is a maximum alcohol and drug abuse care. Emergency ambulance, is 55 years or older, then beneficiary 12-month look-back period For most services, plan will pay Audiology, Podiatry, Benefits will vary depending can continue COBRA until he or she and a maximum 24-month for 80% of covered charges Ambulatory surgical services, on the chosen plan. is eligible for other group health exclusionary period for after you satisfy your annual Durable medical equipment, insurance or Medicare. pre-existing conditions deductible if you receive care in- Prosthetics and orthotics, There is a maximum 6-month on enrollees with no prior network. After paying maximum Vision care, Family planning, look-back and a maximum Mini-COBRA: Coverage available for 18–36 coverage. amount of coinsurance charges Rehabilitative services and months depending on qualifying Coverage 12-month exclusion period for covered in-network services, therapies, Midwife services, for pre-existing conditions events. Benefits are what you had with Coverage options vary MHIP will pay 100% of your Federally qualified health on enrollees that do not have your previous employer. by carrier, but most covered charges for the rest of centers or rural health clinics, prior creditable coverage or HIPAA: Benefits are based on program offer plans that are HSA the calendar year. Psychiatry, Transplants, whose coverage had a break of selected. There is no expiration of (Health Savings Account) Home and community based more than 63 days. coverage. compatible. Pre-Existing Health Conditions services, Waivers to person 65 Covered and older, Persons with AIDS, Pre-Existing Health Conditions HIPP: Benefits are the same as what you Pre-Existing Health or developmentally disabled Covered had with your previous employer. HIPP Conditions Covered individuals, Early and periodic is a premium assistance program. with Some Limitations screening, diagnosis and treatment (EPSDT) for children Pre-Existing Health Conditions Covered under 21 years old. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size 2–50 employees. COBRA: Available for employees who Eligibility is based on MHIP: Must be a Missouri Must be U.S. citizen or an work for businesses with 20 or more medical underwriting. resident with a qualifying health eligible qualified non-citizen Owner can count as an employees. You have 60 days from date condition and show proof of one living in Missouri. employee. of termination to sign up for COBRA Must be resident of state or of the following: 1) Rejection for coverage. Income limits: documented immigrant. health coverage by an insurers Proprietor-name on license Mini-COBRA: Available for employees for pre-existing condition; 2) Infants ages 0–1: 185% FPL. must draw wages. who work for employers with less than If you are denied coverage Offer of coverage similar to for a medical condition, you but at rates higher than MHIP’s Children ages 1–5: 133% FPL. 20 employees. Must elect coverage Small group health plans are within 31 days of termination of group may be eligible for MHIP or coverage; 3) Involuntary loss Children ages 6 –18: 100% FPL. typically required to treat all of insurance. PCIP. See next column. of coverage for a reason other eligible employees (generally than non-payment of premium Parents/caretakers living with employees who work at least HIPAA: Must have had 18 months of or fraud; 4) Being a dependent children ages 0–18: 25% FPL. Eligibility 30 hours a week) equally and continuous coverage and completely of a person eligible for MHIP; may not discriminate against exhausted COBRA or state continuation 4) Eligibilty for HIPAA or Trade Pregnant women: 185% FPL. those who are ill or become ill. coverage. Must not have lost coverage Adjustment Assistance. Aged, blind, and disabled: 85% due to fraud or non-payment of FPL with asset limit of $1,000 for premiums. You have 63 days to enroll in PCIP: Must be a Missouri resident, singles and $2,000 for couples. a HIPAA-eligible plan. be uninsured for at least six months, and show proof of the Limited assets such as cash, HIPP: Enrollee or least one family following: 1) Lawful presence in savings, stocks and bonds. member of enrollee is eligible for the United States; 2) Having a or enrolled in MO HealthNet, and is pre-existing health condition. employed or eligible for COBRA, and the employer or ex-employer offers group insurance. Costs depend on employer contribution and ± 25% of the COBRA/Mini-COBRA: Premiums range from 102%–150% of group health rates. Various price ranges depending on deductible MHIP: Monthly premiums range from $144 to $4,208 depending $0 or minimal share of cost. Monthly Cost insurance company’s index and what plan you buy. on age, gender, and plan rate. HIPAA: Premiums will depend on plan There are no rate caps . chosen. chosen. PCIP: Monthly premiums range HIPP: $0 or minimal share of cost. from $150 to $548 depending on your age and plan chosen.5049 Missouri
    • Publicly-Sponsored Programs Demographic Children with Pregnant Women Women Seniors & Disabled Veterans Special Needs & Children Children and MO HealthNet for Show Me Medicare VA Medical Youth with Special Kids (MHK) Healthy Women 800-633-4227 www.medicare.gov Benefits Package Health Care Needs 888-275-5908 www.dss.mo.gov 573-522-2845 www.dhss.mo.gov 877-222-8387 www.va.gov Program (CYSHCN) (Search: MHK) Medicare Prescription Program (Seach: Show Me Healthy Women) 573-751-6246 800-451-0669 Drug Program health.mo.gov Women-Infant- WISEWoman 800-633-4227 (Search: Children Special Children (WIC) 573-522-2845 Health Care Needs) 573-751-6204 www.dhss.mo.gov/WISEWOMAN 800-392-8209 MO Senior Rx www.dhss.mo.gov/wic 800-375-1406 www.morx.mo.gov Limited coverage includes MHK: Comprehensive care Show Me Healthy Women: Offers Medicare offers Part A, inpatient Comprehensive preventive Tests and evaluations, including but not limited to screenings for breast and cervical care in hospitals and rehabilitative and primary care, Inpatient care, Surgery, doctor visits, mental, dental, cancer. Pelvic exams, Pap tests, centers; Part B, doctor and some outpatient and inpatient Therapy (physical, prescriptions, hospitalization clinical breast examinations (CBE), preventive services and outpatient services. occupational, speech, and more. diagnostic breast and cervical exams, care; Part C allows Medicare benefits language), Prescription and mammograms. through private insurance (Medicare Pre-Existing Health medicines, Equipment, WIC: Nutrition education Advantage); Part C includes Parts A, Conditions Covered and supplies. Covered and services, breastfeeding WISEWoman: Offers health screenings B, and C not covered by Medicare. conditions include but promotion and education, and lifestyle education that can Part D covers prescription drugs. are not limited to arthritis, monthly food prescription of reduce the risk of heart disease and Coverage Burns, Cerebral palsy, Cleft nutritious foods, and access stroke. Senior Rx is a prescription discount lip and palate, Cystic fibrosis, to maternal, prenatal and program. Digestive disorders, Ear pediatric health-care services. Pre-Existing Health Conditions infections (chronic), Hearing Covered Pre-Existing Health Conditions disorders, Heart disorders, Pre-Existing Health Conditions Covered Hemophilia, Hydrocephalus, Covered Neuromuscular disorders, Orthopedic disorders, Paraplegia, Quadriplegia, Seizures, Sickle cell disease, Spina bifida, Spinal cord deformities, Traumatic brain injury, Urinary disorders. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE CYSHCN is payer of last MHK: Must be a U.S. citizen or an Show Me Healthy Women: Must be U.S. Medicare: Must be U.S. citizen or ”Veteran status” = active resort. The program‘s service eligible qualified non-citizen citizens or legal permanent residents permanent U.S. resident, and: duty in the U.S. military, coordinator will assist the living in Missouri. Income and live in Missouri. Income limit of naval, or air service and participant/family with limits: 200% FPL. 1) If 65 years or older, you or your a discharge or release resource identification Infants age 0–1: 185% FPL. Must be women ages 50–64, or older spouse worked for at least 10 years from active military and referral. All third party without Medicare Part B. Women in Medicare-covered employment, service under other than liability must be exhausted Children ages 1–5: 133% FPL. ages 35–49 are eligible for pelvic or dishonorable conditions. prior to accessing CYSHCN exams, Pap tests, clinical breast funds. Children ages 6–18: 100% FPL. 2) You have a disability or end- Certain veterans must have examinations (CBE), diagnostic breast Children ages 0–18 with no services if CBE results are suspicious stage renal disease (permanent completed 24 continuous Must be age 0–21, and reside prior health insurance in the for cancer, and diagnostic cervical kidney failure requiring dialysis or months of service. in Missouri, with income limit transplant) at any age. Eligibility last 6 months: 300 % FPL. services if their initial/follow-up Pap of 185% FPL and a eligible test was abnormal. Women ages 50 special health care need. WIC: Pregnant women, non- and older get all benefits above plus Senior Rx: To qualify for Senior RX breastfeeding postpartum mammograms. you must have Medicare Part D. If women (up to 6 months after you are single your income must be delivery or termination of the Cervical cancer screenings are at or below $21,660 and if you are a pregnancy), breastfeeding offered to women who have had a married your income must be below women (up to 1 year after hysterectomies. $29,140. delivery as long as they are breastfeeding the baby), Treatment is available for U.S. citizens children age 0 to 5, and diagnosed with cancer through the individually determined to be Show Me Healthy Women program. at “nutritional risk” by a health Women with MO HealthNet, professional. Income must be Medicare Part B or HMO health at or below 185% FPL and live coverage are not eligible. in Missouri. WISEWoman: Must participate in the Show Me Healthy Women breast and cervical cancer control project and be 35–64 years old. $0 or share of cost. MHK: No cost if family income is up to 150% FPL, but if above Both: $0 Medicare:$0 and share of cost for $0 and share of cost and certain services; deductibles for co-pays depending on Monthly Cost 150% FPL, required monthly certain plans. Part A: $0–$450 based premium will be less than on length of Medicare-covered income level. 5% of their annual income. If employment; Part B: $96.40–$369.10 out-of-pocket expenses reach depending on annual income; Part the 5% limit, then no premiums C: Based on provider; Part D: Varies required. in cost and drugs covered. WIC: $0 or minimal share of Senior Rx: $0 cost.www.CoverageForAll.org Missouri 50
    • Demographic Private Health Insurance Individuals Recently Individuals with Already Insured Small Businesses Covered by an Individuals Pre-Existing, Severe, Small Businesses (2-50 Employees) Employer Health & Families or Chronic Medical (2-9 Employees) Plan Conditions Group Plans Insure Montana COBRA Individual Plans Montana National Association of Health Purchasing Pool and National Association of Comprehensive Health Underwriters Tax Credit Program Then convert to a plan under: Health Underwriters Association (MCHA) 703-276-0220 State Auditor’s Office 703-276-0220 800-447-7828 www.nahu.org www.nahu.org 800-332-6148 406-444-2040 HIPAA www.mthealth.org Health Insurance Portability & Insure Montana Program www.sao.mt.gov/ InsureMontana/index.asp Accountability Act State Auditor’s Montana Affordable Purchasing Pool 866-487-2365 Office State Auditor’s Office www.dol.gov 800-332-6148 Care Plan (MACP) 800-332-6148 406-444-2040 Federal program run by MCHA 406-444-2040 sao.mt.gov 800-447-7828 www.sao.mt.gov/ www.mthealth.org InsureMontana/index.asp www.PCIP.gov NOTE: In Helena, add extension 2128 to the 800 number. There is a maximum look-back 1) Employers receive COBRA: Coverage available for Assorted plans depending on MCHA: Comprehensive plans to period of 6 months and a subsidies that pay a portion 18–36 months depending on medical needs. choose from, the primary difference maximum exclusion period of an employee’s health qualifying events. Benefits are is the annual deductible. Lifetime of 12 months for pre-existing insurance cost. The net of what you had with your previous Elimination riders are maximum of $2,000,000. Waiting conditions on enrollees with employer payment is 25% employer. permitted. periods for certain pre-existing no prior coverage or whose of the employee’s premium. conditions may apply. prior coverage had a break of Employees will get discounts HIPAA: Benefits are based on There is a maximum more than 63 days. of 20%-90% on their premiums program selected. There is no 36-month look-back and MACP: Covers broad range of depending on family annual expiration of coverage. a maximum 12-month benefits, including primary and Coverage Pre-Existing Health Conditions income. exclusionary period limit specialty care, hospital care, and Covered Pre-Existing Health Conditions for pre-existing conditions prescription drugs. 2) Employers get refundable Covered on enrollees with no prior tax credit when they pay some coverage. or all the cost of the group Pre-Existing Health Conditions health insurance plan of their Pre-Existing Health Covered employees and their spouse or Conditions Covered with dependents. Some Limitations Business will be enrolled on a first-come first-serve basis. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size 2–50 employees. Employers with or without COBRA: Available for employees who Eligibility is subject to medical MCHA: Must have lived in Montana for Owner can count as an group health insurance work for businesses with 20 or more underwriting. at least 30 days, cannot be eligible employee. Owner name on for employees. Must offer employees. You have 60 days from for COBRA or any other government business license must draw coverage to all employees date of termination to sign up for If you are denied coverage for programs (except “endstage renal wages from the company. working at least 30 hours COBRA coverage. a medical condition, you may disease” covered under Medicare), per week. May also count be eligible for MCHA or MACP. must prove denial of coverage by 2 “Eligible employee” means an employees working at least HIPAA: Must have had 18 months See next column insurance companies due to qualified employee who works at least 20 hours per week as long this of continuous coverage and pre-existing conditions or proof of 30 hours a week, or at the criterion is applied uniformly completely exhausted COBRA or offer paying 150% higher premium discretion of employer, one on all of the employees. Have state continuation coverage. Must than MCHA. Trade Adjust Assistance Eligibility who works 20–40 hours as 2–9 employees that meet the not have lost coverage due to fraud (TAA) beneficiaries have same long as this eligibility criteria is eligibility criteria established by or non-payment of premiums. You requirements but must have at applied uniformly among all of the State Auditor. All employees have 63 days to enroll in a HIPAA- least 3 months prior coverage, else the employer’s employees. must be paid less than $75,000 eligible plan. a 12-month pre-existing waiting per year (owner excluded). period may apply. HIPAA-eligibles also qualified. Employers who belong to a Multi Employer Welfare Arrangement MACP: Must be a U.S. citizen or (MEWA) are not eligible. lawfully present in the U.S. and have been uninsured for at least 6 The tax credit cannot be more months prior to applying. Must be a than 50% of premiums paid. Montana resident. Must have had a problem getting insurance due to a pre-existing condition. Costs depend on employer Costs depend on employer COBRA: Premiums range from Costs for individual coverage MCHA: Premiums vary based on plans contribution and ±25% of the contribution. 102%–150% of group health rates. vary. There are no rate caps. chosen. Plans have deductibles of insurance company’s index $1K–$10K, 70/30 co-payments, with Monthly Cost rate. HIPAA: Premiums will depend on annual maximum member liability plan chosen. of $5K–$15K. MACP: Monthly premiums range from $171 to $681 depending on your age and plan chosen.5251 Montana
    • Publicly-Sponsored Programs Demographic Low-Income Trade Dislocated Children in Moderate Individuals Women Seniors & Disabled Workers Income Families & Families (TAA Recipients) Medicaid Healthy Montana Kids Montana Cancer Medicare Health Coverage 800-362-8312 www.dphhs.mt.gov (HMK) Screening (Age 65 and up) 800-633-4227 Tax Credit (Search: Medicaid) 877-543-7669 406-444-6971 Program (MCSP) www.medicare.gov 866-628-4282 www.irs.gov 888-803-9343 hmk.mt.gov 406-444-0063 (Search: HCTC) www.dphhs.mt.gov Medicare Prescription Women-Infant-Children Program (Search: Cancer Screening) Drug Program (WIC) 800-633-4227 800-433-4298 406-444-5533 wic.mt.gov State Health Insurance Assistance Program (SHIP) 800-551-3191 www.dphhs.mt.gov (Search: SHIP) Among the services the HMK: Physician, Inpatient and Mammograms, clinical Medicare offers Part A, inpatient Inpatient and outpatient care Montana program may cover: outpatient hospital services, Routine breast exams, Pap tests care in hospitals and rehabilitative (lab tests, x-rays, etc.), Doctor Treatment by physicians, sports or employment physicals, and pelvic exams for the centers; Part B, doctor and some visits, Preventive and major Nurse practitioners, Nurse General anesthesia services, Surgical early detection of breast preventive services and outpatient medical care (surgery, physical midwives, Dentists, Denturists, services clinic and ambulatory and cervical cancer. care; Part C allows Medicare benefits therapy, Durable medical Podiatrists, Lab services and health care services, Prescriptions, through private insurance (Medicare equipment, etc.), Mental x-rays, Inpatient hospital visits, Laboratory and radiological services, Advantage); Part C includes Parts A, health and substance abuse Outpatient hospital visits, Inpatient, outpatient, and residential B, and C not covered by Medicare. care, and Prescription drugs. Family planning, Nursing mental health and substance abuse Part D covers prescription drugs. Coverage facilities, Home health care, services, Dental, Vision exams, Pre-Existing Health Conditions Durable medical equipment; Eyeglasses, Hearing exams. SHIP is a Medicare counseling Covered Outpatient drugs, Mental service. health, Ambulance, and WIC: Nutrition education and services, Eyeglasses. breastfeeding promotion and Pre-Existing Health Conditions education, monthly food prescription Covered Pre-Existing Health Conditions of nutritious foods, and access to Covered maternal, prenatal and pediatric health-care services. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE Must be a Montana resident HMK: Must be U.S. citizen or legal Both: Must be U.S. citizen or Must be receiving TAA (Trade and U.S. citizen or qualified qualified alien and resident of Must be a Montana permanent U.S. resident, and: Adjustment Assistance), or legal alien. Montana. Must be children under resident, uninsured or age 19. Must not be eligible for underinsured. Income 1) If 65 years or older, you or your Must be 55 years or older and Income limits: must be at or below 200% Medicaid, or currently insured, or spouse worked for at least 10 years receiving pension from the Pregnant women: 150% FPL covered by health insurance in the FPL. in Medicare-covered employment, Pension Benefit Guaranty with asset limit of $3,000. past 3 months (some employment- Women 50–64 years old, or Corporation (PBGC). related exceptions apply). Parents or 65 and older that do Children under age 19: 133% must not employed by the state of 2) You have a disability or end- Must not be enrolled in certain FPL. not have Medicare part Montana. Income limit of 250% FPL. B, are eligible for breast stage renal disease (permanent state plans, or in prison, Eligibility Parents/caretakers living with cancer screening. Women kidney failure requiring dialysis or or receiving 65% COBRA children ages 0–18: 56% FPL WIC: Must be a Montana resident, and ages 40–49 are eligible transplant) at any age. premium reduction, or be a pregnant woman, a breastfeeding also if funds are available. claimed as a dependent in tax Aged, blind, and disabled: 75% woman, or a woman who recently had returns. FPL with asset limit of $2,000 a baby, or child 0–5 years old. Must be Women age 39 and for singles; 83% FPL of with determined by a health professional younger can be eligible Must be enrolled in qualified asset limit of $3,000 for couples to be at nutritional or medical risk. if referred by a surgeon health plans where you Income must be at or below 185% FPL or consulting breast pay more than 50% of the Medically-needy: $625 per specialist. premiums. month, with asset limit of $2,000 for singles and $3,000 Women ages 30–64 are for couples. eligible for cervical cancer screening. $0–$5 for some co-pays HMK: $0 to low cost. Maximum co- $0 or minimal share of Medicare: $0 and share of cost for 20% of the insurance Prescription drugs: $25 payment is $215 per year. cost. certain services; deductibles for premium including COBRA maximum per month. $100 per certain plans. Part A: $0–$450 based premium if employer Monthly Cost admission in hospital except in on length of Medicare-covered mental institutions WIC: $0 or minimal share of cost. employment; Part B: $96.40–$369.10 contributes less than 50%. depending on annual income; Part C: Based on provider; Part D: Varies in cost and drugs covered. SHIP: $0 Montanawww.CoverageForAll.org 52
    • Demographic Private Health Insurance Small Individuals with Individuals Recently Low-Income Businesses Individuals Pre-Existing, Covered by an Employer Families & (2-50 & Families Severe, or Chronic Health Plan Medically-Needy Employees) Medical Conditions Group Plans COBRA/Mini-COBRA Individual Plans Nebraska Medicaid Nebraska Association Then convert to a plan under: Nebraska Association Comprehensive 402-471-3121 877-255-3092 of Health Underwriters of Health Underwriters Health Insurance TTD: 402-471-9570 402-397-0280 402-397-0280 www.neahu.org HIPAA www.neahu.org Pool (NECHIP) www.hhs.state.ne.us Health Insurance Portability & Accountability 402-343-3574 (Search: Medicaid) Program Act 877-348-4304 866-487-2365 www.nechip.com www.dol.gov Pre-Existing Nebraska Medical Assistance Condition Insurance Program (NMAP) Plan (PCIP) (Similar to HIPP) Run by U.S. Department of Premium Payment 800-383-4278 Health and Human Services www.dhhs.ne.gov/reg/t471.htm 866-717-5826 (Chapter 30 Payment for Health Insurance www.PCIP.gov Premiums) There is a maximum COBRA: Coverage available for 18–36 months There is no limit to the NECHIP: Hospital room and board, Hospital, Physician, Laboratory 6-month look-back and depending on qualifying events. Benefits are look-back and exclusionary Physician services, Office visits, and x-ray, Nurse midwife and a maximum 12-month what you had with your previous employer. periods for pre-existing Therapies (physical, speech, practitioner services, Clinic exclusionary period for conditions on enrollees occupational, home infusion), services and family planning, pre-existing conditions on Mini-COBRA: Coverage available for 6–12 with no prior coverage. Anesthetics, X-ray and lab, Home health agency and enrollees that do not have months depending on qualifying events. Mammograms, Ambulance personal care aide, Medical prior creditable coverage. Benefits are what you had with your previous Pre-Existing Health services, Nursing, Cardiac and transportation, Ambulance, employer. Conditions Covered with pulmonary rehab, Medical and chiropractic, Durable Pre-Existing Health Some Limitations equipment, Renal dialysis, medical equipment, Orthotics, Conditions Covered HIPAA: Benefits are based on program Hospice, Home health, Prosthetics, and medical Coverage selected. There is no expiration of coverage. Mental health and substance supplies, Prescription drugs and abuse, Surgery, Prescription hearing aid services, Therapies NMAP: Benefits are the same as what you drugs, and more. There are 8 (physical, occupational, had with your previous employer. HIPP is a different deductible options to speech pathology, audiology) premium assistance program. choose from. Waiting period and podiatry, Adult day may apply. treatment, Mental health and Pre-Existing Health Conditions Covered substance abuse, Vision and PCIP: Covers broad range of dental, Preventive care (e.g. benefits, including primary and mammograms). specialty care, hospital care, and prescription drugs. Pre-Existing Health Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE COVERAGE COBRA: Available for employees who work for Eligibility is subject to NECHIP: Must be a legal Nebraska Must be a Nebraska resident Company size 2–50 businesses with 20 or more employees. You medical underwriting. resident for at least 6 months and U.S. citizen or legal employees. have 60 days from date of termination to sign prior to application, uninsured qualified alien. up for COBRA coverage. If you are denied coverage or ineligible for Medicaid or Income limits: Owner can count as an for a medical condition, you Medicare and exhausted COBRA employee; proprietor Mini-COBRA: Available for employees who work may be eligible for NECHIP continuation. Previous coverage Pregnant woman and infants name on license must for employers with less than 20 employees. or PCIP. See next column. terminated for reasons other 0-1: 185% FPL. draw wages. Ex-employee must elect Mini-COBRA within than non-payment of premium 10 days after date of receiving notice of right or fraud, or within last 6 months Children ages 1-5: 133% FPL. Eligible employees must to continue coverage. In case of employee’s was rejected for coverage due Children ages 6–18: 100% FPL. Eligibility work at least 30 hours a death, the surviving covered spouse and to pre-existing conditions, or week. dependent children must elect Mini-COBRA offered coverage with restricted Aged, blind, and disabled: For within 31 days after date of employee’s death. benefits or premiums higher singles, 74% FPL with asset limit than NECHIP’s. You have a of $2,000; for couples not on HIPAA: Must have had 18 months of continuous qualified pre-existing condition. SSI, 82% FPL with asset limit of coverage and completely exhausted COBRA Those eligible for HIPAA plans or $3,000. or state continuation coverage. Must not have Trade Adjustment Assistance are lost coverage due to fraud or non-payment also qualified. Parents/caretakers living with of premiums. You have 63 days to enroll in a children ages 0–18: 58% FPL. HIPAA-eligible plan. PCIP: Must have been uninsured Medically-needy: Singles and for at least 6 months prior to couples earning $392 a month, NMAP: You may be eligible for HIPP if you have applying. Must prove being a with asset limit of $4,000 for a high-cost health condition (e.g., pregnancy, U.S. citizen or legal U.S. resident, singles and $6,000 for couples. HIV/AIDS), and are on Medicaid. a Nebraska resident, and having problems getting insurance due to a pre-existing condition. Costs depend on COBRA/Mini-COBRA: Premiums range from 102%–150% of group health rates. Costs depend on age and NECHIP: Monthly premiums $1–$3 co-pays and may employer contribution county/zone. range from $131.65 to $2,956.98 share in some costs. and ± 25% of the depending on age, gender, Monthly Cost HIPAA: Premiums will depend on plan chosen. insurance company’s If you are self-employed tobacco use, and deductible. index rate. NMAP: $0 or minimal share of cost. and buy your own insurance you are eligible PCIP: Monthly premiums range to deduct 100% of the cost from $132 to $568 depending of the premium from your on your age and plan chosen. federal income tax.5453 Nebraska
    • Publicly-Sponsored Programs Demographic Native Trade Dislocated Low-Income Cancer Screening American Seniors & Disabled Workers Children for Men & Women Indians (TAA Recipients) Kids Connection Every Woman Indian Health Medicare Health Coverage Program (KCP) Matters (EWM) Services 800-633-4227 www.medicare.gov Tax Credit (S-CHIP) www.hhs.state.ne.us/hew/ 605-226-7582 866-628-HCTC 402-323-7455 (Lincoln) owh/ewm www.ihs.gov 866-628-4282 800-383-4278 (Search: Aberdeen) Medicare www.irs.gov (keyword: HCTC) www.hhs.state.ne.us/med/ Nebraska Colon Prescription Drug Program kidsconx.htm Cancer Screening Program Women-Infant- Program (NCCSP) 800-633-4227 www.hhs.state.ne.us/CRC Children (WIC) 800-942-1171 402-471-2781 For both: 800-532-2227 www.dhhs.ne.gov/wic 402-471-0929 TTD: 800-833-7352 KCP: Hospital services, Physician EWM: Breast exams, The Aberdeen Area Office in Offers Part A, inpatient care Inpatient and outpatient care (lab services, Laboratory and x-ray, Mammograms, Pap test every Aberdeen, South Dakota, works in hospitals and rehabilitative tests, x-rays, etc.), Doctor visits, Family planning, Health checks, 2 years, Pelvic exams, various together with its 13 Service centers; Part B, doctor and Preventive and major medical care Home health agency, Medical checkups. Units to provide health care to some preventive services and (surgery, physical therapy, Durable transportation, Ambulance, approximately 94,000 Indians outpatient care; Part C allows medical equipment, etc.), Mental Chiropractic, Dental, Durable NCCSP: Fecal occult blood on reservations located in Medicare benefits through health and substance abuse care, medical equipment, Orthotics, test (FOBT) kits for at home North Dakota, South Dakota, private insurance (Medicare and Prescription drugs. Prosthetics and medical supplies, testing, colonoscopies, and Nebraska, and Iowa. The Advantage); Part C includes Prescribed drugs, Hearing aids, education about healthy Service Units include nine Parts A, B, and C not covered Pre-Existing Health Conditions Therapy (physical, occupational, living. hospitals, eight health centers, by Medicare. Part D covers Covered Coverage speech, pathology, and two school health stations, and prescription drugs. audiology), Podiatry, Mental several smaller health stations health and substance abuse, and and satellite clinics. Pre-Existing Health Conditions Vision. Covered Pre-Existing Health Conditions WIC: Nutrition education Covered and services, breastfeeding promotion and education, monthly food prescription of nutritious foods, and maternal, prenatal and pediatric health- care services. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE KCP: Must be a Nebraska resident Both: Must be a Nebraska Must exhaust all private, state, Must be U.S. citizen or Must be receiving TAA (Trade under 19 years of age or be a resident and U.S. citizen or a and other federal programs. permanent U.S. resident, and: Adjustment Assistance), or primary care giver with a child qualified alien. Income limit of under the age of 19, and a U.S. 225% FPL. Must be regarded by the local 1) If 65 years or older, you or Must be 55 years or older and citizen or legal alien and with community as an Indian; is a your spouse worked for at least receiving pension from the Pension household income of 200% FPL. EWM: Must be ages 40–74. member of an Indian or Group 10 years in Medicare-covered Benefit Guaranty Corporation Must not be covered by health Must not belong to an HMO under Federal supervision; employment, or (PBGC). insurance (including Medicaid). (Health Maintenance resides on tax-exempt land Organization), or have or owns restricted property; 2) You have a disability or end- Must not be enrolled in certain WIC: Must reside in Nebraska. Medicaid or Medicare. actively participates in tribal stage renal disease (permanent state plans, or in prison, or Eligibility Must either be a pregnant affairs; any other reasonable kidney failure requiring dialysis receiving 65% COBRA premium woman, a breastfeeding woman, NCCSP: Men and women who factor indicative of Indian or transplant) at any age. reduction, or be claimed as a a woman who recently had a are at least 50 years old. descent; is a non-Indian woman dependent in tax returns. baby, or a child up to age 5 years. pregnant with an eligible Must be determined by a health Indian’s child for the duration Must be enrolled in qualified health professional to be at nutritional of her pregnancy through plans where you pay more than or medical risk. Income limit is post-partum (usually 6 weeks); 50% of the premiums. 185% FPL. is a non-Indian member of an eligible Indian’s household and Also see NECHIP. 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. KCP: $0 for most members. EWM: $0 $0 or minimal share of cost. $0 and share of cost for 20% of the insurance premium Suggested donation of $5 certain services; deductibles for including COBRA premium if for patients earning 100% to Monthly Cost certain plans. Part A: $0–$450 employer contributes less than WIC: $0 to minimal share of cost. 225% FPL. based on length of Medicare- 50%. NCCSP: $0 to minimal share covered employment; Part B: of cost. Colonoscopy requires $96.40–$369.10 depending on 10% co-payment. annual income; Part C: Based on provider; Part D: Varies in cost and drugs covered.www.CoverageForAll.org Nebraska 54
    • Demographic Private Health Insurance Individuals with Individuals Recently Low-Income Small Businesses Individuals Pre-Existing, Covered by an Individuals & (2-50 Employees) & Families Severe, or Chronic Employer Health Plan Families Medical Conditions Group Plans COBRA/Mini-COBRA Individual Plans Pre-Existing Medicaid National Association Then convert to a plan under: National Association Condition Insurance 775-684-3600 800-992-0900 of Health Underwriters of Health Underwriters Plan (PCIP) dwss.nv.gov 703-276-0220 HIPAA 703-276-0220 Run by U.S. Department of www.nahu.org www.nahu.org Program Health Insurance Portability & Health and Human Services To find address and phone Accountability Act 866-717-5826 number of welfare office near you: 866-487-2365 www.PCIP.gov dwss.nv.gov www.dol.gov (Under: DWSS Offices Telephone and Fax Numbers) HIPP Health Insurance Premium Payment Run by Health Management Systems Access to Health Care (HMS) Network (AHN) 877-385-2345 775-335-1040, 800-856-8839 775-284-8989 www.hms.com/our_services/ www.accesstohealthcare.org services_hipp.asp Carriers can impose a maximum COBRA/ Mini-COBRA: Coverage available Elimination riders are Covers broad range of benefits, Medicaid: Diagnosis (services to 6-month look-back and for 18–36 months depending on permitted. including primary and specialty find out what is wrong), Physician a maximum 12-month qualifying events. Benefits are care, hospital care, and services, Check-ups (medical exclusionary period for what you had with your previous There is a maximum prescription drugs. and dental), Family planning, pre-existing conditions on employer. look-back period of 6 Maternity, Prenatal and newborn enrollees who do not have prior months and no limit to Pre-Existing Health Conditions care, Prescriptions, Hospital or whose coverage had a break HIPAA: Benefits are based on program the maximum exclusion Covered services, Comfort care, Hospice, of more than 63 days. selected. There is no expiration of period for pre-existing Dental services, Drug and alcohol Coverage coverage. conditions on enrollees treatment, Mental health services. Pre-Existing Health Conditions HIPP: Benefits are the same as with no prior coverage. Covered what you had with your previous AHN: Hospitals, Family doctors, employer. HIPP is a premium Limits on Pre-Existing Cancer care, care from Specialists, assistance program. Health Conditions May X-ray & labs, Diagnostics, Apply Children’s health services, Pre-Existing Health Conditions Maternity care, Women’s health Covered services, Prescription drug assistance Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size 2–50. COBRA: Available for employees who Eligibility is subject to Must have been uninsured for at Medicaid: Must be a U.S. citizen or work for businesses with 20 or more medical underwriting. least 6 months prior to applying. qualified alien and live in Nevada. Owner can count as an employees. You have 60 days from date Must prove being a U.S. citizen of termination to sign up for COBRA Income limits: employee. HIPAA-eligible must be or legal U.S. resident, a Nevada coverage. offered two standard resident, and having problems Pregnant women: 185% FPL. Proprietor-name on license Mini-COBRA: Available for employees policies. getting insurance due to a pre- must draw wages. existing condition. Infants ages 0–1: 133% FPL. who work for employers with less than 20 employees. Must have been covered If you are denied coverage Children ages 1–5: 133% FPL. Eligible employees must work by group insurance for 12 consecutive for a medical condition, at least 30 hours a week. months before date of termination. you may be eligible for Children ages 6–18: 100% FPL Must sign up for Mini-COBRA within 60 PCIP. See next column. Aged, blind, and disabled singles: days after date of receiving notice of Eligibility Asset limit of $2,000 for all; aged, right to continue coverage. living independently up to 86% HIPAA: Must have had 18 months of FPL; blind, living independently continuous coverage and completely up to 87% FPL; disabled, up to exhausted COBRA or state continuation 75% FPL. coverage. Must not have lost coverage Aged, blind, and disabled couples: due to fraud or non-payment of Aged, living independently, premiums. You have 63 days to enroll in a up to 89% FPL; blind, living HIPAA-eligible plan independently, up to 114% FPL; HIPP: Enrollee must be eligible for full disabled up to 83% FPL. coverage from NV Medicaid, not eligible Parents/caretakers living with for Medicare, and have health insurance. children ages 0–18: Non-working, 25% FPL; working, 86% FPL. AHN: Must be uninsured and live in Nevada. Must have income between 100% to 200% FPL. Be able to show picture ID, proof of residency, and proof of income. Costs depend on employer COBRA/Mini-COBRA: Premiums range from Rates are ±50% of the Monthly premiums range from Medicaid: $0 or may share in contribution and ± 25% of the 102%–150% of group health rates. base individual market $113 to $487 depending on your some costs. insurance company’s index rate. age and plan chosen. rate. HIPAA: Premiums will depend on plan chosen. AHN: Monthly premiums range If you are self-employed Monthly Cost from $120 to $770 depending on and buy your own number of dependents and plan HIPP: $0 or minimal share of cost. insurance you are eligible chosen. to deduct 100% of the cost of the premium from your federal income tax.5655 Nevada
    • Publicly-Sponsored Programs Demographic Children with Trade Dislocated Children Developmental Women Seniors & Disabled Workers Delays (TAA Recipients) Nevada Check Up Nevada Early Women’s Health Medicare Health Coverage (877-543-7669) 800-360-6044 Intervention Services Connection (WHC) 800-633-4227 www.medicare.gov Tax Credit 775-684-3777 (NEIS) 888-463-8942 775-684-4285 866-628-4282 www.irs.gov 800-522-0066 www.nevadacheckup.state.nv.us health.nv.gov Medicare Prescription (keyword: HCTC) Program health.nv.gov/BEIS.htm Women-Infant- (Search: Womens Health Connection) Drug Program 800-633-4227 Children (WIC) Maternal Child 800-863-8942 health.nv.gov/WIC.htm Health (MCH) Line Senior Rx 800-429-2669 866-303-6323 health.nv.gov www.dhhs.nv.gov/SeniorRx.htm (Search: MCH) NV Check Up: Physician, Chiropractor, Audiology (hearing) services WHC: Breast and cervical Medicare offers Part A, inpatient Inpatient and outpatient Dental, Vision, Medical Equipment, Family training, Counseling and cancer screening services. care in hospitals and rehabilitative care (lab tests, x-rays, etc.), Hospital Inpatient and Outpatient home visits, Health services, Pelvic exams, Pap smears, centers; Part B, doctor and some Doctor visits, Preventive and hospital, Laboratory and X-Ray, Medical services for diagnostic clinical breast exams, preventive services and outpatient major medical care (surgery, Prescription Drugs, Ambulance, or evaluation purposes, Nutrition mammograms. care; Part C allows Medicare physical therapy, Durable Non-Emergency Transportation, counseling, Occupational benefits through private insurance medical equipment, etc.), Mental Health, Home Health, therapy, Physical therapy, MCH: Provides prenatal (Medicare Advantage); Part C Mental health and substance Well-Child, Well-Baby Visits, and Psychological services, Service care and other maternity includes Parts A, B, and C not abuse care, and Prescription Coverage Immunizations. coordination, Social work services. covered by Medicare. Part D covers drugs. services, Special instruction, prescription drugs. WIC: Nutrition education and Speech and language services, Pre-Existing Health services, breastfeeding promotion Transportation services, Senior RX offers extra coverage Conditions Covered and education, monthly food Vision and more. for medication. There are plans prescription of nutritious foods, for seniors with Medicare Part D and maternal, prenatal and Pre-Existing Health Conditions and for seniors without Medicare pediatric health care services. Covered Part D. Pre-Existing Health Conditions Pre-Existing Health Conditions Covered Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE NV Check Up: Must be a Nevada Must be a child 0–3 years old WHC: Nevada women 40 Medicare: Must be U.S. citizen or Must be receiving TAA (Trade resident and a U.S. citizen or of a Nevada resident. Patient years or older who do not permanent U.S. resident, and: Adjustment Assistance), or “qualified alien” (legal residents must have been diagnosed have health insurance, need to have 5 years residency). with a condition such as Down Medicaid, Medicare Part B, 1) If 65 years or older, you or your Must be 55 years or older and Must be a child age 0–18. Income syndrome, spina bifida, autism, HMO coverage, or whose spouse worked for at least 10 years receiving pension from the limit of 100% to 200% FPL. blindness, deafness, or other health insurance does in Medicare-covered employment, Pension Benefit Guaranty Must not be insured within the diagnosed condition that has a not pay for the program’s or Corporation (PBGC). last 6 months before enrolling or high probability of resulting in a services. Income limit of lost insurance beyond parents’ developmental delay, or shows 250% FPL. 2) You have a disability or end- Must not be enrolled in control, and must not be eligible for significant delays in development stage renal disease (permanent certain state plans, or in such as talking or walking. Women ages 40 or older kidney failure requiring dialysis or prison, or receiving 65% Medicaid. get annual pelvic exams transplant) at any age. COBRA premium reduction, or Eligibility Eligibility is determined for one and annual clinical breast be claimed as a dependent in year unless child moves out of state, exams, and Pap tests. Those Senior RX: Must be age 62 or older tax returns. is enrolled in Medicaid, has other age 50 or older get the Income limit of $25,477 if you are coverage, or becomes financially above benefits plus annual single and $33,963 if you are a Must be enrolled in qualified ineligible. mammograms. married couple. health plans where you MCH: Must be parents of pay more than 50% of the WIC: Must reside in Nevada, and be premiums. a pregnant or recently pregnant children up to age 5 who woman, or a child up to age 5, are Medicaid-eligible. and be determined to have a nutritional risk. Income must be at or below 185% FPL. NV Check Up: $0 or $25–$80 $0 or minimal share of cost. Both: $0 and share of cost Medicare: $0 and share of cost 20% of the insurance every 3 months. sliding scale. for certain services; deductibles premium including COBRA EIS is the payer of last resort. Premiums are based on income. Private insurance and Medicaid for certain plans. Part A: $0–$450 premium if employer No co-payments or deductibles. will be billed first. based on length of Medicare- contributes less than 50%. Monthly Cost Federally recognized Native covered employment; Part B: Americans who can prove their $96.40–$369.10 depending on tribal affiliations pay no premiums. annual income; Part C: Based on provider; Part D: Varies in cost and WIC: $0 or minimal share of cost. drugs covered. Senior RX: $0 or minimal share of cost. Nevadawww.CoverageForAll.org 56
    • Demographic Private Health Insurance Small Individuals with Individuals Recently Low-Income Businesses Individuals Pre-Existing, Severe, Covered by an Employer Individuals (1-50 & Families or Chronic Medical Health Plan & Families Employees) Conditions Group Plans COBRA/New Hampshire (NH) Individual Plans New Hampshire Health Medicaid New Hampshire State Continuation New Hampshire Plan(NHHP) 603-271-4344 800-842-3345 ext. 4344 Association Association 877-888-6447 Then convert to a plan under: www.nhhealthplan.org www.dhhs.nh.gov of Health Underwriters of Health Underwriters www.nhahu.org www.nhahu.org (Search: Medicaid) HIPAA NHHP-FED Health Insurance Portability & Program Federal program run by Benefit Accountability Act Management Inc. 866-487-2365 877-505-0508 www.dol.gov www.nhhealthplan.org www.PCIP.gov HIPP Health Insurance Premium Payment 603-271-8166 Catastrophic 800-852-3345 ext. 8166 Illness Program (CIP) www.dhhs.nh.gov/ombp/medicaid/hipp. 603-271-4495 htm 800-852-3345 ext. 4495 www.dhhs.nh.gov (Search: Catastrophic Illness Program) There is a maximum COBRA: Coverage available for 18–36 months There is a maximum NHHP: Seven plans each with Covered services can look-back period of 3 depending on qualifying events. Benefits look-back period of 3 a different deductible. Offers include Hospital, Physician, months and a maximum are what you had with your previous months and a maximum hospitalization, physician care, Nursing, Home health, exclusionary period of 9 employer. exclusionary period of 9 diagnostic tests, x-rays, prescription Lab and x-ray, Family months on pre-existing months on pre-existing drugs, and some mental health care planning, Rural health health conditions for NH State Continuation: Benefits are what you health conditions for services. clinics, Prescription drugs, enrollees who have no had with your previous employer. Coverage enrollees who have no Therapies (speech, physical, prior health coverage. available for 18–36 months depending on prior health coverage. NHHP-FED: Covers broad range of occupational), Adult qualifying events. When the surviving/ benefits, including primary and medical day care, Medical Pre-Existing Health divorced spouse is at least age 55 at time of Limits on Pre-Existing specialty care, hospital care, and transportation, Durable death of/divorce from covered employee, prescription drugs. Coverage Conditions Covered Health Conditions May medical equipment, then the surviving/divorced spouse can Apply Dental, Chiropractor, continue coverage until he or she is eligible CIP: Provides financial assistance to people with cancer, hemophilia, Psychotherapy, Podiatry, for another employer-based group plan or Interpreter, Midwife, EPSDT Medicare. end stage renal disease, cystic fibrosis, spinal cord injuries, and (early, periodic, screening HIPAA: Benefits are based on program other serious illnesses or injuries. and diagnostic testing), selected. There is no expiration of coverage. Assistance is limited to $2,500 per Newborn home visits, individual per year. Maternity, Vision and HIPP: Benefits are the same as what you hearing. had with your previous employer. HIPP is a premium assistance program. Pre-Existing Health Conditions Pre-Existing Health Covered Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size 1–50. Owner COBRA: Available for employees who work Eligibility is subject to NHHP: Must be a New Hampshire Must be a New Hampshire can count as an employee. for businesses with 20 or more employees. medical underwriting. resident and have a pre-qualifying resident and a U.S. citizen Proprietor name on license You have 60 days from date of termination medical condition. Must have been or an eligible qualified must draw wages. to sign up for COBRA coverage. If you are denied coverage denied coverage due to a health alien. NH State Continuation: Available for any New for a medical condition, condition, or offered coverage Income limits: Eligible employees must Hampshire resident who is an eligible you may be eligible for similar to NHHP’s but with higher work at least 15 hours a employee, or qualified beneficiary of a NHHP. See next column. premiums. Had your previous coverage Infants ages 0–1: 185% FPL. week for coverage. fully insured group or blanket policy of terminated for reasons other than non- payment of premium or fraud. Also Children ages 1–19: 185% health insurance. Must sign up for NH FPL. Insurers are required to State Continuation within 45 days of date qualified: Federally eligible or certified Eligibility give guaranteed issue of receiving notice of right to continue as eligible for TAA or PBGC assistance. Pregnant women: 185% FPL. small group plans to the coverage. Must not be eligible for COBRA or self-employed during open government programs. Parents/caretakers living enrollment periods twice HIPAA: Must have had 18 months of with children ages 0–18: a year. continuous coverage and completely NHHP-FED: Must be a U.S. citizen or 49% FPL. exhausted COBRA or state continuation lawfully present in the U.S. and have Limited guarantee issue to coverage. Must not have lost coverage due been uninsured for at least 6 months Aged, blind, and disabled: sole-proprietors. to fraud or non-payment of premiums. You prior to applying. Must have had a 79% FPL with asset limit of have 63 days to enroll in a HIPAA-eligible problem getting insurance due to a pre- $1,500 for singles; 87% FPL Carrier may not require plan. existing condition. with asset limit of $2,250 for more than 75% when the couples. HIPP: Enrollee must be eligible for Medicaid CIP: Must be a New Hampshire resident, health carrier’s plan is the U.S. citizen, or parent/guardian with Medically-needy: Singles only one offered to the and have health insurance. primary responsibility for applicant with monthly income of $591 employer and 37.5% when child who is a U.S. citizen. Must be age and asset limit of $2,500; the employer is offered 21 or over. Must have a qualifying health couples with monthly more than one plan. condition. income of $675 and asset limit of $4,000. Rates vary ± 25% based on age, industry, heath COBRA/NH State Continuation: Premiums range from 102%–150% of group health rates. Costs depend on age and county/zone. NHHP: Premiums range from $125 to $1 ,835 based on tobacco use, age and $0 to minimal share of cost. Monthly Cost status and geography. Rate plan chosen. Enrollees living up to increases capped at 15% HIPAA: Premiums will depend on plan If you are self-employed 250% FPL may be eligible for premium chosen. and buy your own discounts of up to 20%. insurance, you are eligible HIPP: $0 or minimal share of cost. to deduct 100% of the cost NHHP-FED: Monthly premiums range of the premium from your from $152 to $1,535 depending on federal income tax. your age, tobacco use, and plan chosen. CIP: $0 to minimal share of cost.5857 New Hampshire
    • Publicly-Sponsored Programs Demographic Trade Dislocated Children in Moderate Women Seniors & Disabled Workers Veterans Income Families (TAA Recipients) Healthy Kids Let No Woman Medicare Health Coverage VA Medical 877-464-2447 603-228-2925 Be Overlooked 800-633-4227 www.medicare.gov Tax Credit Benefits Package www.nhhealthykids.com Program 866-628-4282 www.irs.gov 877-222-8387 www.va.gov 800-852-3345 x4931 or www.dhhs.nh.gov 603-271-4931 Medicare Prescription (Search: HCTC) (Search: Healthy Kids) www.dhhs.nh.gov Drug Program Program (Search: BCCP) 800-633-4227 Offers 3 programs: www.expressscript.com Gold, Silver, and Buy-In Women-Infant-Children New Hampshire (NH) (WIC) Senior Prescription 800-942-4321 Discount Program 603-271-4546 888-580-8902 www.dhhs.nh.gov (Search: WIC) Healthy Kids: Physician services, Office Womens health exams, Medicare offers Part A, inpatient Inpatient and outpatient Comprehensive preventive and specialist visits, Checkups and Mammograms, Pap tests, and care in hospitals and rehabilitative care (lab tests, x-rays, etc.), and primary care, physical exams, Immunizations, Pelvic exams. centers; Part B, doctor and some Doctor visits, Preventive and outpatient and inpatient Prescription drugs, Emergency room, preventive services and outpatient major medical care (surgery, services. Inpatient hospital services, Outpatient care; Part C allows Medicare benefits physical therapy, Durable services, Lab and x-ray, Home health through private insurance (Medicare medical equipment, etc.), Pre-Existing Health services, Physical, speech and Advantage); Part C includes Parts A, Mental health and substance Conditions Covered occupational therapy, Outpatient B, and C not covered by Medicare. abuse care, and Prescription and inpatient mental health care, Part D covers prescription drugs. drugs. Hearing aids, Early intervention Coverage services, Regular dental check-ups NH Senior Prescription Discount Program Pre-Existing Health and cleanings, Fluoride treatments, offers discounts on drugs at Conditions Covered and more. participating pharmacies. WIC: Nutrition education and services; Pre-Existing Health Conditions breastfeeding promotion and Covered education; 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 Healthy Kids: For all programs: Must be Must be New Hampshire Medicare: Must be U.S. citizen or Must be receiving TAA (Trade ”Veteran status” = active New Hampshire resident and a U.S. women ages 18–64, with permanent U.S. resident, and: Adjustment Assistance), or duty in the U.S. military, citizen or a legal permanent resident or incomes at or less than naval, or air service and qualified alien. 250% FPL, and must have no 1) If 65 years or older, you or your Must be 55 years or older and a discharge or release Gold program: Must be pregnant women insurance or have insurance spouse worked for at least 10 years receiving pension from the from active military living up to 185% FPL, or children ages that does not pay for breast in Medicare-covered employment, Pension Benefit Guaranty service under other than 0–1 living up to 300% FPL. or cervical cancer screening or Corporation (PBGC). dishonorable conditions. tests. Silver program: Must be children ages 2) You have a disability or end- Must not be enrolled in Certain veterans must have 1-19 living 185%–300% FPL. Must be Women ages 40 and older stage renal disease (permanent certain state plans, or completed 24 continuous Eligibility uninsured for 6 consecutive months get mammograms every kidney failure requiring dialysis or in prison, or receiving months of service. prior to enrolling. 1–2 years and annual breast transplant) at any age. 65% COBRA premium check. reduction, or be claimed as a Buy-In program: Children ages 1–19 NH Senior Prescription Discount Program: dependent in tax returns. living between 300%–400% FPL. Women ages 18–39 get Must be New Hampshire residents Must be uninsured for 3 consecutive annual breast check and ages 65 or older. No income test. Must be enrolled in qualified months prior to enrolling. Rule may medical assessment to health plans where you be waived for certain reasons (e.g. determine mammogram. pay more than 50% of the child loses coverage due parent being premiums. laid off). Women ages 18 and older get WIC: Must reside in New Hampshire. Pap tests every 1–2 years. Must be a pregnant or recently pregnant woman, or child up to age 5, and determined to have a nutritional risk. Income limit of 185% FPL. Healthy Kids: $0 for Gold Program. $0 or nominal co-payment. Medicare: $0 and share of cost for 20% of the insurance $0 and share of cost and certain services; deductibles for premium including COBRA Monthly Cost Monthly premium for Silver and Buy- co-pays depending on certain plans. Part A: $0–$450 based premium if employer In programs range from $32 to $237 on length of Medicare-covered income level. per child based on family size and contributes less than 50%. employment; Part B: $96.40–$369.10 income. depending on annual income; Part C: Based on provider; Part D: Varies WIC: $0 to minimal share of cost in cost and drugs covered. NH Senior Prescription Discount Program: $0 enrollment fee. New Hampshirewww.CoverageForAll.org 58
    • Demographic Private Health Insurance Individuals with Individuals Recently Low-Income Small Businesses Individuals Pre-Existing, Severe, Covered by an Individuals & (2-50 Employees) & Families or Chronic Medical Employer Health Plan Families Conditions Group Plans COBRA/Mini-COBRA Individual Plans Individual Health Medicaid New Jersey Association Then convert to a plan under: New Jersey Association Coverage (IHC) 800-356-1561 609-588-2600 of Health Underwriters of Health Underwriters Program www.state.nj.us/ www.njahu.org www.njahu.org HIPAA 800-838-0935 humanservices/dmahs/home/ Program Health Insurance Portability & wwww.state.nj.us Accountability Act (Search: Individual Health Coverage) 866-487-2365 www.dol.gov NJ Protect Federal program run by the state of New Jersey 888-551-2130 www.PCIP.gov www.state.nj.us (Search: NJ Protect) Groups of 2–5 individuals: COBRA/ Mini-COBRA: Coverage Assorted plans depending IHC: Covers office visits, Hospital Inpatient and outpatient hospital There is a maximum look- available for 18–36 months on medical needs . care, Prenatal and maternity treatment, laboratory tests and back and exclusion period depending on qualifying events. care, Immunizations, Well-child x-rays, early and periodic of 6 months for pre-existing Benefits are what you had with All carriers must guarantee care, Screenings (including screening, diagnostic and conditions for enrollees with no your previous employer. issue coverage to all mammographies, Pap smears and treatment services, home health prior coverage. individuals. prostate examinations), X-ray and care, physician services, nurse- HIPAA: Benefits are based on laboratory services, Certain mental midwife services, assistance Groups of 6–50 individuals: program selected. There is no There is a maximum health and substance abuse services, with family planning and any Insurers may not impose an expiration of coverage. 6-month look-back and Prescription drugs. Individuals may necessary supplies, nursing Coverage exclusion period for pre- a maximum 12-month be subject to a 12-month waiting facilities for people over 21. existing conditions on enrollees Pre-Existing Health Conditions exclusionary period limit period. with no prior coverage. Covered for pre-existing conditions Pre-Existing Health Conditions on enrollees with no prior NJ Protect: Covers broad range of Covered Benefits will vary depending on coverage. benefits, including primary and the chosen plan. specialty care, hospital care, and Pre-Existing Health prescription drugs. Pre-Existing Health Conditions Conditions Covered with Covered Some Limitations Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE Company size 2–50 employees COBRA: Available for employees Must be New Jersey IHC: Must have been a resident of Must be a New Jersey resident (including owner.) who work for businesses with 20 or resident. New Jersey for at least 6 months. and a U.S. citizen or legal more employees. You have 60 days Not eligible for coverage under a permanent resident. An “eligible employee” is one from date of termination to sign up Medical underwriting is not group health plan, governmental Income limits: who works at least 25 hours for COBRA coverage. allowed. plan or church plan. Not eligible for a week. coverage under Medicare. Pregnant women and infants Mini-COBRA: Available for employees If you are denied coverage HIPAA-eligible patients are also ages 0–1: 185% FPL. Eligible employees do not who work for employers with less for a medical condition, you qualified (no length of residency include union employees who than 20 employees. Must sign up may be eligible for IHC or requirement). Infants ages 0–1 born to have collectively bargained for for Mini-COBRA within 30 days of PCIP. See next column. Medicaid-enrolled mothers: their health plan, independent qualifying event. NJ Protect: You must be a U.S. citizen 200% FPL. Eligibility contractors, employees hired or national or lawfully present in Children ages 1–18: 133% FPL. on a temporary or substitute HIPAA: Must have had 18 months the United States and a New Jersey basis, or seasonal employees of continuous coverage and resident. Must have been without Parents/caretakers living with even though they work at least completely exhausted COBRA or any creditable coverage for at least children ages 0–18: 200% FPL. 25 hours a week. state continuation coverage. Must 6 months and you must have a pre- not have lost coverage due to fraud existing condition. Aged, blind, and disabled: Most carriers require the most or non-payment of premiums. You Singles and couples up to 100% recent copy of New Jersey’s have 63 days to enroll in a HIPAA- FPL, with asset limit of $4,000 quarterly wage and tax filing eligible plan. for singles and $6,000 for form. couples. Medically-needy: Singles with income of $367 a month and asset limit of $4,000, couples with monthly income of $434 and asset limit of $6,000. Costs depend on employer contribution and the modified COBRA/Mini-COBRA: Premiums range from 102%–150% of group health Costs for individual coverage vary and are based IHC: Costs vary based on age, gender and/or geographic $0 or small share of cost. community rate. rates. on purely community rate. location, and plans chosen. Renewal increase limited to 15%. Monthly Cost HIPAA: Premiums will depend on plan chosen. NJ Protect: Premiums range from $238.27 to $919.92 depending on your age and plan chosen.6059 New Jersey
    • Publicly-Sponsored Programs Demographic Cancer Screening Trade Dislocated Moderate Income for Men and Seniors & Disabled Workers Veterans Families Women (TAA Recipients) NJ Family Care Cancer Education Medicare Health Coverage VA Medical Program and Early Detection 800-633-4227 www.medicare.gov Tax Credit Benefits Package 800-701-0710 (CEED) 866-628-4282 www.irs.gov 877-222-8387 www.va.gov www.njfamilycare.org 609-292-8540 800-328-3838 Medicare Prescription (Search: HCTC) Program Women-Infant- www.state.nj.us Drug Program (Search: Cancer Education) 800-633-4227 Children (WIC) 866-446-5942 609-292-9560 Senior Gold Program www.state.nj.us/health/fhs/wic 800-792-9745 www.nj.gov/health/seniorbenefits/ seniorgold.shtml NJ Family Care: Doctor visits, Services include education Medicare offers Part A, inpatient Inpatient and outpatient care Comprehensive preventive Eyeglasses, Hospitalization, about and screening services care in hospitals and rehabilitative (lab tests, x-rays, etc.), Doctor and primary care, outpatient X-rays & lab tests, Prescriptions, for breast, cervical, colorectal centers; Part B, doctor and some visits, Preventive and major and inpatient services. Checkups, Mental health, and and prostate cancers, and preventive services and outpatient medical care (surgery, physical Dental (for children). case management, tracking, care; Part C allows Medicare benefits therapy, Durable medical Pre-Existing Health Conditions follow-up. through private insurance (Medicare equipment, etc.), Mental health Covered WIC: Nutrition education Advantage); Part C includes Parts A, and substance abuse care, and and services, breastfeeding B, and C not covered by Medicare. Prescription drugs. promotion and education, Part D covers prescription drugs. Coverage monthly food prescription of Pre-Existing Health Conditions nutritious foods, immunization Senior Gold is a state funded Covered screenings, and maternal, prescription discount program. prenatal and pediatric health- care services. Pre-Existing Health Conditions Covered Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE NJ Family Care: Must be New Must be a New Jersey resident Medicare: Must be U.S. citizen or Must be receiving TAA (Trade ”Veteran status” = active duty Jersey resident, not covered with income at or below 250% permanent U.S. resident, and: Adjustment Assistance), or in the U.S. military, naval, or by health insurance (including FPL. air service and a discharge or Medicaid), and be a U.S. citizen 1) If 65 years or older, you or your Must be 55 years or older and release from active military or legal permanent resident for Must have no insurance or have spouse worked for at least 10 years in receiving pension from the service under other than at least 5 years. insurance that does not cover Medicare-covered employment, or Pension Benefit Guaranty dishonorable conditions. Eligible children must be under the services offered by CEED. Corporation (PBGC). 19 and have family income of 2) You have a disability or end- Certain veterans must have up to 350% FPL. stage renal disease (permanent Must not be enrolled in certain completed 24 continuous kidney failure requiring dialysis or state plans, or in prison, or months of service. Eligible parents/guardians and transplant) at any age. receiving 65% COBRA premium Eligibility their children under 19 must reduction, or be claimed as a have income of up to 133% FPL. Senior Gold: Must be New Jersey dependent in tax returns. resident and be at least 65 years old, WIC: Must be New Jersey resident, or at least 18 years old and receiving Must be enrolled in qualified be a pregnant or recently Social Security Disability Title II health plans where you pregnant woman, or a child up benefits. Must be participating in pay more than 50% of the to age 5, and be determined to Medicare Part D. Income limits of premiums. have a nutritional risk. Must live $24,432–$34,432 for singles, and at or below 185% FPL. $29,956–$39,956 for couples. Also contact Aetna of New Jersey. NJ Family Care: $0-134.50 $0 or minimal share of cost. Medicare: $0 and share of cost for 20% of the insurance $0 and share of cost and monthly premium per child or certain services; deductibles for premium including COBRA co-pays depending on income parent/guardian and $5-$35 co- certain plans. Part A: $0–$450 based premium if employer level. Monthly Cost pays, depending on income. on length of Medicare-covered contributes less than 50%. employment; Part B: $96.40–$369.10 depending on annual income; Part WIC: $0 to minimal share of C: Based on provider; Part D: Varies cost. in cost and drugs covered. Senior Gold: Premiums depend on chosen Medicare Part D plan.www.CoverageForAll.org New Jersey 60
    • Demographic Private Health Insurance Private/Public Program Individuals Recently Small Businesses Individuals Individuals Below Covered by an Employer (1-50 Employees) & Families 200% FPL Health Plan Group Plans COBRA/New Mexico (NM) Individual Plans State Coverage New Mexico State Association of Health Continuation Coverage Insurance (SCI) New Mexico State Association 888-997-2583 Underwriters of Health Underwriters www.nmsahu.org Then convert to a plan under: www.insurenewmexico.state. www.nmsahu.org nm.us/SCIHome.htm Small Employer New Mexico HIPAA There is a waiting list for individual Insurance Health Program Health Insurance Portability applicants, but not for SCI Program (SEIP) Insurance & Accountability Act applications submitted as part of 866-773-9939 Alliance 866-487-2365 employer groups. www.gsd.state.nm.us/ "The Alliance" www.dol.gov rmd/seip.html 800-204-4700 There is an enrollment 888-997-2583 waitlist for SEIP. www.nmhia.com There is a maximum 6-month look-back and a COBRA: Coverage available for 18–36 months There is a maximum 6-month Benefits are limited to $100,000 maximum 6-month exclusionary period for pre- depending on qualifying events. Benefits are look-back and exclusionary payable per member per benefit existing conditions on enrollees that do not have what you had with your previous employer. period limit on pre-existing year. Benefits include doctor visits; prior coverage. health conditions. pre/post natal care; preventive NM Continuation Coverage: Coverage lasts up to 6 services; inpatient and outpatient SEIP: Annual claims limit of $100,000 per enrollee. months. Benefits are what you had with your Pre-Existing Health Conditions hospital care; home health; Offers comprehensive health insurance. previous employer. Covered with Some Limitations physical, occupational and speech The Alliance: Offers comprehensive PPO and HMO HIPAA: Benefits are based on program selected. therapies; medical supplies; plans. Waiting period of 30–180 days for all There is no expiration of coverage. emergency and urgent services; prescription drugs; diabetes Coverage employees. Pre-Existing Health Conditions Covered treatment; and behavioral health Pre-Existing Health Conditions Covered and substance abuse. Pre-Existing Health Conditions Covered GUARANTEED COVERAGE GUARANTEED COVERAGE GUARANTEED COVERAGE - SEIP & The Alliance: Company size is 2–50 employees COBRA: Available for employees who work for Eligibility is subject to medical Employers: Must do business in New (including owner). Eligible employees must work businesses with 20 or more employees. You have underwriting. Mexico, have 50 or fewer eligible 20 hours per week. 60 days from date of termination to sign up for employees, and not currently offer COBRA coverage. If you are denied coverage for health insurance. SEIP: Self-employed people may qualify also. NM Continuation Coverage: Must have been a medical condition, you may The Alliance: 50% of employees must be New continuously covered under an Alliance plan be eligible for NMMIP or PCIP. Individuals: Must be a U.S. citizen or Mexico residents. Also eligible are self-employed (see “Small Business 1–50 Employees” column) See the "Individuals with Pre- legal permanent resident with at people with at least one dependent. 50% of for at least 6 months, even if employer Existing, Severe, or Chronic least 5 years residency in the U.S. eligible employees must participate in plan. ceases to do business or terminates its group Medical Conditions" column. and an uninsured adult the ages Eligibility Employer must not participate in other health coverage under the Alliance. Employee must of 19–64, and live in New Mexico. plans, including paying for their employees’ apply for continuation coverage through the Must not have voluntarily cancelled individual policies. Alliance within 31 days of the loss of his or her one’s health insurance within eligibility for group coverage. last 6 months, and not be eligible for certain government health HIPAA: Must have had 18 months of continuous insurance benefits (i.e. Medicaid, coverage and completely exhausted COBRA Medicare, CHAMPUS). Income or state continuation coverage. Must not have limit of 200% FPL. No asset test for lost coverage due to fraud or non-payment eligibility. of premiums. You have 63 days to enroll in a HIPAA-eligible plan. SEIP: Premiums are determined by age, gender, and COBRA: Premiums range from 102%-150% of Costs for individual coverage Employer pays $0 to $75 and geographic location. Employers pay at least 50% group health rates. vary according to age, gender, employee pays $0 to $35 of the of employees’ monthly premiums. smoking and geographic monthly premium. If you make Monthly Cost NM Continuation Coverage: Premiums are location. There are no rate caps. less than 100% FPL the state The Alliance: Costs depend on employer calculated at individual coverage rates. contributes to the premium contribution and ± 25% of the insurance Premiums are about 9% higher than what is payment. company’s index rate. charged for similar plans. Self-employed individuals pay both HIPAA: Premiums will depend on plan chosen. employer and employee premiums