U.S. Directory of Health Care Options

Vol. IV, July 2010 The U.S. Directory of Health Coverage Options U.S. Directory of Health Care Options A state-by-state...

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Vol. IV, July 2010 The U.S. Directory of Health Coverage Options

U.S. Directory of Health Care Options A state-by-state guide to helping Americans navigate their public and private health coverage options

FHCE

How to use this Directory: Use the Income Worksheet(page “v”) to determine the Federal Poverty Level percentage of you or the person whom you are trying to assist. This percentage usually determines if an individual is eligible for various public programs. Find your state’s Health Care Options Matrix for a complete list of private and public health coverage programs, along with additional valuable resources. Consult the Appendices for COBRA subsidy information, state-by-state program contact information, uninsured statistics for each state, as well as the glossary of terms found within this book.

Foundation for Health Coverage Education “Coverage for All Through Education” 101 Metro Drive, Suite 250 • San Jose, CA 95110 • www.coverageforall.org ISBN-13: 978-1-42432862-8 © Copyright 2010 by Philip Lebherz and the Foundation for Health Coverage Education All Rights Reserved. Printed in the U.S.A.

Printing for this version of the U.S. Directory of Health Care Options provided by the generous support of Pfizer, Inc.


Created by

Phil Lebherz 2010

Dedication I want to dedicate this book to the thousands of workers in the private and public health insurance systems across the country who are attempting to reach our goal of lowering the number of uninsured people in America. I especially want to thank Leonard Schaeffer who provided his knowledge, inspiration, and vision to this project. - Phil Lebherz

table of contents Acknowledgements About the FHCE Income Worksheet Federal Poverty Level Table Health Care Options Matrices by State

ii

New Jersey

59

iii

New Mexico

61

iv

New York

63

v

North Carolina

65

North Dakota

67

Alabama

1

Ohio

69

Alaska

3

Oklahoma

71

Arizona

5

Oregon

73

Arkansas

7

Pennsylvania

75

California

9

Rhode Island

77

Colorado

11

South Carolina

79

Connecticut

13

South Dakota

81

Delaware

15

Tennessee

83

Florida

17

Texas

85

Georgia

19

Utah

87

Hawaii

21

Vermont

89

Idaho

23

Virginia

91

Illinois

25

Washington

93

Indiana

27

Washington, D.C.

95

Iowa

29

West Virginia

97

Kansas

31

Wisconsin

99

Kentucky

33

Wyoming

101

Louisiana

35

Maine

37

Maryland

39

Massachusetts

41

Michigan

43

Minnesota

45

Mississippi

47

Missouri

49

Montana

51

Nebraska

53

Nevada

55

New Hampshire

57

Appendices How to Understand the COBRA Subsidy

104

Other Services (by State)

105

State-by-State Comparison

112

The Uninsured In America

113

Glossary of Terms

114

i

Acknowledgements The following individuals and associations generously donated their time, energy, and resources to creating this book: Aetna Foundation

Health Coverage Foundation, Inc.

The Poizner Family Trust

Alain Enthoven

Health Net of California

Anthem Blue Cross Foundation

Kaiser Foundation

Portland Association of Health Underwriters

Beere & Purves, Inc.

Los Angeles Unified School District

Blue Shield of California

Larry Glasscock

CAHU Charitable Community Foundation

Leonard Schaeffer LISI

Cal Locket

Saint Joseph Health Center Foundation

Massachusetts Association of Health Underwriters

Schmitt Family Foundation

National Association of Health Underwriters

Sharp Health Plan

California Association of Health Underwriters California State Legislators

Professional Exchange Service Company Inc. Rio Grande Association

San Diego Office of Education

North Nevada Association of Health Underwriters

Spahr Insurance

Oregon Association of Health Underwriters

The Sugg Group

Peter and Renuka Patel

Warner Pacific

Peter Farrell

George and Clare Schmitt

Pfizer, Inc.

Washington Association of Health Underwriters

Greater Washington Association of Health Underwriters

Philip and Vivian Reed

WellPoint Foundation

Cathay Post No. 384 David and Nancy Helwig Dickerson Employee Benefits, Inc. Ernie Ramirez Florida Association of Health Underwriters

The Rauser Agency Word and Brown

Placer County Office of Education

Collaborative Efforts We would like to recognize the following organizations for their collaborative efforts in helping lower the ranks of the uninsured by referring individuals to FHCE’s resources: Aetna Inc. American Cancer Society American Diabetes Association American Heart Association American Lung Association Anthem Blue Cross of California Blue Shield of California

Catholic Healthcare West Hospitals California Department of Insurance Community Medical Centers Daughters of Charity Hospitals E-Health Insurance Google, Inc. NAHU

NAIC Robert Wood Johnson Foundation Sharp Health Care United Way of the Bay Area United Health Care WellPoint, Inc.

Appreciated Media Support The FHCE’s resources have had over 2 billion media impressions thanks to the following media outlets: AARP ABC View From The Bay ABC News American Medical News CBS Bay Sunday Chicago Tribune CNN Consumer Digest Costco Connection Kiplinger’s Personal Finance

ii

KTLA TV Channel 5 Los Angeles Times Men’s Health Magazine MSNBC New York Daily News Parenting.com Parents Magazine San Francisco Business Times San Francisco Chronicle Self Magazine

Smart Money, AOL Money & Finance The Angie Strader Show The New York Times The Wall Street Journal The Washington Post USA Today U.S. News & World Report

the Foundation for Health Coverage Education (FHCE) FHCE is a non-profit 501(c)3 organization with a mission to provide simplified public and private health insurance information in order to help more people access coverage. We offer a variety of health coverage resources to help consumers, health care professionals, employers, and the uninsured navigate the complex health insurance system. This directory of Matrices from all 50 states and the District of Columbia represents the entire health insurance system in our country. Different states have different approaches to insurance. Certainly California, with a population of 37 million, has different needs than Idaho where approximately 1.5 million people reside. The FHCE views the uninsured as a humanitarian issue, as well as a public health issue. Proper education of the public could improve our country’s health and save our health care system billions of dollars in claims. We have the infrastructure and capacity to take care of everyone. The U.S. has world class providers, hospitals and technology. We need to improve the administration, financing and distribution of publicly-funded programs, so that everyone who is eligible signs-up for health coverage. Together, we can lower the ranks of the uninsured.

FHCE Resources U.S. Uninsured Help Line™ The U.S. Uninsured Help Line (800-234-1317) provides live, one-on-one assistance to individuals with questions about their health coverage options. The Help Line is staffed 24/7 with friendly information specialists and interpreters who speak over 140 languages and provide basic screening for both public and private health coverage.

CoverageForAll.org All of FHCE’s resources and guides, including the Health Care Options Matrix, are available to download for free on CoverageForAll.org. The online Health Coverage Eligibility Quiz provides visitors with a personalized list of the public and private health coverage options for which they may qualify, along with each program’s signup check list and application link.

Disclaimer: An online version of this Directory is updated regularly for your convenience. Download the most recent version on www.CoverageForAll.org.

iii

iNCOME WORKSHEET Step One Use this worksheet to calculate your family or household total income after deductions.

Step Two Look for the income amount closest to the number in step one within the chart on the opposite page to determine which percentage of the Federal Poverty Level(FPL) you are.

Step Three Remember this percentage, as it will help you determine for which public programs you are eligible. Your monthly income + __________________ Spouse’s monthly income + __________________

TOTAL INCOME = __________________

Please fill in the following information, separate from amount that you just calculated: Begin with $0. For each working parent in the household, add $90.

+ __________________

If you pay for childcare for children under the age of 2, add $200 for each child. + __________________ If you pay for childcare for children over the age of 2, or for a child with disabilities, add $175 for each child. + __________________ If you receive child support, add $50 for each child. + __________________ If you pay alimony and/or child support, enter the amount. + __________________

Total Deductions = __________________

Now, subtract your Total Deductions from your Total Income.

TOTAL INCOME

__________________

TOTAL DEDUCTIONS -

__________________

TOTAL INCOME AFTER DEDUCTIONS =________________ Find an amount closest to this total within the chart on the opposite page to determine your Federal Poverty Level (FPL) percentage.

iv

Note: This income worksheet is only intended to serve as a guide. Some factors in determining your eligibility may not be represented above. Deductions listed here are typical for most public programs, but may vary by agency.

Federal Poverty Level Your Federal Poverty Level (FPL) Based on monthly family gross income

Family Size (Household)

100%

133%

175%

200%

250%

300%

400%

1

$903

$1,200

$1,579

$1,805

$2,256

$2,708

$3,610

2

$1,214

$1,615

$2,125

$2,428

$3,035

$3,643

$4,857

3

$1,526

$2,029

$2,670

$3,052

$3,815

$4,578

$6,103

4

$1,838

$2,444

$3,216

$3,675

$4,594

$5,513

$7,350

5

$2,149

$2,858

$3,761

$4,298

$5,373

$6,448

$8,597

6

$2,461

$3,273

$4,306

$4,922

$6,152

$7,383

$9,843

7

$2,773

$3,687

$4,852

$5,545

$6,931

$8,318

$11,090

8

$3,084

$4,102

$5,397

$6,168

$7,710

$9,253

$12,337

Based on yearly family gross income 1

$10,830

$14,404

$18,953

$21,660

$27,075

$32,490

$43,320

2

$14,570

$19,378

$25,498

$29,140

$36,425

$43,710

$58,280

3

$18,310

$24,352

$32,043

$36,620

$45,775

$54,930

$73,240

4

$22,050

$29,327

$38,588

$44,100

$55,125

$66,150

$88,200

5

$25,790

$34,301

$45,133

$51,580

$64,475

$77,370

$103,160

6

$29,530

$39,275

$51,678

$59,060

$73,825

$88,590

$118,120

7

$33,270

$44,249

$58,223

$66,540

$83,175

$99,810

$133,080

8

$37,010

$49,223

$64,768

$74,020

$92,525

$111,030

$148,040

• A pregnant woman counts as two for the purpose of this chart. • Add $311/month for each additional family member after eight. • Contact individual programs for deduction allowances on child/dependent care; working parent’s work expenses; alimony/child support received or court ordered amount paid. Source: Federal Register Vol. 74, No. 14, January 23, 2009, pp. 4199-4201. Monthly percentage data calculated by FHCE and rounded to the nearest dollar. Federal Poverty Levels for Hawaii and Alaska are slightly higher. Please visit www.coverageforall.org for further details and updates on the 48 continuous states, Hawaii and Alaska FPL charts.

Reminder

There is no universal administrative definition of income that is valid for all programs that use the poverty guidelines. The office or organization that administers a particular program or activity is responsible for making decisions about the definition of income used by that program (to the extent that the definition is not already contained in legislation or regulation). To find out the specific definition of income used by a particular program or activity, you must consult the office or organization that administers that program. v

Demographic

Private Health Insurance Small businesses (2-50 employees)

Individuals recently covered by an employer health plan

Individuals & families

U.S. Uninsured Help Line

COBRA


Program

800-234-1317

Group Health

Alabama Association of Health Underwriters 703-276-0220 www.nahu.org www.alanahu.org

And then

HIPAA

Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov

800-234-1317

Individual Plans Alabama Association of Health Underwriters 703-276-0220 www.nahu.org www.alanahu.org

Individuals with pre-existing, severe or chronic medical conditions

Low-income individuals & families

AHIP

Medicaid (SOBRA & MLIF)

Alabama Health Insurance Plan 866-833-3375 334-263-8311 www.alseib.org

334-242-5000 800-362-1504 https://insurealabama.adph. state.al.us

HIPP

(Health Insurance Premium Payment Program) 334-242-3722 www.medicaid.state.al.us If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply

Coverage

Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered

COBRA: Coverage available for up to 18 months depending on qualifying events, must have 20 employees or more. Benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage

Assorted plans depending on medical needs There is a 6-month look-back and 12-month exclusionary period limit for pre-existing conditions in traditional individual market health insurance products in Alabama Limits on pre-existing health conditions may apply

HIPP: Benefits are the same as what you had with your previous employer, HIPP is a premium assistance program

Two plans are available for member and certain dependents - a Blue Cross and Blue Shield of Alabama Traditional Indemnity Plan and a Managed Care Plan through United HealthCare Both plans provide doctor visits, prescription drugs, outpatient and in-hospital care, maternity, labs and x-rays, transplants, rehabilitation, durable medical equipment, and mental health and substance abuse, also emergency care while away from home and more Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

Company size 2-50 employees

COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA

Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage

Eligibility

Owner can count as an employee Owner name on business license must draw wages from the company

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for AHIP, see next column

GUARANTEED COVERAGE

GUARANTEED COVERAGE

You must have chosen to extend coverage under COBRA, group health plan, government plan, or church plan and exhausted those benefits and submitted your application within 63 days of your last day of coverage to sign up for AHIP

Medicaid Pregnant Women-133% of FPL Children (ages 0-5)-133% of FPL Children (Ages 6-19)-100% of FPL Supplemental Security Income Recipients-74% of FPL Working Parents-19% of FPL Non-Working Parents-13% of FPL Asset limits for some people

Must be a permanent Alabama resident with at least 18 months of continuous healthcare coverage without being terminated due to fraud or failure to pay

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even with pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA.

SOBRA: pregnant women ONLY get pregnancy related services covered Pre-Existing Health Conditions Covered

Pre-Existing Health Conditions Covered GUARANTEED COVERAGE

Among some of the services: ambulatory surgical center, birth center services, child health check-up, chiropractic care, durable medical equipment and supplies, federally qualified health centers, home health, hospital inpatient/outpatient care, laboratory, licensed midwife, physician, podiatry, prescriptions, rural health clinics, therapy, X-Rays

Legal Alabama resident

AHIP is specifically aimed at those who have purchased coverage from their employer and whose benefits have run out.

SOBRA: Must not be in an institution; must not be eligible for dependent coverage under state employees' insurance (including Public Schools)

Traditional Indemnity Plan premium could range between $169 to $957 depending on age, sex, smoker or non-smoker, and plan you choose. Managed Care Plan premium could range between $247 to $862 depending on age, sex, and smoker or non-smoker.

Medicaid: $0 to $3.00 for office visits, prescription drugs and some other services

Monthly Cost

HIPP: You may be eligible for HIPP if you have a high-cost health condition Costs depend on employer contribution and ± 20% of the insurance company’s index rate

COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column

Costs for individual coverage varies

SOBRA: $50 co-payment for each inpatient hospital stay

HIPP: $0 or minimal share of cost

1

Alabama

800.234.1317

Children in moderate income families

Women

ALL Kids

Breast and Cervical Cancer Prevention

877-252-3324 www.adph.org/earlydetection

Medicare

Health Coverage Tax Credit

VA Medical Benefits Package

800-MEDICARE 800-633-4227 www.medicare.gov

866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)

877-222-8387 www.va.gov

800-633-4227

Alabama State Health Insurance Assistance Program

800-726-2289 https://insurealabama.adph. state.al.us/

800-243-5463

A pelvic exam and a Pap smear A clinical breast exam An appointment and voucher for a mammogram if 50 and over Certain diagnostic services if needed, such as ultrasound, diagnostic mammogram, colonoscopy or biopsy

Pre-Existing Health Conditions Covered

Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D

Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer)

ASHIAP is a Medicare counseling service


Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits

Comprehensive preventive and primary care, outpatient and inpatient services Pre-Existing Health Conditions Covered

Coverage

AL Child Caring Program: outpatient services only

Veterans

Medicare Prescription Drug Program

AL Child Caring Program

All Kids: regular check-ups and immunizations, sick child doctor visits, prescriptions, dental and vision care, hospital and physician services, limited mental health/substance abuse services, and a toll-free 24 hour nurse line for health questions, and more

Trade Dislocated Workers (TAA recipients)

Program

888-373-KIDS 888-373-5437 334-206-5568 877-774-9521 https://insurealabama.adph. state.al.us or www.adph.org/allkids

Seniors and Disabled


GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Both: Be Under the age of 19 and an Alabama resident. Not be covered by any other health insurance; Be ineligible for Medicaid

Women age 40 - 64

Age 65 and older

Women under age 40 who have a problem with their breast can undergo a clinical breast exam to determine if they are eligible to receive a free breast cancer screening through the program

Disabled people of all ages

Must be receiving TAA (Trade Adjustment Assistance)

”Veteran status” = active duty in the U.S. military, naval, or air service and a discharge or release from active military service under other than dishonorable conditions

All Kids: Be a U.S. citizen or eligible immigrant; Not be in an institution; Family incomes between 101-200% FPL

Both: $0 or small co-pays

Income eligibility at or below 200% of FPL

Not enrolled in certain state plans Individuals who are eligible for the federal Health Care Tax Credit can also use their credit funds to purchase a private health insurance product developed by Blue Cross Blue Shield of Alabama

Women without insurance or who are underinsured

$0 or minimal share-of-cost

Must not have access to employer plan that pays 50% of coverage cost

$0 and share of cost for

certain services; deductibles for certain plans

20% of the insurance premium

Certain veterans must have completed 24 continuous months of service

$0 and share of cost and co-pays depending on income level

www.coverageforall.org Alabama

Monthly Cost

All Kids: Yearly costs range from $50 to $100 per child, per year up to the first 3 children (no cost for additional children). Small co-pays are required at the time of service. There are no co-pays for preventive services

People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

Eligibility

AL Child Caring Program: Not be eligible for ALL Kids and all other plans; Be enrolled in school (if of age)

Demographic

Publicly Sponsored Programs

2

Demographic

Private Health Insurance Small businesses (2-50 employees) U.S. Uninsured Help Line

Program

800-234-1317

Group Health 703-276-0220 www.nahu.org

Click on Consumer Info then Find an Agent/Member

Group Coverage as selected by employer with a variety of plan designs available

Coverage

If uninsured for previous 63 - 90 days, a waiting period for coverage of pre-existing conditions may apply Pre-Existing Health Conditions Covered

Eligibility

Then convert to

HIPAA


COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer, but paid by the individual

U.S. Uninsured Help Line 800-234-1317

Individual Plans 703-276-0220 www.nahu.org

Assorted deductible and plan design options for selection Limits on pre-existing health conditions may apply

COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Company size 2-50

COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage

Name on license must draw wages

Monthly Cost

COBRA

(Consolidate Omnibus Budget Reconciliation Act)


No Guarantee Issue for group sized 50+

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for an Alaska Comprehensive Health Insurance Association plan, see next column

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA

Costs depend on employer contribution and ± 35% of the insurance company’s index rate


Alaska

Individuals with pre-existing, severe or chronic medical conditions Alaska Comprehensive Health Insurance Association

Low income children and families Medicaid

907-465-3347 800-780-9972 www.hss.state.ak.us/dpa/ programs/medicaid

888-290-0616 www.achia.com

ACHIA offers six different comprehensive PPO plans with different deductibles ACHIA also offers a Traditional non-PPO plan. This plan pays 80% of the allowed charges after the $1,000 annual deductible has been satisfied. Once the deductible and out of pocket maximum have been satisfied, ACHIA will pay claims at 100% Pre-Existing Health Conditions Covered


Owner can count as an employee, proprietor

3


Inpatient and outpatient hospital services, prenatal care, vaccines for children, physician services, nursing facility services for persons aged 21 or older, family planning and supplies, rural health clinic, home health care for persons eligible for skilled-nursing, laboratory and x-ray, pediatric and family nurse practitioner, nurse-midwife, early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21 Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Individuals unable to obtain private health insurance for reasons other than cost; You are an Alaska resident, You have at least 18 months of prior health insurance coverage without a 90 day or more break in such coverage; Your most recent health insurance coverage was under a group plan; You are not eligible for other group health insurance coverage including Medicare, Veteran’s benefits, Native Health Care or Medicaid; Your most recent health insurance coverage was not terminated due to nonpayment of premium or fraud; You have elected and exhausted any COBRA or similar coverage; You do not have other health insurance coverage

Family Income can be up to 185% of the FPL Working Disabled - 250% of the FPL Contact your local Division of Public Assistance office or your community’s village fee agent for more information

This is also the option for TAA recipients

Costs vary dependent on age and medical underwriting

Costs vary dependent on age and plan selection

$0 for families below 100% of the FPL

Rates are set at 150-175% of average standard risk rate for health insurance sold in Alaska with similar benefits

800.234.1317

Moderate income children and families Denali Kid Care

Native American Indians

CAMA

Indian Health Services

(Chronic and Acute Medical Assistance) 800-780-9972 www.hss.state.ak.us/ dhcs/cama

(Alaska Area) 907-729-3686 www.ihs.gov/FacilitiesServices/ AreaOffices/Alaska/index.asp For eligibility information visit: www.ihs.gov/GeneralWeb/ HelpCenter/CustomerServices/ elig.asp

All programs offer a variety of prevention and treatment services such as: doctor's visits, check-ups & screenings, vision exams & eyeglasses, dental checkups, cleanings & fillings, hearing tests & hearing aids, speech therapy, physical and mental health therapy, substance abuse treatment, chiropracty, foot doctor's services, hospital care, laboratory tests, prescriptions, medical transportation

Prescription drugs and medical supplies, limited to 3 prescriptions per month and no more than a 30day supply of any drug

IHS services are provided directly and through tribally contracted and operated health programs. Health services also include health care purchased from more than 9,000 private providers annually. The Federal system consists of 36 hospitals, 61 health centers, 49 health stations, and 5 residential treatment centers. In addition, 34 urban Indian health projects provide a variety of health and referral services



Physician services Chemotherapy and radiation services for a recipient with cancer requiring chemotherapy, if provided in an outpatient setting Outpatient laboratory and X-ray services


Medicare




Medicare Prescription Drug Program 800-633-4227

Medicare offers to standard plans Part A: Hospital Insurance and Part B: Medical Insurance, as wells several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D Pre-Existing Health Conditions Covered

Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Coverage through Alaska high-risk health insurance pool, the Alaska Comprehensive Health Insurance Association Pre-Existing Health Conditions Covered

HS-funded, tribally-managed hospitals are located in Anchorage, Barrow, Bethel, Dillingham, Kotzebue, Nome and Sitka. There are 37 tribal health centers, 166 tribal community health aide clinics and five residential substance abuse treatment centers

Coverage

Or contact the Division of Public Assistance office nearest you or the fee agent in your community


Program

Toll Free Outside Anchorage 888-318-8890 Anchorage Area 269-6529 www.hss.state.ak.us/dhcs/ DenaliKidCare

Adults with chronic medical conditions

Demographic



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

You are an Alaskan resident

Must be a U.S. Citizen or legal alien; have one of following: a terminal illness; cancer requiring chemotherapy; chronic diabetes or diabetes insipidus; chronic seizure disorders; chronic mental illness; chronic hypertension

Must be regarded by the local community as an Indian or Alaska Native; Is a member of an Indian or Alaska Native Tribe or Group under Federal supervision; Resides on taxexempt land or owns restricted property; Actively participates in tribal affairs; Any other reasonable factor indicative of Indian descent; Is a non-Indian woman pregnant with an eligible Indian's child for the duration of her pregnancy through post partum (usually 6 weeks); Is a non-Indian member of an eligible Indian's household and the medical officer in charge determines that services are necessary to control a public health hazard or an acute infectious disease which constitutes a public health hazard.

Age 65 and older


$0 for an IHS qualified


ou are a child 18 or younger Y Children with other health insurance < 150% FPL Children with no Health Insurance < 175% FPL

Denali KidCare income guidelines are based on family size. Assets do not count towards Eligibility. It's best to apply, but call Denali KidCare to ask about the income guidelines

Youth who are 18 years-old may be required to share a limited amount of the cost for some services

Household income must be: < $300/mo. for one person < $400/ mo. for two people add $100 for each additional person < $500 in countable resources that could be used to pay medical bills: cash, bank/credit union accounts, or personal property, your home, one vehicle, income producing property, property that is used for your job (boat, fishing gear, etc.), or a fishing permit

$0 and $1 per prescriptions or medical supplies

beneficiary

Must not have access to employer plan that pays 50% of coverage cost Not enrolled in certain state plans

certain services: deductibles for certain plans


www.coverageforall.org Alaska

Monthly Cost

$0 for eligible children, teens and pregnant women

No other resources to meet the health care you need


Eligibility

ou are pregnant and can Y provide proof of pregnancy from your health care provider Pregnant Women with or without Health Insurance < 175% FPL


4

Demographic

Private Health Insurance

Small businesses (2-50 employees)




COBRA


Program

800-234-1317

Group Health

Coverage

HIPAA

Arizona Association of Health Underwriters 480-292-7746 www.aahu.net


HCG

And also...

(Health Care Group of Arizona) 602-417-6755

All group health insurance carriers can impose a 6-month look-back/ 12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered

COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium

Arizona Association of Health Underwriters 480-292-7746 www.aahu.net

Usually up to $5M, assorted deductibles depending on age and ZIP code Limits on pre-existing health conditions may apply


Company size 2-50 employees (or self-employed)


Owner name on business license must draw wages from the company

Individual Plans

HIPAA: Benefits are based on the program selected and there is no expiration of coverage

GUARANTEED COVERAGE

Owner can count as an employee

800-234-1317

AHCCCS

Low income families and adults

AHCCCS

Arizona Health Care Cost Containment System (Medical Expense Deduction Program) 800-352-8401 www.ahcccs.state.az.us

Arizona Health Care Cost Containment System (Arizona’s Medicaid Program) In State: 602-542-9935 Out Of State: 800-962-6690 800-352-8401 www.ahcccs.state.az.us

The Medical Expense Deduction (MED) program provides medical coverage for individuals who do not qualify for other AHCCCS programs because their income is too high; they may be eligible for MED if they have medical expenses in the month of application (or the previous month) that reduce their monthly income to 40% of the Federal Poverty Level (FPL)

Offers health, dental, vision, and prescription coverage

Conversion Policies

GUARANTEED COVERAGE


Eligibility

And then




GUARANTEED COVERAGE

GUARANTEED COVERAGE

Eligibility is subject to medical underwriting

Must not be eligible for other AHCCCS programs

Ages 0-5 up to 133% FPL

If you are denied coverage for a medical condition, you may be eligible for the Medical Expense Deduction program of AHCCCS, see next column

Monthly income can not exceed $707 for a family of four, after deducting medical expenses. Other deductions include childcare and each person employed

Ages 6-19 and childless adults: Up to 100% FPL Pregnant women - 150% FPL Arizona residents

Resources can not exceed $100K. (Only $5K may be liquid assets: cash, bank accounts, stocks, bonds, etc.) Home equity is counted toward the resource limit, but one vehicle is not counted


Must be an Arizona resident

Church organizations may be excluded

Monthly Cost

Must live in Arizona

5

Costs depend on employer contribution or health condition of self-employed and ± 60% of the insurance company’s index rate

Arizona

COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium



Both: $0 or minimal shareof-cost

COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column

800.234.1317


Women

Pregnant women & children


KidsCare

Well Woman Health Check

Baby Arizona


877- 764-5437 602- 417-5437 www.kidscare.state.az.us

888-257-8502

800-833-4642 www.babyarizona.gov

Phoenix Area 602-364-5179 http://www.ihs.gov/ FacilitiesServices/AreaOffices/ Phoenix/Index.cfm

Medicare



Program

(An enrollment cap is in place for KidsCare due to a lack of funding. Individuals and families can still apply and be placed on a waiting list, and they will be contacted when funding becomes available)

Navajo 928-871-4811 http://www.ihs.gov/ FacilitiesServices/AreaOffices/ Navajo/


Demographic


Tucson Area 520-295-2405 http://www.ihs.gov/ FacilitiesServices/AreaOffices/ Tucson/index.asp Provides treatment for breast and/or cervical cancer or precancerous cervical lesions

Provides a simple, faster way for pregnant women to apply for AHCCCS medical coverage



Choose one of the doctors; Make an appointment for a prenatal (pregnancy) visit; at your first visit, the office staff will assist you in completing an application for AHCCCS medical coverage; you will be asked to take information with you to your first visit to show you are eligible for the Baby Arizona program

Available programs vary depending on health center and may include primary and child care, prenatal and post delivery care, family planning (birth control), minor surgical and orthopedic care, pharmacy, dental and orthodontics, optometry, nursing, mental health, laboratory and radiology.

Medicare offers to standard plans Part A: Hospital Insurance and Part B: Medical Insurance, as wells several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D Pre-Existing Health Conditions Covered


Coverage

A wide array of medical services including behavioral health services


GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Children under age 19

At or below 250% FPL No limit on resources

Provides medical coverage to pregnant women, and children up to the age of 19 years.

Must be ineligible for no-cost Medicaid or employer-based coverage

Arizona resident and qualified resident

Pregnant women - 150% FPL

No access to other health insurance including Medicare

Ages 1-6: 133% FPL

Must be regarded by the local community as an Indian; Is a member of an Indian or Group under Federal supervision; Resides on taxexempt land or owns restricted property; Actively participates in tribal affairs; Any other reasonable factor indicative of Indian descent; Is a non-Indian woman pregnant with an eligible Indian’s child for the duration of her pregnancy through post partum (usually 6 weeks); Is a non-Indian member of an eligible Indian’s household and the medical officer in charge determines that services are necessary to control a public health hazard or an acute infectious disease which constitutes a public health hazard.

Age 65 and older

At or below 200% FPL



No limit on resources Arizona residents Parents also qualify with a income of 200% of the FPL

Ages 6 and older: 100% FPL


$0 or share-of-cost

No limit on resources or property that may be owned


www.coverageforall.org Arizona

Monthly Cost

$10 to $25 a month for one child or $15-$35 a month for two or more children

Women who are screened by the Arizona Department of Health Services Well Women HealthCheck Program, Hopi Women’s Health Program, and Navajo Nation Breast and Cervical Cancer Prevention Program are eligible for AHCCS


Eligibility

No health insurance for the last three months at time of application

Children < age 1: 140% FPL


6

Demographic





COBRA/Mini-COBRA


Program

800-234-1317

Group Health

Arkansas Association of Health Underwriters 703-276-0220 www.arkansas-ahu.org

Coverage

All group health insurance carriers can impose a 6-month look-back/ 12-month exclusionary period for preexisting conditions on enrollees that do not have prior creditable coverage Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered

And then

HIPAA


COBRA or Mini-COBRA: Coverage available for 12 to 18 months depending on qualifying events for COBRA, Mini-COBRA for up to 120 days. Benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage

800-234-1317

Individual Plans

Individuals with pre-existing, severe or chronic medical conditions CHIP

(Comprehensive Health Insurance Plan) 800-285-6477 www.chiparkansas.org

Arkansas Association of Health Underwriters 703-276-0220 www.arkansas-ahu.org

Assorted plans depending on medical needs There is a 12-month look-back and 24-month exclusionary period limit Limits on pre-existing health conditions may apply


Low income individuals and families Medicaid

(Including ARKids A) 800-482-8988 800-482-5431 501-682-8233 www.medicaid.state.ar.us

Safety Net Benefits Program 800-540-7566 www.arhealthnetworks.com

$1M lifetime benefits offering: comprehensive coverage of doctor visits, prescription drugs, outpatient and inhospital care, ambulance, labs and x-rays, skilled nursing care, home health visits, maternity, preventive care, transplants, rehabilitation, durable medical equipment, mental health and substance abuse, and physical and occupational therapy among other services Pre-Existing Health Conditions Covered

Medicaid & ARKids A: Family planning, home health inpatient, laboratory and x-ray nurse-midwife, nursing facility outpatient, physician, ambulatory surgical center, hearing, chiropractic, dental durable medical equipment, ElderChoices, Prescription Drugs, Prosthetics, Psychology Services, Rehabilitative Services for Persons with Mental Illness and Physical Disabilities, Targeted Case Management, Transportation Services, Ventilator Equipment, Visual Services …and more Safety Net Benefits: You get limited benefits each 12 months including: 7 inpatient days a year, 2 major outpatient services (emergency room and major services performed in the office), 6 physician office visits, 2 prescriptions a month, maximum annual benefit of $100,000 Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE Company size 2-50 employees (including owner)

Monthly Cost

Eligibility


7

Owner name on business license must draw wages from the company Most small group carriers also require 75% employee participation and accept employees who sign a waiver indicating other coverage as counting towards the 75%


Arkansas

GUARANTEED COVERAGE COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for CHIP, see next column

COBRA is for businesses with 20+ employees, Mini- COBRA is for business with under 20 employees HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. For HIPAA, you cannot be eligible for Medicare or other public or group insurance programs

COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Resident of Arkansas for at least 90 days or resident for at least 30 days with evidence of coverage under a Qualified High Risk Pool of another state

Medicaid: Pregnant women & children ages 0-19: 200% FPL Supplemental Security Income Recipients: 74% FPL Parents: 15% FPL

Not be enrolled in or eligible for Group Health Plan, Part A or B of Medicare or the Arkansas Medical Assistance Program (Medicaid and ARKids). Cannot be eligible for group coverage or COBRA, or government programs (must have exhausted this option)

ARKids A: Children under age 6 with family income up to 133 FPL; children ages 6 through 18 up to 100 FPL; also covers children between 133 and 200% FPL who do not meet certain ARKids B eligibility

May need to prove denial of coverage or offer of higher premium

Safety Net Benefits: Must live in Arkansas, Employees must be between the ages of 19-64, Must be a U.S. Citizen, Income at or below 200% of the FPL

May also be federally-eligible for CHIP


$1000 out-of-pocket

deductible and $1000 outof-pocket annual maximum for in-network care Monthly rates are determined by Age, Gender, and Tobacco Usage

$0 or minimal share-of-cost Safety Net Benefits: $100 annual deductible (does not apply to office visits & Rx) After deductible, 15% co-coverage will be required $1,000 maximum out of pocket annually, including deductible

800.234.1317


Women

ARKids First B

Breast Care

877-670-CARE 877-670-2273 501-661-2513 www.arbreastcare.com

Arkansas MotherInfant Program 501-661-2154 www.adhhomecare.org/ maternal.htm

Maternity Program 501-661-2480


Breast Care: Mammograms, pap tests and pelvic exams, breast exams, colonoscopy, colonoscopy with biopsy. Free information about how to find breast and cervical cancer early Arkansas Mother-Infant Program: Skilled home nursing visits for new mothers and infants to meet their medical, social and nutritional needs Maternity Program: Prenatal and postpartum care including a medical, nutritional and social assessment and case management, education on pregnancy, nutrition, labor and delivery, infant care, reproductive

Veterans

Medicare






877-222-8387 www.va.gov

800-633-4227

Senior’s Health Insurance Information Program (SHIIP) 800-224-6330 501-371-2782



SHIIP is a Medicare counseling service




Coverage

Two plans that include many of the following: ambulance (emergency only), chiropractor, dental care (orthodontia included) durable medical equipment, ER services, EPSDT screens, family planning, hearing, home health, hospice, immunizations, inpatient hospital, inpatient, psych laboratory and x-ray, midwife outpatient mental and behavioral health, physician, psychology, podiatry, drugs, prescription therapy services (speech), occupational, and physical transportation, vision


Program

(Children’s Health Insurance Plan) 501-682-8269 888-474-8275 www.arkidsfirst.com


Demographic




GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

ARKids B covers uninsured children through age 18 with family income up to 200% FPL

All: No health insurance, or your health insurance does not cover the services

Both: Age 65 and older


Age restrictions for each service

People with End-State Renal Disease (permanent kidney failure requiring dialysis or kidney transplant


Under approximately 180% FPL




20% of the insurance


Eligibility

Not enrolled in certain state plans

of durable medical equipment and inpatient hospital care, which both require a 20 percent coinsurance payment for ARKids B


$0 and share of cost for certain services; deductibles for certain plans

premium

www.coverageforall.org Arkansas

Monthly Cost

$0-$10 with the exceptions

8

Demographic

Private Health Insurance Small Businesses (2-50 employees)




COBRA or Cal-COBRA


800-234-1317

Program

Group Plans

California Association of Health Underwriters 800-322-5934 www.cahu.org

Then convert to

HIPAA

(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov

800-234-1317

Individual Plans California Association of Health Underwriters 800-322-5934 www.cahu.org

Individuals with pre-existing, severe or chronic medical conditions MRMIP

Medi-Cal

(Major Risk Medical Insurance Program) 800-289-6574 www.mrmib.ca.gov

California’s Medicaid Program 800-952-5253 888-747-1222 www.medi-cal.ca.gov

Due to changes in the program, MRMIP has opened up a waitlist

Or contact local county social services agency www.dhs.ca.gov

AIM

HIPP

Access for Infants & Mothers 800-433-2611 www.aim.ca.gov

(Health Insurance Premium Payment) www.dhcs.ca.gov/

Different plans cover different medical services

Coverage

Sometimes coverage is limited to $1M in a lifetime; often $5M and some plans have no limit

COBRA or Cal-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium

These factors affect the monthly premium and deductibles


If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply



Low income families & medically needy

Different plans will cover different medical services There may also be a lifetime maximum of benefits, for example $5M Limits on Pre-Existing Health Conditions May Apply

MRMIP is a 36 month program. After that, subscribers can enroll in guaranteed coverage with private health plans Under MRMIP, there is a $75K annual limit and $500 annual deductible Coverage increases to $200K per year (with a $750K lifetime limit) once subscriber moves to a GUARANTEED COVERAGE private insurance individual plan MRMIP offers a variety of medical services provided by HMOs and PPOs.


Medi-Cal: Offers health, dental, vision, and prescription coverage; Treatment for special health problems like breast cancer, kidney problems, nursing home needs, and AIDS AIM: comprehensive medical care for mother provided (not just maternity); mothers continue coverage up to 60 days after delivery; after birth, infant is automatically enrolled in Healthy Families Program up to age 1 Pre-Existing Health Conditions Covered

MRMIP has a 3 month exclusion period for pre-existing conditions. Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE


COBRA or Cal-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage

Eligibility

Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage Owner can count as an employee Owner name on business license must draw wages from the company

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for MRMIP, see next column

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA

Monthly Cost

COBRA or Cal-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Cal-COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column

GUARANTEED COVERAGE

Eligible if previous coverage was terminated for reasons other than non-payment of premium or fraud (such as a pre-existing condition)

Medi-Cal: Age < 1: Up to 200% FPL Ages 1-5: Up to 133% FPL Ages 6-18: Up to 100% FPL If you are pregnant, your income can be up to 200% FPL; Children under 21 in foster care, parents: Up to 107% FPL If you are elderly or disabled, your income can be up to 133% FPL

Must prove denial of coverage or offer of higher premium than MRMIP Cannot be eligible for COBRA, CalCobra, or government programs (except “end stage renal disease” covered under Medicare)

Cal-COBRA: Applies to small businesses with less than 20 employees

Live in California Subscriber must select from health plan carriers that offer post-MRMIP GUARANTEED COVERAGE Cannot be eligible for both Part A and Part B of Medicare

HIPP: You may be eligible for HIPP if you have a high-cost health condition (e.g., pregnancy, HIV/AIDS), and are eligible for Medi-Cal Cost depends on the employer contribution and ±10% of the insurance company’s index rate

GUARANTEED COVERAGE


Costs vary depending on age, region in CA, and program $2,500/year out-of-pocket max for subscribers. Annual out-ofpocket limits per household (subscriber + dependents) is approximately $4,000

AIM: 200%-300% FPL for AIM Pregnant less than 31 weeks; Live in California; California resident for at least 6 months; legal immigration status; You cannot be receiving no-cost Medi-Cal or Medicare Part A and Part B benefits as of the application date; Cannot be covered by private insurance costing $500 or less

Medi-Cal: $0 or minimal share of cost AIM: 1.5% of family annual income for AIM


9

California

800.234.1317

Children in low income families or undocumented children Healthy Kids Plans

(County based program) www.partnershiphp.org www.champ-net.org/programs/hkLA.cfm

CaliforniaKids

Kaiser Permanente Child Health Plan

800-464-4000 http://info.kp.org/childhealthplan/

Children Health and Disability Prevention (CHDP)

Medi-Cal

California’s Medicaid Program 800-952-5253 888-747-1222 www.medi-cal.ca.gov

AIM

Access for Infants & Mothers 800-433-2611 www.aim.ca.gov

Healthy Families Program

800-880-5305 888-747-1222 www.healthyfamilies.ca.gov

Adults without dependents

Immigrants awaiting legal status

County Medical Services Program (CMSP)

Restricted Medi-Cal

Contact local county social services agency www.cmspcounties.org

Genetically Handicapped Persons Program (GHPP)

916-327-0470 800-639-0597 www.dhcs.ca.gov/services/ ghpp

California’s Medicaid Program 800-952-5253 www.medi-cal.ca.gov

Family PACT

(Family planning) 916-650-0414 www.familypact.org For local programs contact www.dhs.ca.gov

Adults in need of cancer screening IMPACT

800-409-8252 www.california-impact. org

Breast and Cervical Cancer Screening & Treatment 800-824-0088 www.dhs.ca.gov/ cancerdetection

Program

818-755-9700 www.californiakids.org

Pregnant women, infants, & moderate income children

Demographic


Call your local CHDP provider www.dhs.ca.gov/pcfh/cms/chdp/ Healthy Kids, California Kids & KPCHP: All programs offer a variety of health, dental, and vision plans from which to choose, includes hospitalization KPCHP: Effective July 17, 2009, enrollment is now closed to new membership from Southern California. A future re-open date has not been determined.


AIM: comprehensive medical care for mother provided (not just maternity); mothers continue coverage up to 60 days after delivery; after birth, infant is automatically enrolled in Healthy Families Program up to age 1 Healthy Families Program: Offers a variety of health, dental, vision, and prescription plans from which to choose Pre-Existing Health Conditions Covered

CMSP: Program availability varies by county, Medically necessary physician and hospital-related services; Depending on county, may provide coverage for other services such as dental and vision; Benefits vary by county, please refer to social services agency in county of residence GHPP: Special care center services, hospital stay, outpatient medical care, pharmaceutical services, surgeries, nutrition products and medical foods, durable medical equipment, and other services

Restricted Medi-Cal: covers emergencies, pregnancy related care (prenatal and delivery), kidney dialysis, treatment for breast and cervical cancer Family PACT: provides comprehensive family planning services Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Healthy Kids: Must be a resident of Solano, Napa, Yolo or Sonoma County. Must not be covered by an employer sponsored plan now or in the last 3 months. Children must be between the ages of 0-18. Children’s family income can be between 0-300% of the FPL. Not Eligible for no-cost full-scope Medi-Cal or Healthy Families. Undocumented children are eligible.

Medi-Cal: If you are pregnant, your income can be up to 200% FPL

CMSP: Must be between the ages of 21-64, Must not be eligible for Medi-Cal; Must reside in county where applying; In CMSP counties, income can be up to 200% FPL; In non-CMSP counties, eligibility income standards vary, please refer to social services agency in county of residence

Restricted Medi-Cal: Age < 1: Up to 200% FPL Ages 1-5: Up to 133% FPL Ages 6-18: Up to 100% FPL

KPCHP: California resident living near Kaiser or in county plan area. Must not be eligible for employer based coverage CHDP: Children and youth between birth and age of 19 whose family is at 200% FPL or less. Also children in Headstart, State Preschool programs, and Foster Care.

Healthy Families Program: Age < 1: 200%-250% FPL Ages 1-5: 133%-250% FPL Ages 6-18: 100%-250% FPL Must be ineligible for no-cost MediCal or employer-based coverage; California residents and legal immigrants

GHPP: Must be diagnosed with a genetic condition that is covered by GHPP; Applicants must be residents of California; Applicants must be 21 years of age or older (some persons younger than 21 years of age may be eligible); there is no income limit; Applicants may be required to apply for Medi-Cal.

If you are pregnant, your income can be up to 200% FPL If you are elderly or disabled, your income can be up to 133% FPL Family PACT: up to 200% FPL No insurance or ineligible for Medi-Cal Insurance does not cover family planning or birth control methods. Have not met deductible of current insurance.

GUARANTEED COVERAGE IMPACT: California resident over 18 years old, Little or no insurance, Up to 200% FPL, Abnormal DRE, PSA or diagnosed with prostate cancer BCCST: 40 years old or older, with an income of 200% of the FPL, uninsured or have medical insurance that does not cover these services; not getting these services through Medi-Cal or another government-sponsored program; Women 25 and older can receive cervical cancer screening

Eligibility

GUARANTEED COVERAGE

CaliforniaKids: Must not be eligible for other government plans such as Medi-Cal or Healthy Families Program

BCCST: women can get screening and treatment Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

AIM: 200%-300% FPL for AIM; Pregnant less than 31 weeks; Live in California; California resident for at least 6 months; legal immigration status; You cannot be receiving nocost Medi-Cal or Medicare Part A and Part B benefits as of the application date; Insurance deductibles or copayments over $500 may qualify you

IMPACT: Provides men with radical prostatectomy, external beam radiation therapy, hormone therapy, watchful waiting, brachytherapy, chemotherapy, counseling and more

Coverage

CHDP: Only covers general check ups required for school, sports, etc. (Does not cover hospital, medicines, or any emergencies)

Medi-Cal: pregnancy related care (prenatal and delivery) is covered. Mothers are covered up to 60 days after delivery

Have Medi-Cal with share of cost but you have not met your share of cost.

Medi-Cal: $0 or minimal share of cost AIM: 1.5% of family annual income for AIM

Healthy Families : $4-$24 per child depending on income and choice of plan, with a $72 family maximum; $5 copay for doctor visits and prescriptions; some check-ups are no-cost

CMSP: $0 or minimal share of cost

$0 or minimal share of cost


GHPP: Some clients may also be required to pay an annual enrollment fee to GHPP. The amount of enrollment fee is based on income and family size.

www.coverageforall.org California

Monthly Cost

Healthy Kids: Monthly premiums are $0-6; $5 co-pay for most outpatient services. CaliforniaKids: $10-20 per month per child; $5-50 co-pays for services KPCHP: $8-15 per child per month ($45 max per family), co-pays range from $5-$35 for some services with a $250/child or $500 for two or more children maximum CHDP: $0 or minimal share of cost

10

Demographic

Private Health Insurance Small businesses (1-50 Employees)




Low Income Families and Medically Needy


COBRA/ Mini-COBRA


CoverColorado

Colorado Health Plan

HIPAA

Individual Plans

Program

800-234-1317

Group Health

Colorado State Association of Health Underwriters 703-276-0220 www.nahu.org

Then convert to


800-234-1317

800-930-3745 303-894-7490 www.dora.state.co.us/ insurance

(Colorado Medical Insurance Pool) 303-749-1111 888-770-1120 877-461-3811 (Billing) 303-863-1960 (Enrollment) www.covercolorado.org (Colorado Blue Cross Blue Shield Plan Administrator)

Waiting periods for coverage on certain conditions may apply

Coverage


Contact your local county offices for Medicaid information in your county. List of numbers can be found here: www.cdhs.state.co.us/ servicebycounty.htm

Or

State Continuation Coverage Assorted deductibles

(Medicaid) 800-283-3221 www.chcpf.state.co.us

COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer

Different plans will cover different medical services

COBRA Subsidy: 15 months of partially subsidized COBRA premium

Limits on Pre-Existing Health Conditions May Apply

There may also be a lifetime maximum of benefits, for example $5M

HIPAA: Individual-plan conversion benefits are based on the program selected and there is no expiration of coverage

CoverColorado offers a statewide major medical plan, with eight deductible levels to choose from Hospitalization, physician care, diagnostic tests, x-rays, prescription drugs, and some mental health care services If you have not been insured within the past 90 days prior to applying, expenses related to any pre-existing medical condition will not be covered for the first 6 months

Diagnosis (services to find out what is wrong), Physician services, check-ups (medical and dental), family planning, maternity, prenatal, and newborn care, prescriptions, hospital services, comfort care, hospice, dental services, drug and alcohol treatment, mental health services Pre-Existing Health Conditions Covered

If you have been insured, for at least six continuous months, within 90 days of application to CoverColorado, you will not be subject to the 6-month preexisting waiting period



GUARANTEED COVERAGE

Company size 1-50

COBRA or Mini-COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage

Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage

Eligibility

Owner can count as an employee Proprietor-name on license must draw wages If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions- not counting birth or adoptionmay apply, (1-6 months respectively)

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for CoverColorado, see next column

COBRA is for businesses with 20+ employees, Mini- COBRA is for business with under 20 employees

GUARANTEED COVERAGE

GUARANTEED COVERAGE

You must have resided in Colorado as a legal resident for at least six months prior to applying for coverage, unless you are HIPAA eligible or transferring from another state’s high risk insurance pool; Cannot be eligible for Medicaid, Medicare or any other health insurance; Must not have been terminated from CoverColorado in the 12 months prior to your application or have received $1,000,000 in benefits from the CoverColorado program; unless you are HIPAA eligible

Pregnant women and children under the age of 6 income at or below 133% of the FPL Children age 6-18 income at or below 100% of the FPL Parents income at or below 60% of the FPL SSI Disabled income at or below 74% of the FPL Some eligibility requirements change from county to county so contact your local county department

Monthly Cost


11

Costs depend on employer contribution and +10% or -25% of the insurance company’s index rate

COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column

Colorado

Costs depend on age and county/zone If you are self-employed and buy your own insurance you are eligible to deduct 100% of the cost of the premium from your federal income tax

Premiums vary based on the plan and deductible you choose and underwriting guidelines

$0 for children and pregnant

women; $0 or small co-pays for Adults

800.234.1317

Low Income Children

Women



Veterans

Child Health Plan Plus

Women’s Wellness Connection




(WCC) 303-692-2581 866-951-WELL 866-951-9355 www.cdphe.state.co.us/ pp/cwcci

970-563-9443 www.ihs.gov/FacilitiesServices/ AreaOffices/AreaOffices_index. asp


877-222-8387 www.va.gov

Listed under "Albuquerque Area" for "Southern Colorado UTE Service Unit"

Regular checkups, Immunizations (shots), Prescriptions (medicine), Hospital services, Eye glasses, Hearing aids

Cancer treatment for some women qualified through Medicaid


Care includes medical, nursing, dental, optometry, nutrition, health education, community health nursing, mental health, social services, substance abuse, and environmental health services, well-child, chronic diseases, allergy, women's health, and podiatry. Pharmacy, laboratory and radiology services are all provided at the centers, including in-patient and specialty care with providers in neighboring areas

Will cover 80% of COBRA if employer contributes less than 50% (or spouses’ employer)

Comprehensive preventive and primary care, outpatient and inpatient services




Coverage

Dental services up to $600 a year including exams, cleanings, and some other services

Some diagnostic services such as ultrasound, breast biopsy, surgical consultation, colonoscopy

Program

(CHP+) 800-359-1991 www.cchp.org

Demographic



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Must not be eligible for Medicaid

Age 40-64

The Southern Colorado Ute Service Unit serves the Southern Ute and the Ute Mountain Ute Tribes



Colorado residents; U.S. citizens or permanent U.S. residents (who have had an Alien Registration number for at least 5 years)

Income below 250% FPL Must not have had pap or mammogram test in last 12 months




$0 and share of cost and co-

Eligibility

Not covered by any other insurances

Under-insured or uninsured

18 and younger Household income of 200% FPL

$0 for most members

$0 or small share of cost


www.coverageforall.org Colorado

Monthly Cost

pays depending on income level

For those who have to pay, enrollment fee is $25 for one child, $35 for 2+children. Co pays are $2 - $15 per visit for routine medical care

12

Demographic






COBRA/ Mini-COBRA


Group Plans

HIPAA

Connecticut Health Reinsurance Association

Individual Plans

Program

800-234-1317

Connecticut Insurance Department 800-297-3900 800-203-3447 www.ct.gov/cid

(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov 617-565-9600

800-234-1317

Connecticut Insurance Department 860-297-3900 800-203-3447 www.ct.gov/cid

800-842-0004 www.hract.org/hra

Low income individuals and families

Medicaid

800-842-1508 800-842-4524 (TDD/TYY) www.dss.state.ct.us

Or

State Conversion Policy

Coverage

Mostly plans with co-pays, some with deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions- not counting birth or adoptionmay apply, (1-6 months respectively) Pre-Existing Health Conditions Covered


Different plans will cover different medical services


Limits on Pre-Existing Health Conditions May Apply

There may also be a lifetime maximum of benefits, for example $5M


GUARANTEED COVERAGE

Company size 1-50


If in business 90 days or more, can usually qualify

Eligibility

Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage Owner can count as an employee; Proprietor name on license must draw wages Twice annually, self-employed persons can join a small group health plan with guarantee issue

Choose from three conversion plans: HMO, PPO and a Special Health Care Plan (no waiting period for pre-existing conditions if you qualify) All benefits are the same except the Special plan which does not cover out patient prescriptions


Choose from two individual plans: PPO or a Special Health Care Plan (12 month waiting period for pre-existing conditions)

Diagnosis, physician services, check-ups (medical and dental), family planning, maternity, prenatal, and newborn care, prescriptions, hospital services, comfort care, hospice, dental services, drug and alcohol treatment, mental health services Some services may need prior approval Pre-Existing Health Conditions Covered


GUARANTEED COVERAGE


Guaranteed to all Connecticut residents

Residents with legal immigration status

If you are denied coverage for a medical condition, you may be eligible for a Connecticut Health Reinsurance Association Plan, see next column

If HIPAA-eligible then no pre-existing exclusion period

Pregnant Women, Infants, and Children up to the age 19: 185% FPL (called Husky A)

Previous coverage terminated for reasons other than nonpayment of premium or fraud Anyone under age 65

Non-Working Parents: 100% of FPL Working Parents: 107% of FPL Medically Needy Individual: 80% or 66% of FPL


Couple: 76% or 59% of the FPL Supplemental Security Income Recipients: 69% of the FPL

Monthly Cost


13

Costs depend on employer contribution and the Modified Community Rate

COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium


Premiums vary depending on the applicants income level, age, sex, family size,and plan chosen

$0; may share in some costs

Rates are usually capped by state law at a level between 150 and 200% of standard market rates

COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column

Connecticut

800.234.1317


SAGA

Call 211 or contact local social services office

Women

Adults

HUSKY

Connecticut Breast and Cervical Cancer Early Detection Program

Charter Oak Health Plan

(Health Care for Uninsured Kids and Youth) 877-CT-HUSKY 877-284-8759 800-656-6684 www.huskyhealth.com

860-509-7804 www.dph.state.ct.us

877-77-CTOAK 877-772-8625 www.ct.gov/coh/site/default. asp


Medicare

(Age 65 and up) 800-MEDICARE 800-633-4227 www.medicare.gov


Program

(State Administered General Assistance) 866-361-SAGA 866-361-7242 www.chnct.org

Children

Demographic

Low income persons ineligible for other public programs

Connecticut CHOICES Program (Medicare advice) 800-994-9422

Comprehensive medical care with the exception of long term care and non-emergency medical transportation

There are two plans: Husky A and Husky B Husky A is Medicaid Pre-Existing Health Conditions Covered

Screening and Diagnostic Services Include: office visits, mammograms, breast biopsies and ultrasounds, fine needle aspirations, pap tests, LEEP, Surgical consultations, clinical breast exams, and Colposcopies and Colposopydirected biopsies

Covers primary care, specialist office visits, preventive care, ambulance, emergency room visit, prescription medication, durable medical equipment, behavioral health services, inpatient and outpatient services, pre- and post-natal care, Lifetime maximum benefit of $1 million, annual maximum benefit $100,000




Connecticut CHOICES Program is a Medicare counseling service

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Ineligible for state or federal programs such as Medicaid

Children must be under age 19 and reside in Connecticut

Be at or below 200% FPL

Connecticut adults between the ages of 19 to 64.

The income limit for an individual ranges from $502.22 monthly to $610.61, depending on what region of the state he or she lives in. The asset limit is $1,000 per household

Income level numbers, HUSKY A (Medicaid) is for children, parents and other caregivers with incomes under 185% of the federal poverty level. It also covers pregnant women with incomes under 250% of the federal poverty level.

Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).


HUSKY B is only for children with family incomes over 185% of poverty. There is no income limit for HUSKY B, so any child can qualify. Families with an income greater than 300% of the FPL can buy into a HUSKY plan

Have an insurance deductible of $1,000 or more Be 40 to 64 years of age for Mammograms

There are no income limits. Depending on your income, your monthly premiums may be subsidized.

19 to 64 years of age for Clinical Breast Exams & Pap tests

No co-pays or premiums

$93-$296 for monthly premiums depending on your family income



Primary Care Office Visit: $25 co-pay; Specialist Office Visit: $35 co-pay

www.coverageforall.org Connecticut

Monthly Cost

Husky A: No premiums or co-pays Husky B: Families between 185235% FPL have a max of $760 on yearly co-pays and no premiums; family between 235%-300% FPL have a $1,360 maximum combination of co-pays and premiums; Over 300% FPL buy into the plan at negotiated group price.

Uninsured or insurance plan without diagnostic coverage

Cannot be covered six months prior to apply for Charter Health Oak Plan. There are exceptions to this rule.

Eligibility

No categorical program requirements; eligibility is based on income and assets only. The income limit for an individual ranges from $476.19 monthly to $574.86, depending on what region of the state he/ she lives in; and the asset limit is $1,000 per assistance unit (household). SAGA medical is not automatically linked to SAGA cash

Women age 40 and older (35-39 if history or symptoms, age 19 and older may qualify for pap test)

Coverage


Comprehensive care through a managed care program

14

Demographic





Parents and children


COBRA


Medicaid

Children and Families First

800-234-1317

Program

Group Health

Delaware Association of Health Underwriters 703-276-0220 www.nahu.org

Coverage


Eligibility Monthly Cost

HIPAA



800-234-1317

Individual Plans

800-734-2388 www.cffde.org

Delaware Association of Health Underwriters 703-276-0220 www.nahu.org

Assorted plans depending on medical needs There are no restrictions on carriers to look at pre-existing conditions Limits on pre-existing health conditions may apply


Doctor visits, hospital care, labs, prescription drugs, transportation, routine shots for children, mental health and substance abuse services, X-rays, home health care, hospice care, dental care (up to age 21)

Special medical foster care, resource mothers program, counseling, education and more



GUARANTEED COVERAGE

GUARANTEED COVERAGE

Company size 1-50 employees (including owner)



15

And then

302-255-9500 800-372-2022 www.dhss.delaware.gov/dhss/


Costs depend on employer contribution or health condition of self-employed and ± 35% of the insurance company’s index rate


GUARANTEED COVERAGE

Pregnant women and infants age 0-1: 200% FPL

Low income in need of services

Children (ages 1-5): 133% FPL Parents: 117% FPL Children ages 6-19 and working parents: 100% FPL (also aged, blind and disabled) SSI recipients: 133% FPL U.S. citizens or qualified legal residents

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs


GUARANTEED COVERAGE


No premium no co-pay

No premium no co-pay


Delaware

800.234.1317

Children

Adults

Delaware Healthy Children Program

Delaware Screening for Life

800-996-9969 www.dhss.delaware.gov/dhss/

800-464-HELP 800-464-4357 www.state.de.us/dhss/dph/ dpc/sfl.html



Veterans

Medicare




877-222-8387 www.va.gov

Program



800-633-4227

ELDER Info 800-336-9500

Office visits, mammograms and clinical breast exams for breast cancer, pap tests, colorectal cancer screening tests recommended by your doctor, health education, help with coordinating associated care Pre-Existing Health Conditions Covered


Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug progam called Medicare Part D


ELDER Info is a Medicare counseling service that educates and assists Medicare beneficiaries, those eligible for Medicare, and caregivers about Medicare, Medicaid, Medigap, prescription drug benefits, and other issues related to health insurance benefits.




Coverage

Well-baby and well-child checkups, drug/alcohol abuse treatment, speech/hearing therapy, immunizations physical therapy, eye exams ambulance services, prescription drugs, hospital care, physician services, X-rays, lab work, assistive technology, mental health counseling, limited home health and nursing care, case management and coordination, hospice care, and comprehensive dental service

Demographic



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Under age 19; Family Income at or below 200% FPL; Must not have other comprehensive health insurance coverage; Must reside in the State; Must be a U.S. citizen or qualified noncitizen; and not be a dependent of a permanent State employee

You are between the ages of 18 and 64

Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with EndStage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).



Waiting period may apply

No insurance or private HMO; and not eligible for Medicare or Medicaid

DE Screening: 65+ if not eligible for Medicare

Not enrolled in certain state plans Age 55 and older


Eligibility

Underinsured: High, unmet deductible; or insurance that does not cover Pap tests, mammograms or colorectal screenings


At or below 250% FPL Age restrictions for each service Age 18-49 - Office visit, Pap test, pelvic exam, clinical breast exam, breast exam education Age 40-49 - Mammograms, with an abnormal clinical breast exam in past 6 months Age 50-64 - ALL services + colorectal screening Age 65+ - ALL services + colorectal screening if not eligible for Medicare

$0 or share of cost




$0 and share of cost and

co-pays depending on income level

www.coverageforall.org Delaware

Monthly Cost

$10 to $25 monthly premium and no co-pays depending on income. For every 3 months you pay in advance, you get the 4th month free.

16

Demographic Program






COBRA and Mini-COBRA


Cover Florida

800-234-1317

Group Health

Florida Association of Health Underwriters www.fahu.org

Coverage

Up to $5M lifetime maximum, assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply Pre-Existing Health Conditions Covered

And then

HIPAA

Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov COBRA or Mini-COBRA: Coverage available for 18 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE




Eligibility

Owner can count as an employee Owner name on business license must draw wages from the company Groups of one have open enrollment during limited times during the year

800-234-1317

Individual Plans

Florida Association of Health Underwriters www.fahu.org

Assorted plans depending on medical needs There is a 24-month look-back and exclusionary period limit for pre-existing conditions in traditional individual market health insurance products in Florida Pre-existing conditions may not be considered for HIPAA-eligible population Limits on pre-existing health conditions may apply

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for Cover Florida, see next column

877-MY-FL-CFO 877-693-5236 850-413-3089 (out of state) www.coverfloridahealthcare. com

Six carriers have designed 27 creative health insurance products. Each carrier offers at least two benefit options – one with catastrophic and hospital coverage, and one without. Benefits include preventive services, screenings, office visits, as well as office surgery, urgent care, hospital coverage, emergency care, prescription drugs, durable medical equipment, and diabetic supplies. Pre-Existing Health Conditions Covered

Monthly Cost

17


Florida

Among some of the services: ambulatory surgical center birth center services, child health check up chiropractic care, durable medical equipment and supplies, federally qualified health centers, home health hospital inpatient/outpatient care, laboratory, licensed midwives, physician, podiatry prescriptions, rural health clinics, therapy, X-rays Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

Ages 19 to 64 who have been without health insurance for at least six months – even if there are pre-existing health conditions. May also qualify if you lost your job that provided employer-sponsored health benefits, lost of benefits under COBRA; death of, or divorce from, a spouse who has provided employer-sponsored health benefits.

Pregnant Women: 185% FPL Children (Ages 0-1): 200% FPL Children (ages 1-5): 133% FPL Children (ages 6-19): 100% FPL Aged, Blind and Disabled: 90% FPL Supplemental Security Income Recipients: 74% FPL Working Parents: 62% FPL Non-Working Parents: 23% FPL Medically Needy: 25% FPL, there is an asset limit $5,000+ depending on family size



Medicaid

850-488-3560 www.fdhc.state.fl.us/Medicaid

GUARANTEED COVERAGE

No asset or resource requirements for children or pregnant mothers

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs Costs depend on employer contribution and ± 15% of the Modified Community Rate


Florida resident


Premiums vary depending on the applicant’s age, gender and chosen benefit options.

$0 or $1-3 co-pays, and

coinsurance is limited to 5% up to $300 for each visit to the Emergency Room No cost for pregnant women, children and certain others

800.234.1317

Children

Women

Florida KidCare


800-227-2345 www.doh.state.fl.us/Family/bcc


Veterans

Medicare






877-222-8387 www.va.gov

Program

MediKids, Healthy Kids, Children’s Medical Services and Medicaid 888-540-5437 877-316-8748 TTD www.floridakidcare.org


Demographic


800-633-4227

Comprehensive health insurance coverage


Medicare offers two standard plans, A: Hospital Insurance and B: Medical Insurance, as well as several supplemental and advantage plans Pre-Existing Health Conditions Covered

Will cover 80% of your COBRA if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits


Coverage

Benefits vary based on the segment of the program in which a child participates— MediKids, Healthy Kids, or the Children’s Medical Services (CMS) Network for children with special health care needs

Breast and cervical cancer screening exams (mammograms, pap smears and clinical breast exams) are provided to diagnostic exams are provided as necessary case management is provided to all clients


Outreach, public education and professional education is provided Treatment for eligible women may be paid by Medicaid

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Under age 19 and uninsured

Uninsured and underinsured women 50 to 64 years of age, at or below 200% of FPL




Have an income at or below 200% of the FPL Be a U.S. citizen or qualified non-citizen Cannot be eligible for Medicaid

Age 55 and older






www.coverageforall.org Florida

Monthly Cost

Premium is based on household size and monthly income. Most families pay either $15 or $20 per family per month; some families may pay more. There may be co-payments required based on the service provided


Eligibility

Not be the dependent of a state employee eligible for health insurance and not in a public institution


18

Demographic





Children


COBRA


Medicaid

PeachCare for Kids

Program

800-234-1317

Group Health

Georgia Association of Health Underwriters 703-276-0220 www.gahu.org

Then convert to

HIPAA


800-234-1317

Individual Plans

866-211-0950 770-570-3373 http://dch.georgia. gov/00/channel_

877-GA-PEACH 877-427-3224 www.peachcare.org

Women-InfantsChildren (WIC)

Georgia Association of Health Underwriters 703-276-0220 www.gahu.org

404-657-2900 800-228-9173 www.health.state.ga.us/ programs/wic/index.asp

or

State Conversion Policies Pre-existing conditions can be excluded for a limited time depending upon the type of group plan you are joining

Coverage


COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage

Depends on plan Plans are required by state to offer certain benefits such as mammograms, childhood immunizations and automatic coverage for newborns or adopted children

Medical, dental and vision, prescriptions, hospitalization and more depending on program Pre-Existing Health Conditions Covered

PeachCare for Kids: Doctor visits, check-ups, immunizations, preventive care specialist care, dental care, vision care, hospitalization, emergency room services, prescriptions, and mental health care WIC: Nutrition assessment, health screening, medical history, body measurement (weight and height), hemoglobin check, nutrition education, breast-feeding support and education, and vouchers for food supplements

Limits on pre-existing health conditions may apply



GUARANTEED COVERAGE

GUARANTEED COVERAGE




Eligibility

Proprietor name on license must draw wages

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Eligibility is based on medical underwriting

Pregnant women at or below 200% FPL

There is a 12 month look back period during first two years of coverage. If condition is deemed preexisting there can be a 24 month exclusionary period.

Children age 0-1 up to 185% FPL

PeachCare for Kids: Low income children up to age 19 under 235% FPL; Uninsured and ineligible for Medicaid; U.S. citizens, certain qualified legal residents, refugees or asylees who reside in Georgia

Must be resident of state or documented immigrant

Children age 1-5 up to 133% FPL Children age 6-19 up to 100% FPL Working parents up to 52% FPL Non-working parents up to 29% FPL Medically needy individual up to 35% FPL


WIC: Pregnant or postpartum women and children up to the age of 5 years with a family income at or below 185% of the FPL. Must be a state resident; and be at nutritional or medical risk, as determined by a health professional.

Medically needy couple up to 41% FPL Georgia resident or documented immigrant

Monthly Cost

Must be a Georgia resident

19



Georgia

Various price ranges depending on deductible and what plan you buy.


PeachCare for Kids: $0 for children under age 6, $10-35 for one child, max of $70 for two or more children WIC: $0 or minimal share-ofcost

800.234.1317

Infants and children with developmental delays

Women

Babies Can’t Wait

Georgia Cancer Screening Program 404-657-6611 www.georgiacancer.org

Babies Born Healthy 404-657-3147 www.health.state.ga.us/ programs/perinatal


Veterans

Medicare






877-222-8387 www.va.gov

Program

404-657-2726 888-651-8224 www.babiescantwaitcentralga. org


Demographic


800-633-4227

Georgia Cares

800-669-8387 (Assistance for seniors)

Comprehensive preventive and primary care, outpatient and in-patient services Pre-Existing Health Conditions Covered

Babies Born Healthy: Comprehensive, quality, prenatal services as early as possible in their pregnancy



Georgia Cares is a Medicare counseling service




Coverage

Georgia Cancer Screening Program: Offers clinical breast examinations, mammograms, and pelvic examinations and pap tests if you’re older than 40 years old. If screened and diagnosed for breast or cervical cancer may be eligible for complete health coverage through Medicaid



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Babies Can’t Wait: Generally children may qualify if they are very far behind in learning to move, talk or use their hands or; they are automatically eligible if they are diagnosed with certain physical and mental conditions.

Georgia Cancer Screening Program: Must be Georgia resident and have legal immigration status For mammograms must be between 40 and 64 years of age









For cervical screening must be between 18 and 64 years of age Must be uninsured or underinsured, ineligible for Medicaid with income under 200% of FPL

Eligibility

Covers babies from birth up to their third birthday


Babies Born Healthy: Pregnant women and newborns with a family income at or below 250% of the FPL. Cannot be eligible for Medicaid.

Georgia Cancer Screening Program:

$0

Babies Born Healthy: $0 or minimal share-of-cost


premium

www.coverageforall.org Georgia

Monthly Cost

$0 or share-of-cost and copays depending on income level

20

Demographic





Children


COBRA


Medicaid

HMSA Children's Plan

Program

800-234-1317

Group Health

National Association Of Health Underwriters 703-276-0220 www.nahu.org

Coverage

Hawaii does not have a statute that defines the size of their small group market. Most carriers define it as 1-50 however some use the definition of 1-100 Individuals who attempt to obtain coverage as a business group of one must satisfy criteria set by the carrier Pre-Existing Health Conditions Covered

Then convert to

HIPAA



800-234-1317

Individual Plans

Options vary depending on applicant needs and plan selected Limits on pre-existing health conditions may apply


Eligibility

All employers are required to offer coverage to most employees who work 20 hours per week


All individual market carriers are subject to a 6-month look-back and a 12-month exclusionary period limit on pre-existing health conditions

Monthly Cost

21


GUARANTEED COVERAGE

HI resident and legal citizen or qualified immigrant

Age 0 to 19 years old; must live in Hawaii; income up to 300% FPL; and be a U.S. citizen, U.S. national, lawful permanent resident (have a “green card”), refugee, or citizen of the Marshall Islands, Federated States of Micronesia, or Palau

Children (ages 0-19): 300% FPL Pregnant Women: 185% FPL

Family: At or below 250% qualify for free health insurance

Must be ineligble for Medicaid

Family: between 250-300% FPL qualify for low cost. Medically needy: 51% FPL Asset limits of $2,000 for a household of one, $3,000 for a household of two $250 per additional person Asset limits do not apply to individuals under age 19, or to pregnant women for the duration of the pregnancy plus 60 days

Must be a Hawaii resident


Basic care, preventive care, immunizations, doctor visits

GUARANTEED COVERAGE

Parents or the blind, aged or disabled: 100% FPL


Costs depend on employer contribution and rates must be approved by the state Department of Insurance

Depending on program, inpatient hospital services, outpatient hospital services, prenatal care, vaccines for children, physician services, nursing facility services for persons aged 21 or older, family planning services and supplies, rural health clinic services, home health care for persons eligible for skilled-nursing services, laboratory and x-ray services, pediatric and family nurse practitioner services, nursemidwife services and more Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

Owner can count as an employee, proprietor-name on license must draw wages

Hawaii's Medical Service Association 800-620-4672 www.coveringkids.com

National Association Of Health Underwriters 703-276-0220 www.nahu.org


Company size: 1-50 employees

800-316-8005 808-524-3370 www.med-quest.us

Various price ranges depending on deductible and what plan you buy

$0, minimal share of cost or 'buy-in'; Premiums range between $15-60 per child per month

$55 per month


Hawaii

800.234.1317

Women

Adults with substance abuse problems

Breast and Cervical Cancer Program

Department of Health Alcohol and Drug Abuse Division 808-692-7506 www.hawaii.gov/health/ substance-abuse/


Veterans

Medicare






877-222-8387 www.va.gov

Program

808-692-7460 http://healthuser.hawaii.gov/ health/family-child-health/ chronic-disease/bcccp/index. html


Demographic


800-633-4227

Sage Plus 888-875-9229

Clinical breast exam, mammogram, pelvic exam, pap test, follow-up diagnostic care for abnormal results

Comprehensive system of services to meet the treatment and recovery needs of individuals and families Inpatient and out-patient programs


Sage is a Medicare counseling and application service




Coverage




GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Woman age 50 to 64; Income at or below 250% of the federal poverty level; Uninsured or under-insured

Treatment services have, as a requirement, priority admission for pregnant women and injection drug users










Eligibility

$0

www.coverageforall.org Hawaii

Monthly Cost

$0 or share of cost; Costs vary depending on which program you choose.

22

Demographic



Program

800-234-1317

Group Health

Idaho Association of Health Underwriters 703-276-0220 www.iahu.org

AHI

(Access to Health Insurance) 866-326-2485 www.accesstohealthinsurance. idaho.gov

Coverage

Up to $5M lifetime maximum, assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply AHI is a premium assistance program that makes health insurance more affordable for employees of qualified small businesses

Eligibility

COBRA


Consolidated Omnibus Budget Reconciliation Act Or

Conversion Plans Then

Individual Plans

Idaho Association of Health Underwriters 703-276-0220 www.iahu.org

COBRA: Coverage available for up to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium

Up to $5M, assorted deductibles depending on age and ZIP code Limits on Pre-Existing Health Conditions May Apply


GUARANTEED COVERAGE



Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for HRP, see next column



Low-income individuals and families

HRP

Medicaid

Idaho Individual High Risk Reinsurance Pool 208-334-4250 800-721-3272 www.doi.idaho.gov

800-926-2588 866-326-2485 TDD 208-332-7205 www.healthandwelfare. idaho.gov Or contact local health or welfare agency

HIPAA

GUARANTEED COVERAGE


800-234-1317





Monthly Cost




23



There are five HRP plans. All plans cover the same health benefits but cost sharing varies. All insurers sell the same HRP plans. This standardization of benefits will help you compare the cost of coverage from different companies. HRP plans cover hospital and physician services, preventive care, maternity care, prescription drugs, and limited mental health and substance abuse treatment.

Four plans to choose from: Medicaid Standard Plan, Medicaid Basic Plan, Medicaid Enhanced Plan, and the Medicare-Medicaid Coordinated Plan



GUARANTEED COVERAGE

GUARANTEED COVERAGE

First, if you applied for individual health insurance and were turned down due to your health status or claims history, that insurer must offer you the option to buy a HRP plan

Children Age 0-19 income at or below 133% of the FPL (copayments vary depending on the families qualifying income)

Second, if an individual health insurer offered to sell you a policy at a surcharged premium, that insurer must offer you the option to buy a HRP plan

Adults: 25% FPL

Offers health, dental, vision, and prescription coverage Treatment for special health problems like breast cancer, kidney problems, nursing home needs, and AIDS

Pregnant Women: 133% FPL

Supplemental Security Income Recipients: 74% FPL

Third, if you are HIPAA eligible, you are eligible to buy a HRP policy from any approved insurer in Idaho

Must be a U.S. citizen or legal non-citizen

You are also eligible to apply for HRP if there is a reasonable probability that you will exceed your lifetime benefit maximum under your existing coverage within 90 days and if the lifetime benefit maximum of your existing plan is at least $500,000


Costs vary depending on age, region and program.



Idaho

800.234.1317

Children

Women


Children’s Access Card

Women’s Health Check

Emergency Medicaid

800-926-2588 www.idahohealth.org

800-926-2588 TDD 208-332-7205 866-326-2485 (Emergency Processing Center) Or contact local health or welfare agency

Annual clinical breast examination (CBE)


Annual pelvic examination; Annual Pap test — After three consecutive normal Pap tests, Women’s Health Check will cover one Pap test every three years

Annual mammogram

Emergency Medicaid covers emergencies, pregnancyrelated care (prenatal and delivery), kidney dialysis, treatment for breast and cervical cancer Pre-Existing Health Conditions Covered

Medicare





800-633-4227





GUARANTEED COVERAGE

GUARANTEED COVERAGE






Diagnostic Services, if needed

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Between 133-185% FPL

Women without health insurance that covers mammograms or Pap tests;

Children ages 0-19, up to 150% FPL

Age 30-49 and have not had a Pap test in 5 years or longer or have never had a Pap test;

Non-Working Parents: 24% FPL

Must be ineligible for no-cost Medicaid or employer-based coverage Residents and legal immigrants

Age 65 or older and is NOT eligible for Medicare, or does not have Medicare Part B

Working Parents: 31% FPL Supplemental Security Income Recipients: 74% FPL U.S. citizenship not required




www.coverageforall.org Idaho

Monthly Cost

Income below 200% FPL


Eligibility

$0 or share of cost

Pregnant Women: 133% FPL

Coverage

Medical services, Dental, Mental health services, Vision, Pharmacy, Hearing, Hospitalization, and more


Program

800-926-2588 www.healthandwelfare. idaho.gov


Demographic


24

Demographic





COBRA


Program

800-234-1317

Group Health www.dol.gov/ebsa 866-444-3272

Illinois Association of Health Underwriters

Then convert to

HIPAA


Coverage

Individual Plans

www.healthinsuranceinfo.net

Illinois Association of Health Underwriters

Low income families and individuals

CHIP

Medicaid

(Illinois Comprehensive Health Insurance Plan) Main Number: 217-782-6333 Illinois Residents Only General Information: 800-9628384 Eligibility Information: 866851-2751 800-545-2455 (TTY) www.chip.state.il.us

If uninsured for previous 6-12 months, a waiting period for coverage of pre-existing conditions, (6-12 months respectively) will apply

COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer

Benefits will vary depending on the chosen plan


Covers certain state mandated items, however Illinois does not require standardization. Coverage options vary by carrier, but most offer plans that are HSA (Health Savings Account) compatible Limits on Pre-Existing Health Conditions May Apply


GUARANTEED COVERAGE

GUARANTEED COVERAGE



Eligibility

Owner can count as an employee Proprietor name on license must draw wages

FamilyCare

866-255-5437 www.familycareillinois.com

Inpatient and outpatient care, doctor visits, surgery, preventive care, diagnostic care and x-rays, home health care, skilled nursing care, hospice, transplant coverage, speech, physical and occupational therapy, mental health and chemical dependency, separate prescription drug card

Medicaid: Different program variations covering medical, dental and vision, prescriptions, hospitalization and more depending on program. Programs for people with either MS, nursing home needs, kidney dialysis, breast and cervical cancer, AIDS, TB, hyper alimentation, pregnancy

You can now choose High Deductible Health Plans starting in 2008. Call the main number to find out more information on how to change to a HDHP.

FamilyCare: Covers doctor visits, dental care, specialty medical services, hospital care, emergency services, prescription drugs and more

Pre-Existing Health Conditions Covered with Some Limitations


800-843-6154 www.health.illinois.gov www.dhs.state.il.us

703-276-0220 www.nahu.org www.isahu.com

703-276-0220 www.nahu.org www.isahu.com


800-234-1317



Eligibility is based on medical underwriting There is a 12 month look back period during first two years of coverage. If condition is deemed preexisting there can be a 24 month exclusionary period. Must be resident of state or documented immigrant If you are denied coverage for a medical condition, you may be eligible for CHIP, see next column


GUARANTEED COVERAGE

GUARANTEED COVERAGE

Previous coverage terminated for reasons other than nonpayment of premium or fraud

Medicaid: Children ages 1-19: 133% FPL. Pregnant Women and Infants: 200% of the FPL if the mother is enrolled in Medicaid at the time of birth. If not, infants with family incomes of 133% FPL

Cannot be eligible for COBRA, or government programs (must have exhausted this option) Must prove denial of coverage or offer of higher premium than CHIP Illinois resident

Working Parents: 140% FPL Aged, blind or disabled: 85% FPL SSI recipients: 40% FPL Medically Needy Individual: 40% FPL, Couple: 39% FamilyCare: Offers healthcare coverage to parents living with their children 18 years old or younger. FamilyCare also covers relatives who are caring for children in place of their parents. Must live in Illinois and have income up to 200% FPL, Must be U.S. citizens or meet immigration requirements

Monthly Cost

Must be an Illinois resident

25


COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column

Illinois

Various price ranges depending on deductible and what you buy.

Can be 125-150% of the average rates charged individuals for comparable major medical coverage by 5 or more of the largest insurance companies in the individual health insurance market.

Medicaid: $0 or minimal share of cost FamilyCare: Small co-pays from $2 to $3 for doctor visits and prescriptions. Parents in FamilyCare Premium pay a monthly premium from $15 to $40 depending on the number of family members covered

800.234.1317

Children

Women

ALL Kids

Breast and Cervical Cancer Program

866-ALL-KIDS 866-255-5437 www.allkids.com

Healthy Women

800-226-0768 www.illinoishealthywomen. com


BCCP: Offers free mammograms, breast exams, pelvic exams and Pap tests to eligible women Healthy Women: Covers family planning (birth control) and certain services provided at the family planning visit, such as the physical exam, pap tests, lab tests for family planning, testing and medicine for sexually transmitted infections found during a family planning visit, and sterilization. Illinois Healthy Women also covers mammograms, multivitamins and folic acid if they are ordered by the doctor during the family planning visit

Veterans

Medicare






877-222-8387 www.va.gov

800-633-4227

Illinois Cares Rx

800-633-4227 www.illinoiscaresrx.com

Medicare: Offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug coverage program called Medicare Part D


Illinois Cares Rx: Provides state prescription drug assistance to people with and without Medicare




Coverage

Doctor visits, hospital stays, prescription drugs, vision care, dental care and eyeglasses, covers regular checkups and immunization shots, special services like medical equipment, speech therapy and physical therapy for children who need them


Program

IL Department of Public Health’s Health-Line 888-522-1282 www.cancerscreening.illinois. gov


Demographic




GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Illinois resident, 18 and under, uninsured for 12 months to be eligible regardless of income

BCCP: Illinois resident and documented immigrant For mammograms must be between 40 and 64 years of age

Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)



If already insured, income limit is approximately 250% of the FPL.

For pelvic and pap test must be between 35 and 64 years of age

If Medicaid eligible you are not IBCCP eligible Healthy Women: If you have lost regular medical benefits from the Illinois Department of Healthcare and Family Services (HFS), if you are between 19-44, if you are a U.S. citizen or legal permanent resident with a Social Security number and if you live in Illinois, and are at 200% FPL

$0

Medicare: $0 and share of cost for certain services; deductibles for certain plans





Illinois Cares Rx: Costs vary depending on whether applicant has Medicare or not

www.coverageforall.org Illinois

Monthly Cost

Monthly premium based on number of children in family, plus co-pay for each service with $100 limit

Illinois Cares Rx: Individuals with Medicare, people age 65 and older or people under age 65 with certain disabilities are eligible for Illinois Cares Rx. Income limits apply for certain groups


Eligibility

May not have other health insurance and income under 200% of FPL


26

Demographic





COBRA


Program

800-234-1317

Group Health

Indiana Association of Health Underwriters 703-276-0220 www.nahu.org www.inahu.org

Different plans cover different medical services

Coverage

Sometimes coverage is limited to $1M in a lifetime; often $5M and some plans have no limit These factors affect the monthly premium and deductible If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply Pre-Existing Health Conditions Covered

Then convert to

HIPAA


COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage

800-234-1317

Individual Plans Indiana Association of Health Underwriters 703-276-0220 www.nahu.org www.inahu.org

Covers certain state mandated items, however Indiana does not require standardization

Individuals with pre-existing, severe or chronic medical conditions ICHIA

Indiana Comprehensive Health Insurance Association 800-552-7921 317-614-2133 www.ichia.org

Coverage options vary by carrier, but most offer plans that are HSA (Health Savings Account) compatible

Covered services include inpatient hospital services, mental illness /substance abuse, prescription drugs, professional services, skilled home health care, skilled nursing facility, surgical expenses, transplant services


Four annual deductible options $500, $100, $1500, or $2500

Medicaid

(Indiana Family and Social Services Administration) 800-889-9949 www.in.gov/fssa

Different program variations covering medical, dental and vision, prescriptions, hospitalization and more depending on program

20% co-pay Preferred Provider Network; 40% co-pay non preferred provider network



Programs for people with either MS, nursing home needs, kidney dialysis, breast and cervical cancer, AIDS, TB, hyper alimentation, pregnancy Pre-Existing Health Conditions Covered

Ineligible for Medicaid Coverage for spouse and dependents also available Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE




Eligibility

Proprietor-name on license must draw wages


GUARANTEED COVERAGE

GUARANTEED COVERAGE


Must be considered “uninsurable”


Cannot be eligible for COBRA, or government programs (must have exhausted this option)

Under 100% FPL with assets less than $3K for one person (after car, house, clothing), AND...


Must prove denial of coverage or offer of higher premium than ICHIA Must be an Indiana resident

If you are denied coverage for a medical condition, you may be eligible for an ICHIA plan, see next column

Parents of children living in household OR... Adults with certain diseases see above, OR... On Cash Assistance, Welfare or children leaving Foster Care at age 18 No job-based coverage within three months (certain exceptions apply) Indiana resident or documented immigrant

Monthly Cost

Must be an Indiana resident

27




Based on the plan you choose, age, gender, and geographic area you live in. Can not be more than 150% of amount healthy person would pay



Indiana

800.234.1317

Children with chronic medical conditions

Pregnant women, children

Children’s Special Health Care Services

Hoosier Healthwise

Hoosier Healthwise is a health insurance program for Indiana children, pregnant women, and low-income families

Diagnostic evaluations, comprehensive well child and sick child care, specialty care and other services related to the eligible medical conditions, immunizations, prescription drugs, routine dental care, community referrals and information

After birth, care for infant only up to age 1, care for mother up to 60 days


Comprehensive care for mother, not just maternity

Families get check-ups, doctor visits, hospital care, dental and more

Indiana Breast and Healthy Indiana Plan 877-GET-HIP-9 Cervical Cancer Early 877-438-4479 Detection Program 800-433-0746 317-233-7405 www.in.gov/isdh/19851.htm

BCCP provides clinical breast examinations, mammograms, and pap tests for eligible women, as well as diagnostic testing for women whose screening outcome is abnormal Screening, diagnostics, consultations and treatment Pre-Existing Health Conditions Covered

800-403-0864 www.in.gov/fssa/hip/

(Healthy Indiana Plan still has room for adults who have children in their homes, but it has started putting “noncaretaker’’ adults on a waiting list for the program)

Services include: physician services, prescriptions, diagnostic exams, home health services, outpatient hospital, inpatient hospital, hospice, preventive services, family planning, and case and disease management; mental health coverage, substance abuse treatment, inpatient, outpatient, and drugs

Seniors and Disabled Medicare



Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug coverage program called Medicare Part D Pre-Existing Health Conditions Covered



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Ages newborn to 21 years

Income at or below 250% FPL

Family income at or below 250% FPL

Children and ages 18-20 if living with a caretaker

Adults between the age of 19-64

Severe chronic illnesses that have lasted or will last two years or conditions that require special devices or would produce disabling physical conditions if untreated

No residency requirements for Medicaid

Must be Indiana resident and have legal immigration status For mammograms must be between 40 and 64 years of age For pelvic and pap test must be between 35 and 64 years of age

Individuals must not have access to employer sponsored health insurance coverage.

Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

Must have a family income at or below 200% of the FPL

Individuals must be uinsured for the previous six months.

Eligibility

May not have other health insurance and income under 200% of FPL

Each participant's family must also apply for Medicaid

65 and older not enrolled in Medicare

$0-$50 a month depending on family income and the number of family members covered

$0

2-5% of the families gross income depending on the applicants income.



No co-pays except for ER use.

www.coverageforall.org Indiana

Monthly Cost


Coverage

Treatment for chronic medical conditions such as severe asthma, autism, cerebral palsy, arthritis, congenital heart disease, cystic fibrosis, chromosomal disorders, renal disease seizures and more

Adults

Program

(CSHCS) 800-475-1355 www.in.gov/isdh/19613.htm

800-889-9949 www.in.gov/fssa/ompp/2544. htm

Women

Demographic


28

Demographic





COBRA or Mini-COBRA/ Conversion


Program

800-234-1317

Group Health

Iowa Association of Health Underwriters 703-276-0220 www.eiahu.org

Or

HIPP

(Health Insurance Premium Payment) 888-346-9562 Then convert to

800-234-1317

Individual Plans

Individuals with pre-existing, severe or chronic medical conditions HIPIOWA

Low income families and individuals Medicaid

(Health Insurance Plan of Iowa) 877-793-6880 www.hipiowa.com

800-338-8366 800-972-2017 www.ime.state.ia.us/Members Or contact local county Department of Human Services

Iowa Association of Health Underwriters 703-276-0220 www.eiahu.org

HIPAA

(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov Up to $5M lifetime maximum, assorted deductibles

Coverage

If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply Pre-Existing Health Conditions Covered

COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as previous employer’s plan COBRA Subsidy: 15 months of partially subsidized COBRA premium


HIPIOWA offers five comprehensive preferred provider plans each with a pharmacy benefit to choose from and a medicare carveout plan Pre-Existing Health Conditions Covered with Some Limitations

HIPP: Benefits are the same as what you had with your previous employer, HIPP is a premium assistance program HIPAA: Benefits are based on the program selected and there is no expiration of coverage



GUARANTEED COVERAGE




Eligibility

Owner can count as an employee Proprietor name on license must draw wages

Mini-COBRA: Applies to businesses with less than 20 employees HIPAA: After exhausting your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even with pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA

Inpatient and outpatient hospital services, physician services, medical and surgical dental services, nursing facility services for persons aged 21+, family planning services, nurse/midwife services, chiropractors, podiatrists, optometrists, psychologists, dental services, physical therapy, therapies for speech hearing and language disorders, occupational therapy, prescribed drugs, prosthetic devices, vision, mental health, hospice care and more

Eligibility is based on medical underwriting There is a 12 month look back period during first two years of coverage. If condition is deemed preexisting there can be a 24 month exclusionary period. Must be resident of state or documented immigrant If you are denied coverage for a medical condition, you may be eligible for HIPIOWA, see next column

GUARANTEED COVERAGE

GUARANTEED COVERAGE

A notice of rejection of health insurance coverage within the last nine months or reduction of limitation which substantially reduces benefits compared to benefits available to others

Children (ages 1-19): 133% FPL

A notice of refusal to issue insurance except at a rate exceeding the plan rate of a comparable HIPIOWA plan. Other involuntary termination (other than nonpayment)


Ineligible for public programs

Pregnant Women and Infants (ages 0-1): 200% FPL Working Parents: 82% FPL Non-Working Parents: 33% FPL

Medically Needy Individual: 67% FPL Medically Needy Couple: 50% FPL U.S. citizen and Iowa resident

Can get if eligible for HIPAA Iowa residency required

Monthly Cost

HIPP: You may be eligible for HIPP if you have a high-cost health condition Costs depend on employer contribution and ± 25% of the insurance company’s index rate



Can be 125-150% of the average rates charged individuals for comparable major medical coverage by 5 or more of the largest insurance companies in the individual health insurance market.



29

Iowa

800.234.1317

Individuals and families with moderate income IowaCare

Or contact local county Department of Human Services

Inpatient and outpatient hospital, physician or advanced registered nurse practitioner, and dental

Unlike Medicaid, IowaCare is not an entitlement, meaning that it depends on specific appropriations



Hawk-i

Emergency Medicaid



(Healthy and Well Kids in Iowa) 800-257-8563 888-422-2319 TDD www.hawk-i.org/index.html

A child who qualifies will get all of his or her health care services through a health plan that has agreed to participate in the program: doctor visits, outpatient hospital services, vaccines and shots (immunizations) emergency care, inpatient hospital services, prescriptions, vision, dental, hospice, speech and physical therapy, nursing care services, chiropractic care mental health/substance abuse

800-338-8366 www.ime.state.ia.us/Members

Up to 3 days of Medicaid is available to pay for the cost of emergency services for aliens who do not meet citizenship, alien status, or social security number requirements. The emergency services must be provided in a facility such as a hospital, clinic, or office that can provide the required care after the emergency medical condition has occurred.

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Eligible people are adults aged 19-64 in households with adjusted income of up to 200 percent of the federal poverty level (about $1,600/month for a family of two), who are not eligible for Medicaid, who do not have other health insurance, and who agree to pay a small premium

Be under 19 years old

Children (ages 1-19): 133% FPL

Have no other health insurance

Pregnant Women and Infants (ages 0-1): 200% FPL

Treatment for special health problems like breast cancer, kidney problems, nursing home needs, and AIDS Pre-Existing Health Conditions Covered

Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Can use credit to purchase plan through HIPIOWA Pre-Existing Health Conditions Covered

Be a citizen of the United States or a qualified alien Family income must be at or below 200% of the FPL Cannot be the dependent of a State of Iowa employee Children who qualify for Medicaid cannot get Hawk-i


Non-Working Parents: 33% FPL Supplemental Security Income Recipients: 74% FPL Medically Needy Individual: 67% FPL





Medically Needy Couple: 50% FPL


www.coverageforall.org Iowa

Monthly Cost

depending on your income. No one pays more than $40

Working Parents: 82% FPL

GUARANTEED COVERAGE The Aberdeen Area Office in Aberdeen, South Dakota, works in conjunction with its 13 Service Units to provide health care to approximately 94,000 Indians on reservations located in North Dakota, South Dakota, Nebraska, and Iowa. The Area Office’s service units include nine hospitals, eight health centers, two school health stations, and several smaller health stations and satellite clinics

Eligibility

premium

Offers health, dental, vision, and prescription coverage

Each county has one or more health plans Pre-Existing Health Conditions Covered

$1-$3 co-pays and monthly


Or contact local county Department of Human Services


Pregnant women at or below 300% of the FPL (if their medicial costs can bring their monthly income to 200% of the FPL)

605-226-7531 www.ihs.gov

Coverage

Services do not include checkups or pharmaceuticals, with the exception of those needed during and immediately following hospital stays. Emergency services are provided at local hospitals, not via IowaCare


Program

800-338-8366 515-725-1003 www.ime.state.ia.us/IowaCare/ index.html


Demographic


30

Demographic





COBRA/ Mini-COBRA


Group Health

Then

Program

800-234-1317

Kansas Association of Health Underwriters 703-276-0220 www.nahu.org

Coverage

Up to $5M lifetime maximum, assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply There is a 6-month look-back/ 3-month exclusionary period for preexisting conditions on enrollees that do not have prior creditable coverage

HIPAA



800-234-1317

Individual Plans


Low income families and children

KHIA

Medicaid

Kansas Health Insurance Association 800-362-9290 www.khiastatepool.com

Kansas Association of Health Underwriters 703-276-0220 www.nahu.org

Up to $5M, assorted deductibles depending on age and ZIP code


There is a 12-month look-back and 24-month exclusionary period limit for pre-existing conditions





(KMAP) 800-766-9012 785-291- 4414 https://www.kmap-state-ks.us/

Women-InfantChildren (WIC)

800-332-6262 785-296-1320 www.kdheks.gov/nws-wic

Comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, transplants, rehabilitation, durable medical equipment, mental health and substance abuse, physical, speech and occupational therapy, among other services

Medicaid: Physical health services: office visits, regular checkups, immunizations, hospital services, inpatient and outpatient hospital, lab and x-ray, prescription drugs, eye doctor exams and glasses, hearing services and speech, and physical and occupational therapy; Dental health services for children: checkups, cleanings, sealants, x-rays and fillings; Mental Health Services (Inpatient and outpatient): mental, behavioral and substance abuse services


WIC: Provides nutrition education and supplemental foods to infants, children and women who are pregnant, postpartum or are breastfeeding Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE




Monthly Cost

Eligibility


31


Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for KHIA, see next column

Mini-COBRA: Applies to small businesses with less than 20 employees


GUARANTEED COVERAGE

You are eligible if your previous coverage was terminated for reasons other than non-payment of premium or fraud (such as a pre-existing condition)

Medicaid: Children ages 1-5: 133% FPL; Ages 6-19: 100% FPL; Pregnant Women and Infants ages 0-1:150% FPL; Supplemental Security Income Recipients: 74% FPL; Medically Needy Individual: 66% FPL; Medically needy couple: 49%; Working Parents: 34%; Nonworking Parents: 27%; U.S. citizen, Kansas resident

Cannot be eligible for COBRA or government programs (except “end stage renal disease” covered under Medicare) Applicants must have applied for health insurance and been declined by two carriers because of a health condition



GUARANTEED COVERAGE

Must prove denial of coverage or offer of higher premium than KHIA rate

WIC: Women who are pregnant, Breastfeeding, up to baby’s first birthday, Non-breastfeeding mothers, up to six months after baby’s birth, Children under five years old, Family income up to 185%. Automatically eligible if enrolled in Food Stamp Program, Temporary Assistance for Families, and Medicaid Program

Live in KS and had 12 months of continuous coverage


Premium rates are determined according to the KHIA plan you select, your age, gender, and tobacco use.

Medicaid & WIC: $0 or minimal share-of-cost

COBRA, Mini-COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column

Kansas

800.234.1317

Moderate income families

Children with special needs

Women

Low income individuals

Health Wave

Children with Special Health Care Needs

Women’s Health Care and Family Planning Services

800-766-9012 785-296-3959 www.srskansas.org

800-792-4884 800-792-4292 TTY www.kansashealthwave.org

800-332-6262 785-296-1307 www.kdheks.gov/c-f/womens. html

Or contact local social services agency

Early Detection Works

SHICK


Outreach clinics bring specialty diagnosis, consultation, and follow-along care as close to the child's home as possible. Clinics are conducted for hearing loss, orthopedic conditions, neurological impairment, cardiac diseases, and genetic diseases, counseling and planning services Pre-Existing Health Conditions Covered

Senior Health Insurance Counseling of Kansas 800-860-5260 www.agingkansas.org/SHICK/ shick_index.html

Women’s Health Care and Planning Services: Services are provided by a physician or mid-level practitioner with assistance from public health nurses. In larger health departments social workers, health educators and nutritionists are available for consultation. If problems are discovered which are beyond the scope of the clinics, appropriate referrals will be made by the health care provider. Clients are seen on by appointments

Prescription drugs, mental health services and medical (doctor) coverage. We also cover inpatient hospital, hearing, dental, and eye-wear coverage for most persons. A managed care network serves many families and children. Program pays enrolled providers directly for the medically necessary services they perform

Early Detection Works: Services include breast and cervical cancer screenings, treatment and possibly other services


Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also includes a prescription drug program called Medicare Part D SCHICK is a Medicare counseling service Pre-Existing Health Conditions Covered

Cash General Assistance also available


GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

All applications will be screened for HealthWave 19 (Medicaid) first

Under age 22 living in Kansas

Women’s Health Care and Planning Services: Depends on facility

Children up to age 19; pregnant Women, persons who are blind or disabled by Social Security rules, persons age 65 or older, persons receiving inpatient treatment for tuberculosis, low income families with children (people who qualify TAF cash assistance), Persons screened and diagnosed with breast or cervical cancer apply to all medical plans

Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with EndStage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

At or below 200% FPL Live in Kansas Complete the application and list all household members, sign and date the application and provide all household income verification for 3 months (2 months for renewals)

Up to 185% for SHS Program Up to 300% for PKU Food Kansas residents of any age with covered genetic and/or metabolic conditions

Early Detection Works: Age 40 -64 years Do not have insurance or have insurance that does not pay for these services or has insurance with a high deductible Ineligible for Medicare Part B or Medicaid/MediKan Income up to 250% FPL

If self-employed, provide your most recent tax return, including all schedules and attachments, or 3 months of business ledgers

$0 or some people must pay a premium


Kansas Residency citizenship and Immigrant Status- persons must be citizens or immigrants with a certain status. Some immigrants must wait 5 years before they can get coverage




www.coverageforall.org Kansas

Monthly Cost

HealthWave 21: $0 for most families; $20-$30 for others (premiums are subject to change at anytime); no co-pays, deductibles, or exclusions for pre-existing health conditions. HealthWave19: $0 or small share of cost (There are minor copays for adults)

Eligibility

GUARANTEED COVERAGE

Youth with a medical condition covered by the program.

Coverage

Some of the services covered are Physical health services: office visits, regular checkups, immunizations, hospital services, inpatient and outpatient hospital, lab and x-ray, prescription drugs, eye doctor exams and glasses, hearing services and speech, and physical and occupational therapy, dental health services for children (checkups, cleanings, sealants, x-rays and fillings), mental health services - inpatient and outpatient

Diagnostic services and treatment services include medical specialists, outpatient care, hospitalization, surgery, durable medical equipment, reimbursement for transportation to medical specialty care, and interpreter services. A limited amount of therapy (speech, PT, OT) is provided for eligible conditions


877-277-1368 785-296-1207 http://www.kdheks.gov/edw/

All applications will be screened for HealthWave 19 (Medicaid) first.

Medicare


Program

(CSHCN) 800-332-6262 785-296-1313 www.kdheks.gov/cyshcn

MediKan


Demographic


32

Demographic







COBRA


Kentucky Access

Medicaid

Program

800-234-1317

Group Health

Kentucky Office of Insurance 502-564-3630 800-595-6053 800-462-2081 TDD http://www.doi.state.ky.us/

Then

HIPAA

(Health Insurance Portability & Accountability Act) 866-4-USA-DOL www.dol.gov or

800-234-1317

866-405-6145 www.kentuckyaccess.com

Individual Plans

800-635-2570 502-564-4321 www.chfs.ky.gov/dms

Kentucky Office of Insurance 502-564-3630 800-595-6053 800-462-2081 TDD http://www.doi.state.ky.us/

Kentucky Continuation Coverage Pre-existing conditions can be excluded for a limited time depending upon the type of group plan you are joining

Coverage



In Kentucky all insurers are required to offer a “standard plan” which offers the same benefits regardless of the insurer


Insurers are required to offer certain benefits such as maternity stay and mammograms


Kentucky Access offers 3 health benefit plans: Traditional Access (indemnity type plan), Premier Access (PPO type plan), Preferred Access (PPO type plan). Pre-Existing Health Conditions Covered


In Kentucky all insurers are required to offer a “standard plan” which offers the same benefits regardless of the insurer Insurers are required to offer certain benefits such as maternity stay and mammograms Pre-Existing Health Conditions Covered

State conversion plans offered through private health insurance market will vary Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE




Eligibility

Proprietor name on license must draw wages

Medical underwriting will determine eligibility If you are denied coverage for a medical condition, you may be eligible for Kentucky Access, see next column

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Anyone who is eligible for HIPAA; Federally eligible Individuals coming off of group, governmental, church plan, COBRA or state continuation; If you are rejected for private medical coverage; If you can prove higher premium rates than KY Access; If you have a high cost condition

Ages 1-19 up to 200% FPL

If one family member is eligible other family members are eligible


Kentucky resident

Pregnant women and infants up to 185% FPL Working parents up to 62% FPL Non-working parents up to 36% FPL Medically needy individuals up to 30%, couples 28% Limits on family resources such as savings accounts, cash, etc. for all but children and pregnant women

Monthly Cost

Must be a Kentucky resident

33



Depends on plan selected

Each individual plan is priced differently depending on age and gender, no family rates

$0 or nominal co-payment

COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column

Kentucky

800.234.1317

Children

KCHIP

Women-InfantChildren

Women

Commission for Children with Special Health Care Needs

Kentucky Women’s Cancer Screening Program

(CCSHCN) 800-232-1160 http://chfs.ky.gov/ccshcn/ About.htm

502-564-2154 800-4CANCER http://chfs.ky.gov/dph/info/ wpmh/cancerscreening.htm

Veterans

Medicare



877-222-8387 www.va.gov


800-462-6122 502-564-3827 800-648-6056 TTY http://chfs.ky.gov/dph/mch/ns/ wic.htm

State Health Insurance Assistance Program 877-293-7447 http://chfs.ky.gov/dail/ship.htm

Services are provided through a variety of specialty clinics held across the commonwealth (Primary medical care is not covered)

If screened and diagnosed for breast or cervical cancer, may be eligible for complete health coverage through Medicaid, including dental, prescriptions etc.





Coverage

KCHIP: Covers doctor visits, dental care, hospitalization, outpatient hospital services, emergency services, primary care services, psychiatrists, laboratory tests and X-rays, vision exams, hearing services, mental health services, prescription medicines, glasses, immunizations, well-child checkups, physical therapy, speech therapy, transportation, and many other services


Program

(Children’s Health Insurance Program) 877-524-4718 877-524-4719 TTY www.kidshealth.ky.gov

Children with chronic illnesses

Demographic


SHIP is a Medicare counseling and application service Pre-Existing Health Conditions Covered

WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services Pre-Existing Health Conditions Covered GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Kentucky resident less than 21 years old

Must be Kentucky resident Under 64 years of age

Disabled or age 65 and older and people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).



$0 or share of cost and co-pays depending on income level

A medical condition that usually responds to treatment provided by the program Must meet financial guidelines

WIC: Are pregnant or have a pregnant woman or infant in the family who receives Medicaid, or have a member of your family who receives KTAP, or have a household income at or below 185 FPL%.

KCHIP: $0 or $20 monthly premium depending on income $1 to $3 for Prescription Co-Pays, $6 for ER Copays, Max of $450 annually for premiums

Must be uninsured or underinsured, ineligible for Medicaid At or below 250% FPL Women younger than 40 are eligible to receive screening services only if they have a family history of breast cancer





WIC: $0 to minimal share of cost

www.coverageforall.org Kentucky

Monthly Cost

GUARANTEED COVERAGE

KCHIP: Must not be eligible for any other insurance, including individual, group or public; Children under age 19; Kentucky resident and family income at or below 200% FPL; Possible waiting periods for some children at certain income levels

Eligibility

GUARANTEED COVERAGE

34

Demographic





COBRA/ Mini-COBRA


Program

800-234-1317

Group Plans

Louisiana Association of Health Underwriters 703-276-0220 www.la-ahu.org

and then

HIPAA


LaHIPP

800-234-1317

Individual Plans



LHP

Medicaid

Louisiana Health Plan 800-736-0947 225-926-6245 (Baton Rouge) www.lahealthplan.org

888-342-6207 www.dhh.state.la.us/ offices/?ID=92

Four plans offering comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, ambulance, labs and x-rays, skilled nursing care, home health visits, transplants, rehabilitation, durable medical equipment, physical, speech and occupational therapy, vision care, and preventive care, among other services

Physician, hospital, laboratory, x-ray, and nursing home services. Optional programs cover services such as pharmacy and intermediate care facilities for the mentally retarded

Louisiana Association of Health Underwriters 703-276-0220 www.la-ahu.org

Coverage

888-695-2447 www.lahipp.dhh.louisiana.gov Carriers can impose a 6-month look-back/12-month exclusionary period for preexisting conditions on enrollees that do not have prior creditable coverage





HIPAA: Benefits are based on the program selected and there is no expiration of coverage (see LHIA for plan details)

Assorted plans depending on medical needs There is a 12-month look-back and exclusionary period limit for pre-existing conditions in traditional individual market health insurance products in Louisiana Limits on Pre-Existing Health Conditions May Apply



LaHIPP: Benefits are the same as what you had with your previous employer, LaHIPP is a premium assistance program Pre-Existing Health Conditions Covered GUARANTEED COVERAGE

GUARANTEED COVERAGE




Eligibility


Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for LHP, see next column


Monthly Cost

Pregnant women & Children 0-19 Income up to 200% FPL Supplemental Security Income Recipients: 74% FPL Non-Working Parents: 12% FPL Medically Needy Couples and Working Parents: 26% FPL Medically Needy Individual: 14% FPL Legal Louisiana residents Asset limits for some people

Must be declined by two separate insurance carriers There is a 6-month waiting period for pre-existing conditions Eligible with HIPAA

LaHIPP: You may be eligible for HIPP if you have a high-cost health condition and have Medicaid COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium

GUARANTEED COVERAGE

Have an automatically rejectable health condition, or during the 12 months prior to applying for coverage from the Association have been rejected by a licensed insurance company, nonprofit health care services plan or HMO for coverage substantially similar to the Association coverage without material underwriting restriction at a rate equal to or less than the Association plan Not be eligible or receiving health benefits under any federal or state program and not have received $500k in benefits from the Association or any organization similar to the Association



GUARANTEED COVERAGE


Four plan options with deductible choices of $1000, $2000, $3500 and $5000

$0

COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive, see next column LaHIPP: $0 or minimal share of cost

35

Louisiana

800.234.1317

Children in moderate income families LaCHIP


Women

CSHS


Louisiana Children’s Special Health Services 504-896-1340 www.dhh.louisiana.gov/ offices/?ID=256

LaMOMS

800-251-BABY 800-251-2229 www.dhh.louisiana.gov/ offices/?ID=320

WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services

888-342-6207 TTD: 800-220-5404 www.dhh.louisiana.gov/ offices/?id=137 Health care services, medical tests and procedures, hospitalization, therapies, home health services, medical equipment and supplies, parent/family support services (parent liaisons), medications and special diets, nursing, nutrition and social services follow-up, care coordination, case management, and resource development, or over 21 years of age for the Cystic Fibrosis program

BCCP: Screening and/or diagnostic mammograms annually for women 50 years+, ultrasound. Fine needle aspiration of the breast and breast biopsy, if indicated, Annual Pap exams for women 18 years of age and older not already enrolled in a program that provides this service, Colonoscopy and biopsy, if indicated, follow-up and referral for abnormal Pap exams and/or Mammograms

Veterans

Medicare



877-222-8387 www.va.gov




Coverage

LaCHIP: provides Medicaid coverage for doctor visits for primary care as well as preventive and emergency care, immunizations, prescription medications, hospitalization, home health care and many other health services

888-342-6207 504-218-2322 www.dhh.state.la.us/offices/ page.asp?id=92&detail=3879 or http://labchp.lsuhsc.edu/ default.htm



LaMOMS: Pregnancy-related services, delivery and care up to 60 days after the pregnancy ends including doctor visits, lab work/tests, prescription medicines and hospital care


GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

LACHIP: Children must be under age 19 and not covered by health insurance.

Children under age 21, who live in Louisiana, have a condition covered by CSHS, would benefit from rehabilitation services, have a long-term condition that requires specialty care and a multi-disciplinary treatment team, and meet financial requirements may qualify for services

BCCP: U.S. citizens or qualified aliens under 65 years old; uninsured and screened for breast or cervical cancer under the CDC

Disabled or age 65 and older and people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).




Family income cannot be more than 250% of the FPL Louisiana residents and able to document either U.S. citizenship or meet residency requirements

Program

Children’s Health Insurance Plan 877-2 LACHIP 877-252-2447 www.lachip.org

Children with special health care needs

Demographic


Eligibility continues until the course of treatment ends or the criteria for the program are no longer met and may begin up to three months before the month a woman applies for Medicaid. A woman may be eligible to be paid back for services received up to three months before she applied if she used a Medicaid provider and if the service is covered by Medicaid


Eligibility

WIC: Live in Louisiana, Pregnant and postpartum women, infants, and children under age 5; Income must be: Family of 1 $1,670, Family of 2 $2,247, Family of 3 $2,823, Family of 4 $3,400, $577 for each additional family member

Income up to 250% FPL

LaMOMS: Income up to 200% FPL





WIC: $0 or minimal share-ofcost

www.coverageforall.org Louisiana

Monthly Cost

LACHIP: $0-50 monthly premium depending on income

36

Demographic






COBRA/ Mini-COBRA


MaineCare

Program

800-234-1317

Group Health

207-624-8475 800-300-5000 TTY 888-577-6690 Maine Bureau of Insurance www.maine.gov/pfr/insurance

Then convert to

HIPAA


800-234-1317

Individual Plans

207-624-8475 800-300-5000 TTY 888-577-6690 Maine Bureau of Insurance www.maine.gov/pfr/insurance

Moderate income individuals, families employees Dirigo Choice

(Medicaid) 800-321-5557 207-624-7539 207-287-3707 TTY www.maine.gov/bms

(State-sponsored plan) 877-892-8391 207-287-9900 www.dirigohealth.maine.gov (DirigoChoice individual coverage is currently closed. Enrollment will reopen as the program expands in 2010. Financial Assistance is no longer available to new enrollees)

State Conversion Plans

Coverage

Pre-existing conditions can be excluded for a limited time depending upon the type of group plan you are joining (6-12 month look back) Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered

COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage

Depends on plan chosen Plans are required by state to offer certain benefits such as mammograms, childhood immunizations and automatic coverage for newborns or adopted children

Medical, dental and vision, prescriptions, hospitalization and more depending on program

Three plans to choose from. Plans offer doctor visits, hospital care and other preventative care



There is a 6-12 month look-back for pre-existing conditions, possible waiting periods Pre-Existing Health Conditions Covered


GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE



In Maine, no medical underwriting is allowed

Pregnant women at or below 200% FPL; Infants at or below 185% FPL; Working or nonworking parents with children under the age of 18 at or below 200% FPL; Children age 1-20 at or below 150% FPL; Working Disabled at or below 250%; Medically needy individuals qualify for spend down coverage. There is no income limit. Spend down figures out what the medically needy person can afford by seeing how high their income is. The person pays a deductible and then begins their coverage. As the income grows, the deductible gets higher; A waitlist for healthy, childless adults 21 to 64 is still in effect, and individuals could be on the waitlist anywhere from 3 months to a year

Individuals and employees under 300% of the FPL are eligible for DirigoChoice. Currently there is a waitlist for the Individual Category. Business Categories are still available; however, discounted premiums and deductibles are not available to new enrollees


Costs depend on age, region of Maine, and coverage plan selected. Discounted premiums and deductibles are no longer available to new enrollees.


Eligibility


Mini-COBRA: Applies to businesses with less than 20 employees HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA

Currently there is an enrollment freeze for the Individual Category. Business Categories are still available; however, discounted premiums and deductibles are not available to new enrollees Resident of Maine

Monthly Cost

Must be a Maine resident

37

Costs depend on employer contribution and ± 20% of the Modified Community Rate


Premiums vary by 20% above and below community rating Annual deductibles range from $250-$1,500


Maine

800.234.1317


Pregnant women and children

Maine Children with Special Needs Program

CubCare/MaineCare

(As of March 1, 2008, CSHN has capped program enrollment and will no longer be accepting applications for payment of services)


Maine Breast and Cervical Health Program 800-350-5180 207-287-8068 800-438-5514 (TTY) www.maine.gov/dhhs/ bohdcfh/bcp

800-437-9300 207-287-3991 800-438-5514 (TTY) www.maine.gov/dhhs/wic/

Veterans

Medicare



877-222-8387 www.va.gov


Cubcare/MaineCare: Doctor visits, check-ups, immunizations, preventive care, dental, mental, hospitalization

If screened and diagnosed for breast or cervical cancer may be eligible for complete health coverage through Medicaid

Blood disorders, cardiac defects, childhood oncology craniofacial anomalies, gastrointestinal, metabolic ophthalmologic, orthopedic, neurological, neurosensory neuromuscular, respiratory

WIC: Screening for growth and anemia, Healthy advice for families, Nutrition & Healthy Foods, Breastfeeding support, other referrals to other services




Coverage

Medical treatment, including diagnostic, medical, surgical, corrective and other therapeutic interventions for:

Assistance with coordination of care and referral services to families of infants, children, and adolescents with special health needs regardless of income.


Program

207-287-5139 800-698-3624 TTD: 800-438-5514 www.maine.gov/dhhs/boh/ cshn

800-442-6382 877-KIDS-NOW 877-543-7669 www.maine.gov/bms

Women



Demographic



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Must be Maine resident Infants, children, and adolescents who are at or below 225% of FPL

Cubcare/MaineCare: Low income children under age 18

Must be Maine resident Ages 50 and older

Ages 21 and under

Maine residents





No citizenship requirements for pregnant women and children

Income must be equal to or less than 200% of the FPL

Must be uninsured or underinsured, ineligible for Medicaid, MaineCare, and Medicare Part B Limited openings for women age 35-39 who have seen a doctor and need additional tests for a possible breast or cervical cancer or if they have not had a Pap in 5 or more years

Cubcare/MaineCare & WIC: $0 or small monthly premium




www.coverageforall.org Maine

Monthly Cost

WIC: Pregnant or postpartum women and children up to the age of 5 years with a family income at or below 185% of the FPL. Must be a state resident; and be at nutritional or medical risk, as determined by a health professional.


Eligibility


Under 250% FPL

38

Demographic





COBRA


Program

800-234-1317

Group Health

Maryland Association of Health Underwriters 703-276-0220 www.marylandahu.com

and then

HIPAA


800-234-1317

Individual Plans Maryland Association of Health Underwriters 703-276-0220 www.marylandahu.com

Individuals with Low Income pre-existing, Families & severe or chronic Medically Needy medical conditions Maryland Health Insurance Plan

MHIP 888-444-9016 www marylandhealthinsuranceplan. net

Medicaid

410-767-5800 800-492-5231 800-735-2258 TDD www.dhmh.state.md.us/ mma/mmahome.html

Medical Assistance for Families

Coverage

800-456-8900 http://dhmh.state.md.us/ ma4families/






HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered

Assorted plans depending on medical needs There is a 6-month look-back and 12-month exclusionary period limit for pre-existing conditions in traditional individual market health insurance products in Maryland Limits on pre-existing health conditions may apply

Four plans offering comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, transplants, rehabilitation, durable medical equipment, mental health and substance abuse, physical, speech and occupational therapy, and preventive care, and more Choice of one of four plan benefit options Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE




Monthly Cost

Eligibility


39


Costs depend on employer contribution and ± 40% of the Modified Community Rate

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for MHIP, see next column


GUARANTEED COVERAGE

GUARANTEED COVERAGE


Medicaid: Pregnant Women up to 250% FPL; Infants and children (ages 0-19): 200% FPL; Medically Needy Individual: 49% FPL; Medically Needy Couple: 41% FPL; Working Parents: 40% FPL; Non-Working Parents: 33% FPL; SSI Disabled (nonelderly) at or below 74% of FPL; Working Disabled at or below 300% of FPL

Cannot be eligible for group plan, COBRA, or government programs

Or, have/been offered, health insurance that provides limited coverage, or excludes coverage for a specific medical condition or conditions


Medical Assistance for Families: Low-cost or free prescriptions, doctor visits, emergency room visits, hospital stays, x-ray and lab services, and many other services Pre-Existing Health Conditions Covered

Denied coverage due to a medical condition


Medicaid: Doctor visits, prescriptions, hospital care (including emergency care), tests, x-rays, family planning, mental health services, substance abuse services, home health care, dental care, eye care, occupational therapy, physical and speech therapy, and more

Resource requirements for everyone but children or pregnant mothers

Families with an income at or below 300% of the FPL can qualify for discounted premiums also known as MHIP+

Maryland resident and qualified immigrant

Rates shall not exceed 150% of the standard premium rate charged by commercial carriers.

$0 or minimal share of cost,

Medical Assistance for Families: Eligibility is set at or below 121% FPL

no co-pays for emergency services and family planning services


Maryland

800.234.1317

Children and Pregnant Women

Women

MCHP

Breast Cancer Screening Program

MCHP Premium 410-767-6883 800-456-9800 800-735-2258 (TDD)


800-242-4WIC 800-242-4942 www.fha.state.md.us/wic/

MCHP Premium: Access to health coverage through Healthchoice, the Maryland Managed Care Program WIC: Screening for growth and anemia, Healthy advice for families, Nutrition & Healthy Foods, Breastfeeding support, other referrals to other services

Breast and Cervical Cancer Diagnosis and Treatment Program

Veterans

Medicare






877-222-8387 www.va.gov

800-633-4227

410-767-6787 800-477-9774 www.fha.maryland.gov/ cancer/bccdt_home.cfm

Screening mammogram, clinical breast exam, Pap test and pelvic exam cervical biopsy, diagnostic mammogram, colonoscopies, surgical consultation, breast ultrasound, breast biopsy, colposcopy surgery, adjuvant therapy (chemotherapy, radiation therapy), home health, pharmacy, DME (including prosthesis and bras), physical therapy, occupational therapy, wigs and breast reconstruction

Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D Pre-Existing Health Conditions Covered

Will cover COBRA if employer contributes less than 50% (or spouses’ employer)





Coverage

MCHP: Prenatal and post-partum doctor visits, hospital delivery bill, immunizations, lab work and tests, dental and vision care, prescription medicines (including vitamins), transportation to medical appointments, mental health services, substance abuse treatment, after delivery, family planning services

800-477-9774 http://fha.maryland.gov/ cancer/bccp_home.cfm


Program

Maryland Children’s Health Program 800-456-8900 800-735-2258 TTD www.dhmh.state.md.us/ mma/mchp


Demographic




GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

MCHP: Children 0-19; Household income up to 200% FPL; Must not be eligible for Medicaid; Pregnant women any age with income up to 250% FPL

A woman must be a Maryland resident aged 50




WIC: Live in Maryland, Pregnant and postpartum women, infants, and children under age 5; Income must be at or below 185% FPL





Insurance: Uninsured or have health insurance which does not cover the screening procedures. Income: Women with household incomes at or below 250% FPL

$0



MCHP Premium: Monthly fee of

$46 or $58 depending on

family income.


www.coverageforall.org Maryland

Monthly Cost

MCHP: $0 or monthly premium payment depending on family income.


Eligibility

MCHP Premium: Children 0-19; Household income between 200-300%; Must not be eligible for Medicaid or MCHP; Must currently be without health insurance coverage

Women aged 40- 49 who have symptoms of breast cancer, who have a personal history of breast cancer, or who have a mother or sister who developed breast cancer before menopause

40

Demographic Program




COBRA/ Mini-COBRA

Group Plans

Or

For help learning about plans contact: MA Association of Health Underwriters 508-634-7373 www.massahu.org MA Division of Insurance 617-521-7794 www.mass.gov/doi Commonwealth Connector 877-MAENROLL 877-623-6765 www.mahealthconnector.org

Coverage

Many private insurers and HMOs offer health plans to employer groups. Employer groups can purchase health plans either directly from the insurance carrier or can access a select group of health plans that are offered through the Commonwealth Connector Employers may choose one or more employer-sponsored plans for their eligible full-time employees among several carriers and plan designs including Health Savings Accounts plans. Employers may also facilitate the offering of non-employer sponsored plans through the Connector for their part-time and ineligible employees and establish a Section 125 plan enabling employees to use pre-tax dollars to pay health insurance premiums. Each employee can then choose among any of the carriers and plans offered through the Connector Pre-Existing Health Conditions Covered

State Conversion Plans Then

HIPAA


Medical Security Program Premium Assistance Plan 800-908-8801

COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage These programs allow employees to maintain their same health plan and transition to a new plan without a break in health coverage if they meet certain eligibility criteria

Monthly Cost

Eligibility


41

Private/Public Programs

Individuals and Families Above 300% of the FPL Individual Plans

For help learning about plans contact: MA Association of Health Underwriters 508-634-7373 www.massahu.org Or MA Division of Insurance 617-521-7794 www.mass.gov/doi Or Commonwealth Connector 877-MAENROLL 877-623-6765 www.mahealthconnector.org Many private insurers and HMOs offer health plans to employer groups. Employer groups can purchase health plans either directly from the insurance carrier or can access a select group of health plans that are offered through the Commonwealth Connector

Commonwealth Choice plans (Gold, Silver, or Bronze) are lower cost private plans that are available through the Commonwealth Connector and directly through the different insurance carriers. The companies that are offering the plans include: Blue Cross Blue Shield of Massachusetts, Fallon Community Health Plan, Harvard Pilgrim Health Care, Health New England, Neighborhood Health Plan, and Tufts Health Plan Young Adults Plans (YAP) are available to people between 18-26 to years of age and can only be purchased through the Commonwealth Connector Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Employers with one or more full-time employees may establish a group plan with employer contributions so long as the premium contribution towards full-time non-bargaining employees (defined by the state as working 35 hours or more) is not discriminatory. An employer may also establish a Section 125 plan for employees who are not eligible for their group plan and allow them to purchase insurance through the Commonwealth Connector.


Anyone can qualify for these plans

A full-time employee is someone who works 35 hours or more per week at a Massachusetts location (even if they live in another state). Individuals who are not considered full-time employees include: 1) Independent contractors; 2) Seasonal employees; 3) Temporary employees; 4) Workers from temp agencies (they are the temp agency’s employees. Employers with 11 or more full-time equivalent employees have four requirements: 1) You must offer a Section 125 cafeteria plan that meets Commonwealth Connector regulations. If you don’t offer a Section 125 cafeteria plan, you will pay the Free Rider Surcharge if your employees or their dependents get medical care that is paid by the state’s Free Care Pool- now called the Health Safety Net -for the uninsured; 2) You must make a “fair and reasonable” contribution to your employees’ health insurance or pay a Fair Share Contribution or fine of up to $295 per employee per year (see below); 3) Employers must complete an Employer Health Insurance Responsibility Disclosure (HIRD) Form/ Report which must be filed on-line, to report if you offer a Section 125 Plan that complies with Commonwealth Connector regulations; 4) Employers must collect an HIRD Employee Form from employees who decline your employer sponsored health insurance and/or your employer sponsored Section 125 Plan.

Employers must make a “fair and reasonable” contribution to your employees’ health insurance or pay a Fair Share Contribution or fine of up to $295 per employee per year. A “fair and reasonable” contribution by an employer is: (i) 25% of an employer’s full-time employees* are participating in the employer’s group health plan or (ii) an employer’s contribution of at least 33% toward a health plan premium for all full-time employees* who are employed more than 90 days. An employer who meets either (i) OR (ii) will not be subject to the Fair Share Contribution of up to $295 per employee

Massachusetts

Mini-COBRA: Applies to small businesses with less than 20 employees HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA

There is no medical underwriting Commonwealth Choice plans (Gold, Silver, or Bronze) may be right for you if: you are a resident of Massachusetts or are employed by a Massachusettsbased employer, you are age 18 or older, you are not eligible for Commonwealth Care products because family’s income before taxes is above 300% of the federal poverty level Young Adults Plan (YAP) is available to people between 18-26 to years of age.

Medical Security Program: If you have COBRA, your former employer’s group plan, or an individual plan, you may be eligible for monthly reimbursement of your premium payments. To be eligible, you must be responsible for 100% of your monthly premium. If eligible, you will be enrolled in the Premium Assistance plan with the same type of coverage you have on your existing plan. You must continue to pay your monthly health insurance premium. The Medical Security Program will reimburse you upon receipt of a claim form with proof of payment

COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%-150% of group health rates Medical Security Program: You may receive 80% of the actual premium paid, or up to $1,110 per month for a family plan and up to $450 per month for an individual plan

Costs on the Commonwealth Choice Plans Members must pay a monthly premium. The premium the members pay will depend on the health plan and benefit package they choose, and must be paid every month, even if no services are used. Members must pay a fee co-payment each time they use benefits. In addition, there may be a deductible an amount that the member must pay out-ofpocket for services before the health plan begins paying. This amount will vary by health plan and there will be different family and individual out-of-pocket maximum amounts.

800.234.1317

Individuals and Groups Below 300% of the FPL Individual and Group Plans

Children

Breast Cervical Cancer Treatment Program (BCCTP)

Children’s Medical Security Plan (CMSP)

877-414-4447 617-624-5992 TTY www.massresources.org

Healthy Start Program

888-665-9993 (Eligibility) 888-488-9161 (Customer Service)

888-665-9993 800-909-2677 www.cmspkids.com

Women-InfantChildren (WIC) 800-WIC-1007 800-942-1007 www.mass.gov search “WIC”

Seniors

Medicare



Program

For help learning about plans contact: MassHealth Families & Children: MassHealth Standard, MassHealth Family Assistance, Children’s Medical Security Plan Unemployed Adults: MassHealth Essential, Medical Security Plan, MassHealth Basic Pregnant Women: MassHealth Prenatal, Healthy Start Disabled: MassHealth, CommonHealth 888-665-9993 (Enrollment Center) 888-665-9997 TTY (Enrollment Center) 800-841-2900 (Customer Service) 800-497-4648 TTY (Customer Service) www.ma.gov/masshealth

Women

Demographic


Commonwealth Care 877-MA-ENROLL (877-623-6765) www.mahealthconnector.org The Insurance Partnership 800-399-8285 508-698-2070 www.insurancepartnership.org MassHealth members get similar benefits depending on the MassHealth plan they qualify for. There are similar plans with different names for children, adults, families, pregnant women, undocumented immigrants, the disabled and other groups

CMSP: covers doctor visits with your child’s regular doctor and specialists (like a heart doctor); immunizations (shots); eye exams and hearing tests; X-rays and labs; some mental health care; and dental care. Children with pre-existing health conditions are covered for visits


Healthy Start: Offers early, complete prenatal care to pregnant women and children




GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Note: Those who are self employed, are seasonal workers and/or have income is not solely from W-2 income sources with regular pay stubs, should contact an enrollment specialist to determine what their gross income is and to determine what programs they are eligible for.

BCCTP: You are under 65. You have been screened for breast or cervical cancer at a Women’s Health Network site and found in need of treatment. Your income is no greater than 250% of the FPL. Your insurance coverage does not cover the treatment you need. You meet the other eligibility requirements for MassHealth

CMSP: Children under 19 who do not have other insurance. Children can get this insurance even if their family makes too much money for other programs.



CommonWealth Care you must be 19 or older and have a gross income below 300% of the FPL; must be uninsured and eligible as defined by the Commonwealth Connector¹s regulations; and must be a U.S. citizen/ national, qualified alien, or alien with special status. You are considered uninsured if: you are currently insured under COBRA; are paying a full premium for you health insurance in the non group insurance commercial market; are in a waiting period prior to becoming eligible under an employer-provided health plan (where employer covers at least 20% of the cost of the premium of a family health plan or 33% of an individual plan) The Insurance Partnership offers employers with 50 or fewer full time employees assistance with their premiums or their business and income eligible employees. To be eligible, employers must offer (or plan to offer) comprehensive health insurance to its employees and must contribute (or be willing to contribute) at least 50% of the cost of the insurance purchased by the employee. Eligible employees must have family gross income below 300% of the FPL, be between the ages of 19 and 64 (inclusive) and must not have been offered health insurance by their current employer in the past six months, and not have been eligible for health insurance through their spouse’s employer in the past six months

The Insurance Partnership will pay small businesses up to $1,000 a year toward health insurance costs for each qualified employee. The amount depends on the tier of coverage chosen by the employee.

Note: Massachusetts residents age 18 and older under the Individual Mandate law are required to have health insurance that is deemed by the state to be affordable to them at their income level or they risk being fiscally penalized on their personal state income taxes. There is also a waiver/appeals process from the Individual Mandate. On January 1, 2009, individuals, who are NOT exempt from the Individual Mandate, will have to have health insurance that is deemed affordable to them at their income level AND meets "Minimal Creditable Coverage" (MCC) standards set by the Connector. For help contact the local organizations on the back of this Matrix.

No monthly premium for participants with an income below 133%. Participants with an income between 133-250% of the FPL will pay a monthly premium.

CMSP: Depending on your income costs will vary (Premiums between $0-64 per child; Co-pays $2-8, Pharmacy $3-4).



www.coverageforall.org Massachusetts

Monthly Cost

MassHealth and CommonWealth Care costs vary depending on which program suites you best. The costs of each plan are based on a sliding scale.

Healthy Start: Must be pregnant, be a resident of Massachusetts, have little or no health coverage for pregnancy, be ineligible for MassHealth (except MassHealth Limited), Income must be no greater than 200% FPL

WIC: Live in Massachusetts, have a nutritional need (WIC staff can help you determine this), are a child under 5, a new mom, or a pregnant or breastfeeding woman, Income must be at or below 185% FPL

Eligibility

MassHealth you must be one of the following: a parent living with your children under age 19, an adult caretaker relative living with children under age 19 to whom you are related by blood, adoption, or marriage, or are a spouse or former spouse of one of those relatives, and you are the primary caretaker of these children when neither parent is living in the home; or you are under age 19, whether or not you live with your family; you are pregnant, with or without children; or you have been out of work for a long time; or disabled or HIV positive, or you are a woman under 65 with breast cancer or cervical cancer

Coverage

CommonWealth Care benefits include: your own health care provider; preventative care checkups, care when you are sick or injured; prescriptions at your local pharmacy; treatment for alcohol, drug abuse, and mental health problems; vision care; dental care (available to some members only). CommonWealth Care offers four types of plans. Plan Type 1, 2, 3 or 4. A Plan Type is a certain list of health benefits and copayments that is available to members based on their income

BCCTP: Screening will be done through the Women’s Health Network. Insurance coverage will be issued through MassHealth Standard. This coverage includes cancer treatment and comprehensive medical care. You will get your benefits through the Primary Care Clinician (PCC) plan (cannot get coverage through HMO)

42

Demographic




COBRA

Group Health

HIPAA

Program

800-234-1317

Michigan Association of Health Underwriters 703-276-0220 www.mahu.org


Coverage


Eligibility

COBRA: Coverage available for up to 18 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage

GUARANTEED COVERAGE

GUARANTEED COVERAGE




Monthly Cost




Blue Cross/ Blue Shield of Michigan

Medicaid and Healthy Kids

800-234-1317

Individual Plans

Michigan Association of Health Underwriters 703-276-0220 www.mahu.org

800-642-3195 www.michigan.gov/mdch

888-MI-BCBSM 888-642-2276 www.bcbsm.org

Assorted plans depending on medical needs

Plans vary depending on applicant needs

There is a 6-month look-back and 12-month exclusionary period limit for pre-existing conditions in traditional individual market health insurance products in Michigan


Ambulance, dental, doctor visits, family planning, health checkups, hearing and speech, home health care, hospice, hospitalization, lab and X-rays, immunizations, medical supplies, nursing home care, medicine, mental health care, personal care services, prenatal care, surgery, vision, substance abuse treatment, physical therapy

Limits on pre-existing health conditions may apply




43

and then




Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for BCBSM, see next column

GUARANTEED COVERAGE

GUARANTEED COVERAGE


Limited assets such as cash, savings, stocks and bonds (except for pregnant women and children)

HMOs in the state must offer guarantee issue coverage to residents during annual open enrollment periods Must be Michigan resident


Children 1-19 income at or below 150% Non-Working Parents: 39% FPL Working Parents: 66% FPL Medically Needy Individual: 57% FPL Medically Needy Couple: 56% FPL

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for any other insurance programs


Pregnant women and infants up to 185% FPL;

SSI Recipients: 74% FPL


Rates are not restricted and will depend on plan (BCBSM does community rating)

$0 or minimal share-of-cost and no co-pays

$5 monthly payment per family for children


Michigan

800.234.1317

Children in moderate income families MIChild

Healthy Kids

888-988-6300 www.michigan.gov/mdch

MIChild: Regular checkups, shots, emergency care, dental care, hospital, pharmacy, hospital care, prenatal care and delivery, vision and hearing, mental health and substance abuse services

Breast and Cervical Cancer Control Program

Adult Medical Program

800-922-MAMM 800-922-6266 www.michigan.gov/mdch (Click on “Prevention”)

Adult Benefits Waiver www.michigan.gov/mdch Contact local Department of Human Services

Medicare





Medicare/Medicaid Assistance Program

800-26-BIRTH 800-262-4784 www.michigan.gov/mdch (Listed under “Pregnant Women, Children & Families”)



800-633-4227


BCCP: Cancer screening services and follow-up care, including cancer treatment if that should be needed


800-803-7174

Basic medical care, pharmacy, no-inpatient Pre-Existing Health Conditions Covered

Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and ‘advantage’ plans. It also offers a prescription drug program called Medicare Part D Medicare/Medicaid Assistance Program is a counseling service for Seniors and Disabled Pre-Existing Health Conditions Covered

Will cover COBRA if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Under BCBS of MI options are: Health Coverage Community Blue Option with RX Plan 1 or the Blue Value Option 9 with RX Plan 2 Pre-Existing Health Conditions Covered

Coverage

Healthy Kids: Ambulance, dental, doctor visits, family planning, health checkups, hearing and speech, home health care, hospice, hospitalization, lab and x-rays, immunizations, medical supplies, nursing home care, medicine, mental health care, personal care services, prenatal care, surgery, vision, substance abuse treatment, physical therapy. Also offers prenatal care for pregnant women

Adults with no Children

Program

800-843-6447 888-988-6300 www.michigan.gov/mdch (Listed under “health care coverage” and “children & teens”)

Women

Demographic



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

MIChild: Income must be above 150% but below 200% of the FPL; Must be uninsured; Must be ineligible for Medicaid; Residents and U.S. citizens; Families who voluntarily drop employer-based comprehensive insurance must wait six months to enroll; If families drop private insurance, they may immediately enroll in MIChild

BCCP: Have an income 250% FPL or lower

Uninsured, ineligible for Medicaid, meet income and assets test



Be age 40 - 64 for breast/ cervical cancer screening and for diagnostic follow-up of breast/cervical abnormalities or

Countable income at or below 35% of the FPL

Must not have access to employer plan that pays 50% of coverage cost. Not enrolled in certain state plans Also see BCBSM

Be age 18 - 39 and have been identified with a cervical abnormality through the Family Planning program (Title X) Note: Women who are enrolled in a managed care program, a health maintenance organization, or Medicare Part B are not eligible for the BCCC

Eligibility

Healthy Kids: Pregnant women, babies and children under age 19 are eligible, Income must be at or below 150% FPL

Be uninsured or underinsured for these tests and

WIC: Live in Michigan, have a nutritional need (WIC staff can help you determine this), are a child under 5, a new mom, or a pregnant or breastfeeding woman, Income must be at or below 185% FPL

Healthy Kids: $0 to minimal share of cost

BCCP: $0 WIC: $0 to minimal share of cost




www.coverageforall.org Michigan

Monthly Cost

MIChild: $10 monthly premium and no co-pays

44

Demographic






COBRA & Mini-COBRA


Minnesota Comprehensive Health Association

Program

800-234-1317

Group Health

Minnesota Association of Health Underwriters 651-917-6253 www.emahu.org

Then convert to

HIPAA


800-234-1317

Individual Plans

Minnesota Association of Health Underwriters 651-917-6253 www.emahu.org


(MCHA) 952-593-9609 866-894-8053 www.mchamn.com

Medicaid

(Medical Assistance) Twin-Cities Metro Area 651-431-2670 Outside Twin-Cities Metro Area 800-657-3739 www.dhs.state.mn.us www.bridgetobenefits.org

Or

State Conversion Plans Pre-existing conditions can be excluded for a limited time depending upon the type of group plan you are joining

Coverage


COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium

Options vary depending on applicant needs and plan selected Pre-Existing Health Conditions Covered with Some Limitations

HIPAA: Benefits are based on the program selected and there is no expiration of coverage State conversion plans offered through private health insurance market will vary



GUARANTEED COVERAGE

GUARANTEED COVERAGE



Eligibility

Owner can count as an employee, proprietor-name on license must draw wages

All individual market carriers are subject to a 6-month look-back and a 12-month exclusionary period limit on pre-existing health conditions If you are denied coverage for a medical condition, you may be eligible for an MCHA plan, see next column

Monthly Cost

45

Minnesota

COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive

GUARANTEED COVERAGE

GUARANTEED COVERAGE

State resident for the six months immediately preceding the completion of your application

Limited assets such as cash, savings, stocks and bonds (except for pregnant women and children)

Have been rejected for individual health coverage within six months of the application either by a health insurance carrier of a licensed insurance agent; or


Infants (ages 0-2): 280% FPL Pregnant Women: 275% FPL Children (ages 2-18): 150% FPL Elderly, blind and people with disabilities, Parents (and adults ages 19 and 20): 100% FPL SSI Recipients: 70% FPL Medically Needy Individual: 67% FPL, Couple-62%

Have been treated with the last three years for one of the special “Presumptive Conditions” listed on the MCHA application form


Clinic and physician, immunizations, ambulance, emergency room services when used for emergency care, inpatient and outpatient hospital care, lab, X-ray, family planning, pregnancy related services, nurse midwife, medical equipment and supplies, Hearing aids, physical, occupational, speech, respiratory and rehabilitative therapy, transportation, mental health services, alcohol and drug treatment, prosthetics, nursing facilities, home health services, hospice, and more Pre-Existing Health Conditions Covered

Have reached age 65 or over and are not eligible for the health insurance benefits of Medicare Program; or



Professional service, prescription drugs and pharmacy services, mail service, prescription drug program, hospital ambulance, home health care, outpatient, rehabilitation, mental health substance abuse, durable medical equipment and prosthetics, organ and bone marrow transplant, dental infertility services, hospice, reconstructive and restorative surgery, skilled nursing, emergency and more

Disabled are allowed to “spend down” for eligibility

$0 or co-pays for parents

Premiums must be set between 101% - 125% of the weighted average for comparable policies Seven individual plans options, including PPO plans with deductibles of $500, $1000, $2000, $5000, and $10,000, and two different Medicare supplemental policies

800.234.1317

Women

Lower income individuals

Sage Screening Program

MinnesotaCare


800-WIC-4030 800-942-4030 www.health.state.mn.us/divs/ fh/wic/index.html Sage Screening Program: Free screening and follow-up services to uninsured and underinsured women

Twin-Cities Metro Area 651-297-3862 Outside Twin-Cities Metro Area 800-657-3672 www.bridgetobenefits.org MinnesotaCare: Dental services, Doctor and health clinic visits for preventive care, Doctor and health clinic visits for nonpreventive care, Emergency room visits, Inpatient hospital coverage General Assistance: Doctor and clinic visits, routine checkups, family planning, immunizations, inpatient hospital and outpatient surgery, eye exams, prescription drugs, diabetic supplies and equipment, chiropractic care, lab and x-ray services, residential alcohol and drug treatment, and mental health services; families with children can also get dental and vision care

Veterans

Medicare






877-222-8387 www.va.gov

800-633-4227

MinnesotaHelp.info 800-333-2433 TTD: 800-627-3529 http://minnesotahelp.info/

Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D MinnesotaHelp.info is a Medicare counseling service






Coverage


General Assistance


Program

888-643-2584 888-6-HEALTH www.health.state.mn.us/divs/ hpcd/ccs/mbcccp.htm

651-297-3862 Outside Twin-Cities Metro Area 800-657-3672 TTY: 800-6273529 www.bridgetobenefits.org


Demographic




GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Sage Screening Program: Income at or below 200% FPL; Age 40 or older; Have no insurance or are underinsured

MinnesotaCare: Children, families, pregnant women, and adults without children can all get MinnesotaCare. You have to live in Minnesota and have a Social Security number. Adults without Children income at or below 200%, Parents of children under 21, Pregnant women and children under 21 income at or below 275% of the FPL. You cannot get MinnesotaCare if you have had health insurance during the last four months unless the insurance was Medical Assistance. After four months without insurance, then you could get MinnesotaCare




Not enrolled in certain state plans Also see MCHA


Eligibility

WIC: Live in Minnesota, have a nutritional need (WIC staff can help you determine this), are a child under 5, a new mom, or a pregnant or breastfeeding woman, Income must be: Family of 1: $1604 , Family of 2: $2159, Family of 3: $2714, Family of 4: $3269, $555 for each additional family member

Must not have access to employer plan that pays 50% of coverage cost.

General Assistance: Must be an adult between ages 21-64, have no dependent children under age 18, live in Minnesota and have income below the limits. For full medical benefits you must have an income at or below 75% of the FPL; If your income is between 75% and 175% you can receive hospital coverage only


MinnesotaCare: $4 or more

for children, around $22 for adults




General Assistance: $0 to minimal share of cost

www.coverageforall.org Minnesota

Monthly Cost

Sage Screening Program: $0

46

Demographic





COBRA


Program

800-234-1317

Group Health

Mississippi Association of Health Underwriters 703-276-0220 www.nahu.org

Up to $5M lifetime maximum, assorted deductibles

Coverage


and then

HIPAA


COBRA: Coverage available for up to 18 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered

800-234-1317

Individual Plans

Mississippi Association of Health Underwriters 703-276-0220 www.nahu.org

Assorted plans depending on medical needs There is a 12-month lookback and exclusionary period limit for pre-existing conditions in traditional individual market health insurance products in Mississippi Pre-Existing Health Conditions Covered with Some Limitations



MCHIRPA

Medicaid

Mississippi Comprehensive Health Insurance Risk Pool Association 601-899 9967 888-820 9400 www.mississippihealthpool.org

601-359-6050 800-421-2408 www.medicaid.ms.gov

Includes hospital services, physician care, limited mental health care, prescription drugs, and other services

Among some of the services: office visits and family planning services, hospital care, outpatient services, prescription drugs eyeglasses, home health services, long term care services, inpatient psychiatric care, non-emergency transportation services, chiropractic services, dialysis services, dental extractions and related treatment, durable medical equipment and medical supplies, hospice services

Benefits for nervous and mental conditions, alcohol and drug services and certain other treatment and services are provided with substantial limitations Prescription coverage doesn’t begin until you have been enrolled in MCHIRPA for 6 months


Lifetime Maximum Benefit of $1,000,000 Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

Eligibility

Company size 1-50 employees Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage Owner can count as an employee Owner name on business license must draw wages from the company

GUARANTEED COVERAGE COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for MCHIRPA, see next column

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA.You cannot be eligible for Medicare or other public or group insurance programs

GUARANTEED COVERAGE

GUARANTEED COVERAGE

You have been turned down for coverage by an insurance company in the last 12 months or diagnosed with a health condition that causes insurance companies to automatically reject you; or you were offered coverage by an insurance company, but the policy contained a material underwriting restriction (such as an elimination rider); or offered coverage costing more than an MCHIRPA policy and cannot be eligible for or have other, similar coverage from a private or government health plan (including Medicare and Medicaid) in order to get MCHIRPA coverage

Pregnant Women: 185% FPL Children (ages 1-5): 133% FPL Children (Ages 6-19): 100% FPL Aged, Blind and Disabled: 95% FPL Working Parents: 46% FPL Non-Working Parents: 25% FPL Asset limits for some people Legal Mississippi resident

Eligible for MCHIRPA with HIPAA

Monthly Cost

Legal Mississippi resident

47



Mississippi


Premiums vary based on the plan chosen as well as age and gender. Rates are limited to 175% of regular market rates. Deductible amount varies depending on plan chosen

$0 to $10 co-pays

800.234.1317


Infants

Women

Mississippi CHIP

First Steps


601-576-7427 800-451-3903 www.msdh.state.ms.us/ firststeps/home.htm


601-576-7466 800-721-7222 www.msdh.state.ms.us/ msdhsite/_static/41,0,103. html

800-545-6747 www.msdh.state.ms.us/ msdhsite/_static/41.html

Veterans

Medicare



877-222-8387 www.va.gov

Program

Children’s Health Insurance Plan 877-543-7669 877-KIDS-NOW www.medicaid.ms.gov/CHIP. aspx


Demographic



Mississippi Seniorxms.org 888-948-3090 www.seniorxms.org

Comprehensive benefit package that includes coverage of doctor visits, hospitalization, prescriptions, vision, hearing and dental care, and immunizations Pre-Existing Health Conditions Covered

Screening and/or diagnostic mammograms annually for women 50 years of age and older, ultrasound, fine needle aspiration of the breast and breast biopsy, colonoscopy and biopsy, if indicated Follow-up and referral for abnormal pap exams and/or mammograms



Mississippi Seniorxms.org offers assistance and advice to Seniors in need.

Coverage

First Steps: Provides family training and counseling, nursing care, nutritional counseling and planning, psychological services in behavior management, learning and mental health, physical therapy to help teach body movement, crawling, walking, occupational therapy to help teach self-help, playing and eating skills, speech pathologist services to help develop language skills, transportation assistance to and from appointments


WIC: Nutrition education and services; breastfeeding promotion and education; A monthly food prescription of nutritious foods; and access to maternal, prenatal and pediatric health-care services Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Children up to age 19 with family incomes up to: 200% FPL

First Steps: Any child (under the age of 36 months) of a Mississippi resident who has a 25% or greater developmental delay in any one developmental area

MS resident, U.S. citizen or eligible immigrant

Each adult or child applying must provide his or her Social Security number on the application

Yearly costs range from $50.00 to $100.00 per child, per year up to the first 3 children (no cost for additional children); out-of-pocket maximum limits $0-950 depending on income

First Steps & WIC: $0 or minimal share of cost

GUARANTEED COVERAGE

Cannot have Medicaid, Medicare or other insurance or method of reimbursement




Women 40-49 qualify for mammograms while funds are available Must be 40-64 years of age for Pap Exam


Must be 50-64 years of age for Mammogram 18-44 years of age and have had tubal ligation, hysterectomy or post menopausal


www.coverageforall.org Mississippi

Monthly Cost

$0 to 15 co-pays

WIC: Live in Mississippi, have a nutritional need, are a child under 5, a new mom, or a pregnant or breastfeeding woman, Income must be: Family of 1: $1604 , Family of 2: $2159, Family of 3: $2714, Family of 4: $3269, $555 for each additional family member

GUARANTEED COVERAGE Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

Eligibility

Proof of most recent full month's family income, (such as a paycheck stub) must accompany the application.

GUARANTEED COVERAGE

48

Demographic







COBRA


Missouri Health Insurance Plan

MO Healthnet

Program

800-234-1317

Group Health

Missouri Association of Health Underwriters 703-276-0220 www.nahu.org

Then convert to

HIPAA


800-234-1317

Individual Plans

(Medicaid) 888-275-5908 www.dss.mo.gov/mhd/index. htm

800-843-6447 800-821-2231 www.mhip.org

Missouri Association of Health Underwriters 703-276-0220 www.nahu.org

or


Coverage


COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage State conversion plans offered through private health insurance market will vary

Covers certain state mandated services Unlimited look-back and 24-month exclusionary period limit for pre-existing conditions Coverage options vary by carrier, but most offer plans that are HSA (Health Savings Account) compatible Pre-Existing Health Conditions Covered with Some Limitations

GUARANTEED COVERAGE




Eligibility




For most services, plan will pay for 80% of covered charges after you satisfy your annual deductible if you receive care in-network. After paying maximum amount of coinsurance charges for covered in-network services, MHIP will pay 100% of your covered charges for the rest of the calendar year




GUARANTEED COVERAGE

Hospital, physician care, maternity, prescription drugs, some limitations on alcohol and drug abuse care

Eligibility is based on medical underwriting There is a 12 month look back period during first two years of coverage. If condition is deemed preexisting there can be a 24 month exclusionary period.

GUARANTEED COVERAGE

GUARANTEED COVERAGE


Limited assets such as cash, savings, stocks and bonds

Must be Missouri resident

Working parents with household income up to 84% FPL Non-working parents with household income up to 77% FPL Pregnant women and children aged 0-1 up to 185% FPL


Children ages 1-5 up to 133% FPL

If you are denied coverage for a medical condition, you may be eligible for MHIP, see next column

Children ages 6-18 up to 100% FPL Aged, blind, disabled up to 85% FPLL

Monthly Cost

Must be a Missouri resident

49



Missouri


Deductibles: $500, $1000, $2500, and $5000. Also, MHIP charges enrollees different rates based on their age, sex, and the deductible level they choose. MHIP rates cannot be more than twice of the amount that a healthy person would pay if he or she bought a similar plan from the five largest MO insurers


800.234.1317


Pregnant women and children

Women

Children with Special Health Care Needs (CSHCN)

MO HealthNet for Kids

Show Me Healthy Women

(Medicaid) 888-275-5908 www.dss.mo.gov/mhk/index. htm

573-522-2845 www.dhss.mo.gov/ BreastCervCancer/index.html


573-522-2845 www.dhss.mo.gov/ WISEWOMAN

WISEWoman

573-751-6204 800-392-8209 www.dhss.mo.gov/wic/


MO HealthNet for Kids: Comprehensive care including but not limited to doctor visits, mental, dental, prescriptions, hospitalization and more WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services Pre-Existing Health Conditions Covered

Medicare



877-222-8387 www.va.gov


MO Senior Rx 800-375-1406 www.morx.mo.gov

Show Me Healthy Women: Women age 50 to 64 or older without Medicare Part B are eligible for a clinical breast examination (CBE), and mammogram, plus a pelvic exam and pap test Women age 35-39 (with no other funding source available) are eligible for a pelvic examination and pap test and CBE, for diagnostic breast services if the CBE results are suspicious for cancer, and for diagnostic cervical services if their initial/follow-up cervical cancer screening was abnormal



Senior Rx is a prescription discount program

Coverage

Arthritis, burns, cerebral palsy, cleft lip and palate, cystic fibrosis, digestive disorders, ear infections (chronic), hearing disorders, heart disorders, hemophilia, hydrocephalus, neuromuscular disorders, orthopedic disorders, paraplegia, quadriplegia, seizures, sickle cell disease, spina bifida, spinal cord deformities, traumatic brain injury, urinary disorders

Veterans

Program

573-751-6246 800-451-0669 www.dhss.mo.gov/SHCN/ index.html


Demographic



WISEWoman: Offers access to health screenings and lifestyle education that can reduce the risk of heart disease and stroke Pre-Existing Health Conditions Covered GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Participants must meet both medical and financial eligibility guidelines

MO HealthNet for Kids: Low income children up to 300% FPL and uninsured

Both: Must be MO resident and have legal immigration status

Must reside in Missouri

WIC: pregnant women, nonbreastfeeding postpartum women (up to 6 months after delivery or termination of the pregnancy), breastfeeding women (up to 1 year after delivery as long as they are breastfeeding the baby), infants from birth up to 1 year of age, and children up to their 5th birthday; Income must be at or below 185% FPL

Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).


Children up to age 21

$0 or share of cost

WIC: $0 or minimal share of cost

Must be uninsured or underinsured with income under 200% of FPL

Senior Rx: To qualify for Senior RX you must have Medicare Part D. If you are single your income must be at or below $21,660 and if you are a married your income must be below $29,140

Both:

$0





Senior Rx: $0

www.coverageforall.org Missouri

Monthly Cost

MO HealthNet for Kids: $0 or share of cost. Families will pay no more than 5% of their annual income for premiums in a year.

Women age 35-64 years of age

Eligibility

GUARANTEED COVERAGE

50

Demographic


Already insured small businesses (2-9 employees)




Insure Montana Purchasing Pool

COBRA


800-234-1317

Program

Group Health

Montana Association of Health Underwriters 703-276-0220 www.nahu.org

State Auditor’s Office 800-332-6148 406-444-2040 www.sao.mt.gov/ InsureMontana/index.asp

and then

HIPAA


Insure Montana Purchasing Pool

Coverage


MCHA

800-234-1317

Individual Plans

Montana Comprehensive Health Association 800-447-7828 www.mthealth.org

Montana Association of Health Underwriters 703-276-0220 www.nahu.org

State Auditor’s Office

State Auditor’s Office 800-332-6148 406-444-2040 www.sao.mt.gov/ InsureMontana/index.asp



800-332-6148 406-444-2040 http://sao.mt.gov

Provides a refundable state income tax credit to employers who currently pay some or all of the cost of group health insurance for their employees; Also provides additional Tax Credits when employers pay for insurance for the employee’s spouse or their dependents; Approximately 40% of the available funding per year is designated to the Employer Tax Credit; The funds for tax credits will be distributed on a first come, first served basis until the money is fully allocated

COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage (see MCHA for plan details)

Assorted plans depending on medical needs There is a 36-month look-back and 12-month exclusionary period limit for pre-existing conditions in the Montana individual health insurance market Pre-Existing Health Conditions Covered with Some Limitations

Comprehensive plans to choose from, the primary difference is the annual deductible Lifetime maximum of $2,000,000 Waiting period for certain pre-existing conditions may apply Pre-Existing Health Conditions Covered



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE


Employer already provides employee health insurance


Monthly Cost

Eligibility


51


Employer has a number of employees that meets the eligibility criteria established by the State Auditor’s Office (between 2–5 employees; adjustable up to 9 depending on take-up and available revenue) The tax credit cannot be more than 50% of premiums paid No employee is paid more than $75,000 per year (owner excluded)

Costs depend on employer contribution and ±25% of the insurance company’s index rate

Costs depend on employer contribution

If you are denied coverage for a medical condition, you may be eligible for MCHA, see next column


Cannot be eligible for COBRA or any other government programs (except “endstage renal disease” covered under Medicare) Must prove denial of coverage or proof of offer paying 150% higher premium than MCHA May also be automatically eligible with certain health conditions (contact MCHA)



Montana

GUARANTEED COVERAGE Eligibility is subject to medical underwriting

Resident in state for at least 30 days


Premiums and deductibles vary depending on plan Deductibles from $1-10K, 80/20 co-payments, $5-13.5K annual maximum member liability

800.234.1317



Medicaid

Healthy Montana Kids

800-362-8312 www.dphhs.mt.gov/ programsservices/medicaid. shtml

877-KIDS-NOW 877-543-7669 406-444-6971 www.chip.mt.gov


888-803-9343 406-444-0063 www.dphhs.mt.gov/ PHSD/cancer-control/ Breast&Cerv-index.shtml

800-433-4298 406-444-4747 www.dphhs.mt.gov/PHSD/familyhealth/nutrition-wic/nutrition-wicindex.shtml



Medicare




Program


Women

Demographic



State Health Insurance Assistance Program (SHIP) 800-551-3191 www.dphhs.mt.gov/sltc/ services/aging/ship.shtml

CHIP: Physician, inpatient and outpatient hospital services, routine sports or employment physicals, general anesthesia services, surgical services clinic and ambulatory health care services, prescriptions, laboratory and radiological services, inpatient, outpatient, and residential mental health services, inpatient, outpatient, and residential substance abuse treatment services dental, vision exams, eyeglasses, hearing exams



Mammograms, clinical breast exams, pap tests and pelvic exams for the early detection of breast and cervical cancer

Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and ‘advantage’ plans. It also offers a prescription drug program called Medicare Part D SHIP is a Medicare counseling service

Will cover COBRA if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Pre-Existing Health Conditions Covered


Coverage

Among the services the Montana program may cover are: treatment by physicians, nurse practitioners, nurse midwives, dentists, denturists, and podiatrists; lab services, including X-rays; inpatient hospital visits; outpatient hospital visits; family planning; nursing facilities; home health care; durable medical equipment; outpatient drugs; mental health; ambulance; and eyeglasses


GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Newborn-No Income Limit Children (under 6): 133% FPL Pregnant women: 150% FPL Children (Ages 6-19): 100% FPL

CHIP: Children until age 19; Montana residents; US citizens or qualified aliens; Not currently insured or covered by health insurance in the past 3 months (some employmentrelated exceptions apply); Not eligible for Medicaid , Parents not employed by the State of Montana; Income at or below 250% of the FPL

Must be under the age of 65, not have insurance, be a US citizen and Montana Resident, Income cannot exceed 200% of FPL For more information, please contact your local county office




Working Parents: 58% FPL Medically Needy Couple: 54% FPL Non-Working Parents: 33% FPL

WIC: Must be a Montana resident, a pregnant woman, a breastfeeding woman, or a woman who recently had a baby. Infants from birth to 12 months, or children up to 5 years old are also covered. Income must be at or below 185% FPL

CHIP: Families with incomes above 100 percent of the FPL will pay a small co-payment when services are received, no co-payment for wellbaby or well-child care, including age-appropriate immunizations, and no co-payment for dental or eyeglasses. Max co-payment for any family is $215 per family/yr

$0 or minimal share of cost $0 and share of cost for




www.coverageforall.org Montana

Monthly Cost



Eligibility

Medically Needy Individual: 73% FPL


52

Demographic

Private Health Insurance Individuals recently Small businesses covered by an employer (2-50 Employees) health plan U.S. Uninsured Help Line

Program

800-234-1317

Group Health

Nebraska Association of Health Underwriters 402-397-0280 www.neahu.org

COBRA & Mini-COBRA


Then convert to


HIPAA

Individual Plans


800-234-1317


Low income families and medically needy

NECHIP

Medicaid

402-343-3574 877-348-4304 www.nechip.com

402-471-3121 877-255-3092 TTD: 402-471-9570 www.hhs.state.ne.us/med/ medindex.htm

Comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, transplants, rehabilitation, durable medical equipment, mental health and substance abuse, physical, speech and occupational therapy, dental care, vision care, and preventive care, among other services

Hospital, physician, laboratory and radiology (X-ray) , nurse midwife services, nurse practitioner services, clinic services, family planning, home health agency, personal care aide, medical transportation, ambulance, chiropractic, dental, durable medical equipment, orthotics, prosthetics, and medical supplies prescribed drugs, hearing aid services, therapies: physical, occupational, speech pathology & audiology, podiatry, psychiatric, adult day treatment, mental health and substance abuse, visual, mammograms

Nebraska Association of Health Underwriters 402-397-0280 www.neahu.org

HIPP

Health Insurance Premium Payment 402-471-3121 or

State Continuation Coverage Assorted deductibles

Coverage

There is a 6-month look-back/ 12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Pre-Existing Health Conditions Covered

COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium

Up to $5M, assorted deductibles depending on age and residence zone Pre-Existing Health Conditions Covered with Some Limitations

HIPAA: Benefits are based on the program selected and there is no expiration of coverage HIPP: Benefits are the same as what you had with your previous employer. HIPP is a premium assistance program

There are eight different deductible options to choose from; waiting period may apply


GUARANTEED COVERAGE

GUARANTEED COVERAGE

Company size 2-50


Eligibility

Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage Owner can count as an employee; proprietor name on license must draw wages If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions- not counting birth or adoptionmay apply, (1-6 months respectively)


Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for NECHIP, see next column

Mini-COBRA: Applies to small businesses with less than 20 employees HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA


GUARANTEED COVERAGE

GUARANTEED COVERAGE

Must be a legal Nebraska resident for at least six months prior to application

Pregnant Mother & Child up to 185% of FPL

Previous coverage terminated for reasons other than nonpayment of premium or fraud or rejected for coverage within previous 6 months

Children 1-5 up to 133% FPL

Infants aged 0-1 (no parents) up to 150% of FPL

Children 6-18 up to 100% FPL

You have one of the specified health conditions covered by the program (full list available on program web site)

Aged, Blind and Disabled: 100% FPL

Cannot be eligible for COBRA, or government programs

Working Parents: 58% FPL

If an individual's prior coverage was through a continuation of coverage policy or contract available under state or federal law (COBRA), a waiver may be available



Non-Working Parents: 46% FPL


Monthly Cost

HIPP: You may be eligible for HIPP if you have a high-cost health condition (e.g., pregnancy, HIV/AIDS), and are on Medicaid

53

Costs depend on employer contribution and± 25% of the insurance company’s index rate


Nebraska


Premiums vary based on the plan and deductible you choose and underwriting guidelines, can be around 135% of regular rates

$1-$3 and may share in some

costs

800.234.1317

Low income children

Women


Kids Connection Program

Nebraska Every Woman Matters Program


800-532-2227 402-471-0929 TTD: 800-833-7352 www.hhs.state.ne.us/hew/ owh/ewm

605-226-7531 www.ihs.gov


Medicare






Program

(SCHIP) 402-471-8845 877-NEB KIDS 877-632-5437 www.hhs.state.ne.us/med/ kidsconx.htm


Demographic


800-633-4227

800-942-1171 402-471-2781 www.dhhs.ne.gov/wic

Pelvic exam with a pap test, clinical breast exam, teaching of breast self exam, blood pressure check, cholesterol check, blood sugar (glucose) check, mammogram

Care includes medical, nursing, dental, optometry, nutrition, health education, community health nursing, mental health, social services, substance abuse, and environmental health services, well-child, chronic diseases, allergy, women's health, and podiatry pharmacy, laboratory and radiology services are all provided at the centers, including in-patient and specialty care with providers in neighboring areas

Medicare offers two standard plans, A: Hospital Insurance and B: Medical Insurance, as well as several supplemental and 'advantage' plans Pre-Existing Health Conditions Covered

Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Pre-Existing Health Conditions Covered



Coverage

KCP: Hospital services, physician services, laboratory and radiology (X-ray), clinic, family planning, health checks, home health agency, medical transportation, ambulance, chiropractic dental, durable medical equipment, orthotics, prosthetics, and medical supplies, prescribed drugs, hearing aid, therapies, physical, occupational, speech pathology & audiology, podiatry mental health and substance abuse, visual


GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

KCP: Must not be eligible for Medicaid

Women 40 - 64 years of age

Winnebago and Omaha tribes, as well as others



19 years of age or younger

Do not have Medicaid

Household income of 200% FPL

Do not have Medicare

WIC: A pregnant woman, A breastfeeding woman, A woman who recently had a baby, An infant, birth to 12 months, or A child, up to age 5 years. Determined by a health professional to be at nutritional or medical risk, Reside in Nebraska, Below 185% of FPL

Have a low to medium income (Approximately 100% of FPL for free services; woman up to approximately 225% of the FPL can still receive services for a suggested $5 donation)

KCP: $0 for most members



Must not have access to employer plan that pays 50% of coverage cost. Not enrolled in certain state plans Also see NCHA




www.coverageforall.org Nebraska

Monthly Cost

Do not belong to an HMO (Health Maintenance Organization)

Eligibility

State resident and/or qualified immigrant

54

Demographic





Children


COBRA/ Mini-COBRA


NV Medicaid

Nevada Check Up

Group Health

Then convert to

Individual Plans

Program

800-234-1317

Nevada Association of Health Underwriters 703-276-0220 www.nahu.org

HIPAA


800-234-1317

Nevada Association of Health Underwriters 703-276-0220 www.nahu.org

775-684-3600 800-992-0900 http://dwss.nv.gov/ To find address and phone number of welfare office near you: http://dwss.nv.gov/index. php?option=com_content&ta sk=view&id=122&Itemid=319

877-KIDS-NOW (877-543-7669) 800-360-6044 775-684-3777 www.nevadacheckup.state. nv.us


800-8-NEV-WIC 800-863-8942 http://health.nv.gov/WIC.htm

Or

State Conversion Plans www.doi.state.nv.us

Coverage

Assorted plans Carriers can impose a 6-month look-back/12-month exclusionary period for preexisting health conditions on enrollees who do not have prior creditable coverage Pre-Existing Health Conditions Covered


Up to $5M, assorted deductibles depending on age and residence zone Carriers do not have limits on how far back they can look at pre-existing health conditions Limits on Pre-Existing Health Conditions May Apply

Diagnosis (services to find out what is wrong), physician services, check-ups (medical and dental), family planning, maternity, prenatal, and newborn care, prescriptions, hospital services, comfort care, hospice, dental services, drug and alcohol treatment, mental health services Pre-Existing Health Conditions Covered


GUARANTEED COVERAGE

GUARANTEED COVERAGE

Company size 2-50


Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage Owner can count as an employee

Eligibility



Eligibility is subject to medical underwriting HIPAA eligible must be offered two standard policies

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Child to age 5: 133% FPL

NV Check Up: Must not be eligible for Medicaid.If not covered by employer health plan (with employer paying 50% of premium); 19 and younger, Household income between 100-200% of FPL; Eligibility is determined for one year unless child moves out of state, is enrolled in Medicaid, has other coverage, or becomes financially ineligible

Child age 6-19: 100% FPL Non-working parents: 26% FPL Working parent: 91% FPL Pregnant woman: 133% FPL

WIC: Reside in Nevada, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family of 1: $1,670 , Family of 2: $2,247, Family of 3: $2,823, Family of 4: $3,400, $555 for each additional family member

Monthly Cost


55


Nevada

WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services Pre-Existing Health Conditions Covered



NV Check Up: Well baby/well child visits, prescription drugs, mental health benefits, immunizations, dental and vision services


$0 may share in some costs

NV Check Up: $0 for most. Depending on your family income you could pay a quarterly premium of $25-$80. You are not required to pay co-payments, deductibles, or other charges for covered services. WIC: $0 or minimal share-ofcost

800.234.1317

Publicly Sponsored Programs Women

Early Intervention Services

Women’s Health Connection

800-522-0066 http://health.nv.gov/BEIS.htm

Maternal Child Health Line

800-429-2669 http://health.nv.gov/MCHL_ InfantChildCare.htm

WHC: Some diagnostic services such as ultrasound, breast biopsy, surgical consultation, colonoscopy Cancer treatment for some women qualified through Medicaid MHL: Provides prenatal care and other maternity services


Veterans

Medicare






877-222-8387 www.va.gov

800-633-4227

Senior Rx

866-303-6323 775-687-8711 http://www.dhhs.nv.gov/ SeniorRx.htm



Senior RX: Offers extra coverage for medication. There are plans for seniors with Medicare Part D and for seniors without Medicare Part D



Comprehensive preventive and primary care, outpatient and inpatient services. Pre-Existing Health Conditions Covered

Coverage

Audiology (hearing) services family training, counseling and home visits, health services, medical services for diagnostic or evaluation purposes, nutrition counseling, occupational therapy, physical therapy, psychological services, service coordination, social work services, special instruction, speech and language services, transportation services, vision and more


Program

888-463-8942 775-684-4285 http://health.nv.gov/CD_WHC_ BreastCervical_Cancer.htm



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Must live in state

WHC: Age 40 or older (over 50 for annual mammogram)




Children who have one of the covered diagnosed developmental disorders or show significant delays in development such as talking or walking

Under-insured or uninsured Income below 250% FPL MHL: Contact program

scale







Senior RX: $0 or minimal shareof-cost

www.coverageforall.org Nevada

Monthly Cost

$0 and share of cost sliding


Eligibility

Senior RX: Age 62 or older, Seniors with an income at or below $25,477 if you are single and at or below $33,963 if you are a married couple.

Contact program for financial eligibility criteria


Demographic

Children with developmental delays

56

Demographic






COBRA/ Mini-COBRA


New Hampshire Health Plan

Group Health

Then convert to

Individual Plans

Program

800-234-1317

National Association of Health Underwriters 703-276-0220 www.nahu.org

HIPAA


800-234-1317



603-271-5254 800-852-3345 x5254 www.dhhs.state.nh.us/ dhhs/medicaidprogram/ default.htm

877-888-NHHP 877-888-6447 www.nhhealthplan.org

Catastrophic Illness Plan

603-271-4495 800-852-3345 ext. 4495 www.dhhs.state.nh.us/dhhs/ beas/cip.htm

Or

State Conversion Plans

Coverage

Assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions- not counting birth or adoptionmay apply, (1-6 months respectively) Pre-Existing Health Conditions Covered


Up to $5M, assorted deductibles depending on age and residence zone Limits on Pre-Existing Health Conditions May Apply


CIP: Meant to provide financial assistance to persons with cancer, hemophilia, end stage renal disease, cystic fibrosis, spinal cord injuries, and other serious illnesses or injuries. Assistance is limited to $2,500 per individual per year.


GUARANTEED COVERAGE

GUARANTEED COVERAGE

Company size 2-50



Eligibility

Owner can count as an employee Twice annually, self-employed persons can be a small group health plan with guarantee issue Proprietor name on license must draw wages

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for NHHP, see next column


Monthly Cost

57


New Hampshire

Diagnosis (services to find out what is wrong), physician services, check-ups (medical and dental), family planning, maternity, prenatal, and newborn care, prescriptions, hospital services, comfort care, hospice, dental services, drug and alcohol treatment, mental health services Pre-Existing Health Conditions Covered


GUARANTEED COVERAGE

NHHP: Declined for health coverage because of health or medical condition Offered Coverage that is the same as NHHP but at a higher premium. You have a pre qualifying medical condition (see list on web site); Previous coverage terminated for reasons other than non-payment of premium or fraud; Federally eligible or certified as eligible for TAA or PBGC assistance; Cannot be eligible for COBRA, or government programs; New Hampshire resident

Infant: 300% FPL Child Age 1-19: 185% FPL Pregnant woman: 185% FPL Non-working parents: 41% FPL Working parent: 51% FPL Medically needy individual: 76% FPL Medically needy couple: 70% FPL

CIP: A New Hampshire Resident; A US citizen, or the parent or guardian having primary responsibility for the applicant child is a US citizen; Must be age 21 or over, Must have one of the covered health conditions

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA Costs depend on employer contribution and the Modified Community Rate

NHHP: Choose from seven plan options each with a different deductible. Hospitalization, physician care, diagnostic tests, x-rays, prescription drugs, and some mental health care services

Costs depend on age and county/zone. If you are self-employed and buy your own insurance you are eligible to deduct 100% of the cost of the premium from your federal income tax.

NHHP: Premiums vary based on the plan and deductible you choose (approximately 150% of similar plans offered to a healthy individual through private insurance options)

$0 may share in some costs

CIP: $0 to minimal share of cost

800.234.1317


Women

Healthy Kids

Let No Woman Be Overlooked Program 800-852-3345 x4931 603-271-4931 www.dhhs.nh.gov/dhhs/cdpc/ bccp.htm

Medicare






877-222-8387 www.va.gov

NH Senior Prescriptions Discounts

800-942-4321 603-271-4546 www.dhhs.state.nh.us/dhhs/ wic/default.htm

888-580-8902

Women age 18 and younger receive free Pap tests Women age 40 and over receive free mammograms every 1-2 years Cancer treatment for some women qualified through Medicaid







Coverage


Veterans

800-633-4227 www.expressscript.com


HK: Hospital and physician care, prescription drugs, mental health care, and some other services


Program

877-464-2447 603-228-2925 www.nhhealthykids.com or www.dhhs.nh.gov/dhhs/ medassistelig/eligibility/d4.htm



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

HK: New Hampshire Resident, a U.S. citizen, a refugee, an asylee, or a permanent resident who has been in the U.S. for at least five years; Must not be eligible for Medicaid; Children age 1-18 who are at or below 185% FPL and infants at 300% FPL qualify for Healthy Kids Gold Program; Children age 1-18 between 185-400% FPL qualify for Silver or Buy-In Programs

Have income less than 250%









Women under age 40 are eligible for a clinical breast exam, pelvic exam and Pap smear, and a mammogram when a breast lump is found during a clinical breast exam or a breast self exam


Women ages 40 to 64 are eligible for a clinical breast exam, pelvic exam, Pap smear and mammogram Women age 65+ are eligible for a clinical breast exam, pelvic exam, Pap smear and mammogram when not eligible for the Medicare program or not enrolled in Medicare Part B





www.coverageforall.org New Hampshire

Monthly Cost

HK: $0 for Gold Program. Monthly premium for Silver Program is based on family size and household income.


Eligibility

WIC: Reside in New Hampshire, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be at or below 185% FPL

Demographic


58

Demographic






COBRA & Mini-COBRA and then


Individual Health Coverage Program

HIPAA

Individual Plans

Program

800-234-1317

Group Health

New Jersey Association of Health Underwriters www.njahu.org

Coverage

Carriers can impose a 6-month look-back/6-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage (this may only apply to certain groups) Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered


800-234-1317

New Jersey Association of Health Underwriters www.njahu.org




There is a 6-month look-back and a 12-month exclusionary period limit for pre-existing conditions

HIPAA: Benefits are based on the program selected and there is no expiration of coverage (see IHC for plan details)

All carriers must guarantee issue coverage to all individuals



(IHC) 609-633-1882 www.state.nj.us/dobi

All plans cover the following office visits, hospital care, prenatal and maternity care, immunizations, well-child care, screenings (including mammographies, pap smears and prostate examinations), X-ray and laboratory services, certain mental health and substance abuse services, prescription drugs Individuals are subject to a 12 month waiting period for coverage of preexisting conditions


800-356-1561 609-588-2600 www.state.nj.us/ humanservices/dmahs/home/

Inpatient and outpatient hospital treatment, laboratory tests and X-rays, early and periodic screening, diagnostic and treatment services, home health care, physician services, nursemidwife services, assistance with family planning and any necessary supplies, nursing facilities for people over 21 Pre-Existing Health Conditions Covered


GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE



New Jersey resident

Resident of New Jersey at least 6 months

Infants (ages 0-1): 200% FPL (mother is enrolled in Medicaid at the time of birth. If not, infants with family incomes of 185% FPL)


Monthly Cost

Eligibility

Most carriers require the most recent copy of NJ’s quarterly wage and tax filing form

59


Medical underwriting is not allowed If you are denied coverage for a medical condition, you may be eligible for IHC, see next column

Not eligible for coverage under a group health plan, governmental plan or church plan Not eligible for coverage under Medicare

Children (ages 1-19): 133% FPL Pregnant Women: 185% FPL (Expanded coverage for women with incomes between 186 and 200% may also be available) Qualified Parents: 100% FPL


Medically Needy Individual: 51% FPL Medically Needy Couple: 45% FPL


SSI Recipients: 74% FPL Aged, Blind and Disabled: 100% FPL



Costs vary based on selected carrier and plan (premiums, deductibles and co-pays)



New Jersey

800.234.1317


Women

NJ Family Care Program

Cancer Education and Early Detection

800-701-0710 www.njfamilycare.org

866-44 NJ WIC 866-446-5942 609-292-9560 www.state.nj.us/health/fhs/ wic/index.shtml


Veterans

Medicare





877-222-8387 www.va.gov

Program


(CEED) 609-292-8540 800-328-3838 www.state.nj.us/health/cancer/ njceed/index.shtml


Demographic



Senior Gold Program 800-792-9745 www.nj.gov/health/ seniorbenefits/paadapp.htm


Screening mammograms, clinical breast examinations, instructions on breast self-examinations, Pap tests, and pelvic examinations. Diagnostic tests such as needle biopsies, breast ultrasounds and colonoscopies. Case management, tracking and follow-up are provided to all women and major emphasis is placed on rescreening women who are currently being served by the program

Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D Senior Gold: is a state funded prescription discount program





Coverage

NJ Family Care: Physician services, preventive health care, emergency medical care, inpatient hospital services, outpatient hospital services, laboratory services, prescription drugs, eyeglasses, dental services in most cases, emergency transportation, mental health services and more




GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

NJ Family Care: Uninsured children age 18 or younger with family incomes of up to 350% FPL

Income below 250% of FPL




Uninsured or under-insured

Qualified parents at or below 200% FPL

premiums and $0-35 co-pays depending on income WIC: $0 to minimal share of cost




Not enrolled in certain state plans Also contact Aetna of New Jersey





Senior Gold: $0 to minimal share of cost

www.coverageforall.org New Jersey

Monthly Cost

NJ Family Care: $0-128

Senior Gold: at least 65 years old, OR at least 18 years old and receiving Social Security Disability Title II benfits, income restrictions

Eligibility

WIC: Reside in New Jersey, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family of 1: $1604 , Family of 2: $2159, Family of 3: $2714, Family of 4: $3269, $555 for each additional family member


60

Demographic




Individuals Below 200% FPL


COBRA & New Mexico State Continuation


State Coverage Insurance (SCI)

Program

800-234-1317

Group Health

Conversion Coverage

Small Employer Insurance Program (SEIP)

HIPAA


Coverage

Or

New Mexico State Association of Health Underwriters www.nmsahu.org

866-901-4538 http://www.generalservices. state.nm.us/rmd/seip.html

If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply SEIP: Annual claims limit of $100,000 per enrollee Pre-Existing Health Conditions Covered

Or


(Waitlist is currently open The program and enrollment will be closed until further notice from the New Mexico legislature.)

INSURE New Mexico! Solutions 888-997-2583 www. insurenewmexico.state. nm.us/




SEIP: Offer plans to small groups and has special rules

New Mexico State Association of Health Underwriters www.nmsahu.org

888-997-2583 http://insurenewmexico.net

HIPAA: Benefits are based on the program selected and there is no expiration of coverage (benefits are similar to the NM Health Insurance Alliance or the NM Medical Insurance Pool)


GUARANTEED COVERAGE


Individual Plans

Up to $5M, assorted deductibles depending on age and ZIP code Pre-Existing Health Conditions Covered with Some Limitations

Individuals with pre-existing, severe or chronic medical conditions NMMIP

Benefits are limited to $100,000 payable per member per benefit year; Doctor visits; pre/post natal care; Preventive Services; Hospital Inpatient & Outpatient; Home Health; Physical, Occupational & Speech therapy; Medical supplies; Emergency Services; Urgent Services; Prescription Drugs; Diabetes Treatment; and behavioral health and substance abuse


Owner, partners can count as an employee

800-234-1317


GUARANTEED COVERAGE


Eligibility

Private/Public Program

New Mexico Medical Insurance Pool 888-997-2583 505-424-7105 800-432-0750 (Option #4) www.nmmip.com

New Mexico Health Insurance Alliance (The “Alliance”) 800-204-4700 888-997-2583 www.nmhia.com

NMMIP: Hospital and physician care, prescription drugs, and other services, limited home health visits and organ transplant coverage are available, there is no lifetime maximum per member except for certain benefits (e.g., $250,000 lifetime maximum per member for organ transplant), and maternity coverage is available The Alliance: Offers HMO, PPO and indemnity plans Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE


Uninsured adults between the ages of 19-64

NMMIP: Must be a resident of New Mexico

If you are denied coverage for a medical condition, you may be eligible for NMMIP, see the "Individuals with preexisting, severe or chronic medical conditions" column

At or under 200% FPL

You are eligible if your previous coverage was terminated for reasons other than non-payment or fraud

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA For HIPAA, you cannot be eligible for Medicare or other public insurance programs

Not eligible for certain government health insurance benefits (i.e. Medicaid, Medicare, CHAMPUS) Do not have other private or public health insurance

Must prove denial of coverage or offer of higher premium than NMMIP You are also eligible if you have a qualifying medical condition or have reached the maximum allowable coverage limit of your current health insurance plan

No asset test for eligibility New Mexico resident

The Alliance: Must be HIPAA eligible Do not have any health plan available, but have had 18 months of creditable coverage

Monthly Cost

In addition, if you have a policy from the Alliance, you can transfer into NMMIP

61

Costs depend on employer contribution and ± 20% of the insurance company’s index rate SEIP: Premium determined buy age, gender, and geographic location. Employers must contribute at least 50% of the monthly premium

New Mexico


Costs for individual coverage vary according: age, gender, smoking and geographic location

Employer pays a portion ($0 to $75) of the monthly premium, the employee pays a portion ($0 to $35) of the monthly premium, and if you make less than 100% FPL the state contributes the premium payment. Individuals without an employer group pay both the employer and employee premium share which is either $0 or $95 or $110 depending on their income

NMMIP: Premiums vary according to income level. Assistance available for individuals up to 400% FPL Rates cannot be more than 25% higher than the average a healthy person would pay for a similar plan sold by a private NM insurer The Alliance: Alliance premiums for individuals are usually about 9% higher than premiums charged for similar coverage

800.234.1317

Low-income individuals & families Medicaid

888-997-2583 505-827-3100 www.state.nm.us/hsd/mad

Pregnant Women

Women

New Mexikids

Premium Assistance for Maternity (PAM)

Breast & Cervical Cancer Early Detection Program


Offers clinical breast exams (CBE), pelvic exams , mammograms (every two years for women 40-49, yearly for women 50 and older, or when medically indicated) , pap tests, as well as some additional breast and cervical tests if needed, such as ultrasound, biopsies, and other services

In New Mexico, the tribes served are the 19 Pueblos, the Jicarilla and Mescalero Apaches, and the Alamo, Canoncito and Ramah Chapters of the Navajo Nation. Headquarters of the Area are located in Albuquerque. Most health facilities are strategically located near population centers and include 5 hospitals, 11 health centers, and 12 field clinics. The Area’s extensive network provides the Indian people a wide array of inpatient and outpatient services.

888-997-2583 www.insurenewmexico.state. nm.us/default.aspx or www.newmexicokids.org

Premium Assistance for Kids (PAK) 888-997-2583 www.insurenewmexico. net/pakhome.htm

888-997-2583 www.insurenewmexico. state.nm.us/PAMHome.htm


505-248-4500 www.ihs.gov

877-852-2585 www.cancernm.org/bcc

Program

Or contact local county social services agency


Demographic


Medicaid

888-997-2583 www.state.nm.us/hsd/mad


866-867-3124 www.health.state.nm.us/phd/ wicsite/index.php Offers health, dental, vision, and prescription coverage Pre-Existing Health Conditions Covered

PAM: Pre- & Post-Natal Care, delivery, and pregnancyrelated health services.

PAK: Medical underwriting applies so pre-existing health conditions are not covered. Provides assistance with payment of the premium for commercial, comprehensive child health insurance, which usually includes preventive,primary and specialty care, inpatient and outpatient hospitalization, pharmacy, labs and x-rays, physical, occupational and speech therapy.

Medicaid: Offers health, dental, vision, and prescription coverage



If diagnosed with a cancerous or precancerous condition through the BCC Program, you may be eligible for full Medicaid services which include the cost of cancer treatment



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Ages 0-19: up to 235% FPL

New MexiKids: Children ages 0-19 between 185%-235% FPL Must be ineligible for no-cost Medicaid or employer-based coverage

PAM: Income must be too high to qualify for Medicaid. Must be pregnant, a resident of New Mexico and a U. S. citizen

Women age 30 and over

Tribal members from throughout the United States who live, work, or go to school in the urban centers of the area

PAK: Children ages 0-12 or up to age 18 if part of a sibling group that includes a child below age 12. Income must be too high to qualify for Medicaid and SCHIP

Medicaid: Pregnant women can have an income up to 185% of the FPL.

Have no health insurance or have health insurance, but deductibles and/or co-pays are too high

New MexiKids: may require a co-payment at the time each service is provided. Co-payments range from $2-$25 depending on the services, and Native Americans are exempt

PAM: One time premium of either $150 or $300. No co-payments or deductibles.

Pregnant: up to 185% FPL Supplemental Security Income Recipients-74% of FPL Working Parents: up to 69% FPL Non-Working Parents: up to 30% FPL

Parents: up to 31% FPL

Live at or below 250% of the federal poverty threshold

WIC: Reside in New Mexico, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be at or below 185% FPL

Eligibility

Working Parents: up to 71% FPL

Live in state


Coverage

New Mexikids & PAK: Doctor visits, hospital care, prescriptions, and vision, hearing, and dental care.

$0 or share of cost

$0 or share of cost

PAK: The state generally pays 50% of the premium while the family pays 50% per child. Full premiums are approximately between $70-180 monthly per child. Deductibles and co-payments apply.

www.coverageforall.org New Mexico

Monthly Cost

Medicaid & WIC: $0 or minimal share of cost

62

Demographic




COBRA/Mini-COBRA

Program

800-234-1317

Group Plans

New York State Insurance Department 800-342-3736 www.ins.state.ny.us/chealth. htm


Monthly Cost

63



Healthy NY


Medicaid

866-HEALTHY NY (866-432-5849) www.healthyny.com

Individual Plans

HIPAA

COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered

800-541-2831 877-472-8411 718-557-1399 www.health.state.ny.us

New York State Insurance Department 800-342-3736 www.ins.state.ny.us/chealth. htm


COBRA or Mini-COBRA: Coverage available for up to 18 months depending on qualifying events, benefits are the same as what you had with your previous employer

800-234-1317

Inpatient and outpatient hospital services; physician services; maternity care; preventive health services; diagnostic and x-ray services; and emergency services. Applicants may choose a benefit package with or without a limited prescription benefit High Deductible Plan now available

Assorted plans depending on medical needs All carriers must guarantee issue coverage to all individuals, including two comprehensive standardized plans There is a 6-month look-back and a 12-month exclusionary period limit for pre-existing conditions


No medical underwriting Pre-Existing Health Conditions Covered

Smoking cessation agents treatment and preventive health and dental care, hospital inpatient and outpatient services, laboratory and X-ray, nursing home, home health agencies and personal care, treatment in psychiatric hospitals, mental health facilities, family planning, early periodic screening, diagnosis, and treatment for children, medical equipment, and appliances, transportation to medical appointments, emergency ambulance, pre-natal care and other health services Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE



Must reside in New York and you or your spouse must either be currently employed or must have been employed within the past 12 months.

New York resident

Pregnant women and infants (ages 0-1): 200% FPL

Eligibility

Coverage

Carriers can impose a 6-month look-back/6-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage (this may only apply to certain groups)

or

Small businesses & working individuals


Costs depend on employer contribution and the Community Rate

New York

Medically Needy Couple: 93% FPL, Individual: 87% FPL,

Uninsured for the 12-month period preceding application or have lost that coverage due to a qualifying event 30% of the employees must earn wages of $40,000 or less


$0 for some services and $500 for hospital stays,

Qualified Parents: 150% FPL Children (ages 1-5): 133% FPL Children (ages 6-19): 100% FPL

Do not have access to employer health insurance or Medicare



Medical underwriting is not allowed

SSI Recipients: 74% FPL Individuals may also own a home, a car, and personal property and still be eligible. The income and resources of legally responsible relatives in the household will be counted, limits on cash resources

Individuals and Sole Proprietors must have an income at or below 250%



monthly premiums vary but the amounts of the co payments and deductible are the same for each health plan The 2010 deductible amounts are $1,200 for individual coverage and $2,400 for family coverage for the High Deductible Plan

800.234.1317

Low and moderate income children and families Child Health Plus 800-698-4KIDS 800-698-4543 www.health.state.ny.us/ nysdoh/chplus/

877-9FHPLUS (877-934-7587) www.health.state.ny.us/ nysdoh/fhplus/



Veterans

Breast, Cervical, Colorectal and Prostate Cancer Program


Medicare



800-4CANCER 800-422-6237 www.health.state.ny.us/ nysdoh/bcctp/bcctp.htm



877-222-8387 www.va.gov

Program

Family Health Plus

Adults

Demographic


800-633-4227

New York Elderly Pharmaceutical Insurance Coverage (EPIC) Program 800-332-3742

Screening, treatment and comprehensive health care through Medicaid Pre-Existing Health Conditions Covered

Medicare: Offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D EPIC: A state funded prescription discount program





Coverage

Well-child care, physical exams, immunizations, diagnosis and treatment of illness and injury, x-ray and lab tests, outpatient surgery, emergency care, prescription and non-prescription drugs if ordered, inpatient hospital medical or surgical care, short-term therapeutic outpatient services (chemotherapy, hemodialysis), limited inpatient and outpatient treatment for alcoholism and substance abuse, and mental health, dental, vision, speech and hearing, durable medical equipment, emergency ambulance transportation to a hospital, hospice




GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Both: Residents of New York State and are United States citizens or fall under one of many immigration categories

For Breast/Cervical: Be 18 years of age or older; Be in need of treatment for breast and/ or cervical cancer or a precancerous condition




FHP: adults between the ages of 19 and 64 who do not have health insurance - either on their own or through their employers - but have income or resources too high to qualify for Medicaid; Single Adult & Couples with no children-100% of the FPL, Parents/Guardians Living with at Least 1 Child Under 21-150% of the FPL

FHP: $0

EPIC: Seniors with other prescription coverage through Medicare or most other plans can join EPIC to cover drug costs not covered by that other coverage

Not enrolled in certain state plans Contact any HMO or Healthy New York Program


Both: Have income that is at or below 250% Federal Poverty Level (FPL); Not be covered under any creditable insurance; Be ineligible for Medicaid under other eligibility groups; Be a resident of New York State; and Be a U.S. citizen or an alien with satisfactory immigration status





www.coverageforall.org New York

Monthly Cost

CHP: $0-60 premiums and no co-pays

For Colorectal/Prostate: Be screened and/or diagnosed through a CSPP partnership or CSPP provider; Be under 65 years of age; Need treatment for colorectal and/or prostate cancer or pre-cancerous condition


Eligibility

CHP: Uninsured children age 18 or younger with family incomes of up to 400% FPL. Families with incomes above 400% FPL can pay the full premium for CHP.

64

Demographic







COBRA & MiniCOBRA


Inclusive Health

Medicaid

Program

800-234-1317

and then

Group Plans

North Carolina Association of Health Underwriters 703-276-0220 www.ncahu.org

HIPAA


800-234-1317

Individual Plans

North Carolina Health Insurance Risk Pool 866-665-2117 www.inclusivehealth.org

800-662-7030 919-855-4400 (for Wake County) TTY: 919-733-4851 www.dhhs.state.nc.us/dma/ medicaid/

North Carolina Association of Health Underwriters 703-276-0220 www.ncahu.org

or

Conversion Plans

Coverage

All group health insurance carriers can impose a 6-month look-back/ 12-month exclusionary period for preexisting conditions on enrollees that do not have prior creditable coverage Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered


Assorted plans depending on medical needs There is a 6-month look-back and exclusionary period limit for pre-existing conditions in traditional individual market health insurance products Pre-Existing Health Conditions Covered with Some Limitations

Monthly Cost

May have a 6 to 12 month waiting period for pre-existing conditions Lifetime benefit maximum of $1,000,000

Inpatient hospital services outpatient hospital services, prenatal care; vaccines for children; physician services, nursing facility services for persons aged 21 or older. Family planning services and supplies; rural health clinic services; home health care for persons eligible for skilled nursing services; laboratory and x-ray services; pediatric and family nurse practitioner services; nurse-midwife services and possibly more


GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE



Not eligible Medicaid or Medicare; Legal resident of the US and currently reside in North Carolina; Have been a continuous resident of North Carolina for at least 30 days; Do not have access to group coverage as an employee or as a dependent of an employee; Either rejected or refused by an insurer for similar coverage due to medical reasons, offered coverage by an insurer but with a conditional rider limiting coverage, offered coverage at higher premium rate, have been diagnosed with a medical condition that is outlined by Inclusive Health allowing automatic enrollment into Inclusive Health, federally defined HIPAA eligible individual, eligible for the HCTC.


Premiums vary based on age, gender, whether you are a smoker or not, and your choice of plan option.



Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for guarantee issue through Inclusive Health, see next column

Mini-COBRA: Applies to small businesses with less than 20 employees HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for any other insurance programs

65

NCHIRP has several option plans that cover a broad range of services, including preventive care, urgent care, outpatient services, a prescription drug benefit and other common health care services



Eligibility






Children (ages 1-5): 200% FPL, ages 6-19: 100% FPL (also aged, blind and disabled) SSI recipients: 74% FPL Working parents with incomes up to 51% FPL Non-working parents up to 37% FPL Medically Needy Individuals up to 34% FPL Medically Needy Couples up to 33% FPL

Deductible varies depending on plan chosen.

COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive

North Carolina

800.234.1317


Pregnant women and infants

North Carolina’s Health Choice

Medicaid for Pregnant Women

919-707-5700 TTD: 877-452-2514 www.dhhs.state.nc.us/dma/ medicaid


919-855-4260 www.ncdhhs.gov/dma/ services/babylove.htm

919-707-5800 www.nutritionnc.com/wic

Baby Love

NC Family Health Resource Line 800-FOR-BABY 800-367-2229 TTY: 1-800-976-1922


Medicaid for Pregnant Women: Offers prenatal care, delivery and 60 days postpartum care, services to treat medical conditions which may complicate pregnancy (some services require prior approval), childbirth and parenting classes, family planning services Baby Care: Maternity care coordination, childbirth education classes, counseling and emotional support, medical home visits, and referral to other programs NC Family Health Resource Line: Provides information, referral and advocacy services for pregnancy and child care issues

Veterans

Medicare








877-222-8387 www.va.gov

800-633-4227

Senior Insurance Counseling (SHIIP) 919-807-6900 800-443-9354

Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as wells several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D SHIIP answers questions and counsels Medicare beneficiaries and caregivers about Medicare, Medicare supplements, Medicare Advantage, Medicare prescription drug plans, longterm care insurance and other health insurance concerns




Coverage

NCHC: Hospital care; outpatient care; physician and clinic services; Immunizations; surgical services; prescription drugs; laboratory and radiology services; mental health services; durable medical equipment and supplies; vision; hearing; home health care; nursing care; dental care; substance abuse treatment; physical therapy, occupational therapy and therapy for individuals with speech, hearing and language disorders; hospice care and possibly more


Program

800-662-7030 919-855-4440 (for Wake County) www.ncdhhs.gov/dma/cpcont. htm



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

NCHC: Family Income up to 200% of FPL; Cannot be eligible for Medicaid or have any other health insurance; Under age 19; U.S. citizen or lawful alien; North Carolina resident for at least 30 days, except for a newborn; The family’s income must not exceed specified levels

Medicaid for Pregnant Women: Resident of North Carolina






WIC: Reside in North Carolina, Be a pregnant or recently pregnant woman, infant or child up to age 5, Be determined to have a nutritional risk, Income must be at or below 185% FPL

NCHC: $0-100 enrollment fee; $1-20 co-pays depending on service;


If a pregnant woman is covered by Medicaid on the date she delivers, her newborn child may be eligible for Medicaid up to age 1 without a separate application

Must not have access to employer plan that pays 50% of coverage cost. Not enrolled in certain state plans


Baby Love: Pregnant and postpartum women are eligible to receive services




www.coverageforall.org North Carolina

Monthly Cost


Eligibility


Monthly family income cannot exceed 185% FPL

Demographic


66

Demographic Program





COBRA/Mini-COBRA


Group Plans

North Dakota Association of Health Underwriters 703-276-0220 www.nahu.org Up to $5M lifetime maximum, assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply

Coverage

or

800-234-1317


HIPAA

Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer

800-234-1317

Individual Plans

North Dakota Association of Health Underwriters 703-276-0220 www.nahu.org Up to $5M, assorted deductibles depending on age and ZIP code Pre-Existing Health Conditions Covered with Some Limitations

COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered



CHAND

Medicaid

Comprehensive Health Association of North Dakota 800-737-0016 701-277-2271 www.chand.org

800-755-2604 701-328-2321 701-328-8950 (TTY) www.nd.gov/dhs/services/ medicalserv/medicaid/

Two comprehensive coverage options with $500 or $1000 deductibles including: doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, transplants, rehabilitation, durable medical equipment, mental health and substance abuse, physical, speech and occupational therapy, dental care, vision care, and preventive care, and other services

Hospital, nursing facility, clinics, rural health clinics, hospice, physicians, prescription drugs, chiropractor, health tracks (EPDST), home health, durable medical equipment, and supplies, dental, family planning, sterilization, podiatry, mental health, ambulance, transportation, vision, therapies, waivered services home and community based services, traumatic brain injury, out-of-state services

Covered services have a lifetime limit of $1,000,000



GUARANTEED COVERAGE

GUARANTEED COVERAGE




Eligibility


GUARANTEED COVERAGE

GUARANTEED COVERAGE


You have physically resided in ND for at least 183 days

Pregnant women and Children ages 0-5: 133% FPL

If you are denied coverage for a medical condition, you may be eligible for CHAND, see next column

You have written evidence from at least one carrier that within 183 days, you have been; denied health care coverage; offered coverage which substantially restricts benefits for specific conditions; offered an insurance rate exceeding the CHAND rate; or written evidence from a medical professional of the existence of a qualifying condition

Children ages 6-19: 100% FPL


Monthly Cost

67


North Dakota

Medically Needy: 83% FPL SSI Recipients: 74% FPL People with high medical expenses that when subtracted from income they may be eligible

Must be ineligible for health benefits under ND's medical assistance program, COBRA or certain other government programs



Parents: 38% FPL

A Medicare supplement plan is also available


Once deductible is met, CHAND will pay 80% of allowed charges. $3,000 annual limit on out-of pocket spending on deductibles and co-insurance. After that, CHAND pays 100% of covered services


Price depends on age and location CHAND premiums are limited to 135% of the premiums charged in North Dakota for similar coverage.

800.234.1317


Women



Healthy Steps

Caring for Children Program

Women’s Way



877-KIDSNOW 877-543-7669 www.nd.gov/dhs/services/ medicalserv/chip

800-342-4718 701-277-2227 www.ndcaring.org

800-44WOMEN 800-449-6636 www.womensway.net

605-226-7582 www.ihs.gov/FacilitiesServices/ AreaOffices/Aberdeen



Program

Children in low income families

Demographic


800-472-2286 www.health.state.nd.us/wic Primary and preventive health, physician office visits and routine physicals, emergency accident care, well child care and immunizations, limited inpatient and surgical services, mental health and chemical dependency, preventive dental service

Provides clinical breast exams, pap tests, pelvic exams


The Aberdeen Area Office in Aberdeen, South Dakota, works in conjunction with its 13 Service Units to provide health care to approximately 94,000 Indians on reservations located in North Dakota, South Dakota, Nebraska, and Iowa Pre-Existing Health Conditions Covered



Coverage

HS: Offers inpatient hospital stay, medical & surgical services; outpatient hospital and clinic services; mental health and substance abuse services; prescription medications; routine preventive services (i.e. well-baby check-ups and immunizations); dental and vision services; prenatal services. Some plans offer preventive services and some dental and vision services


GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

HS: Uninsured children age 18 and younger who live in families with qualifying incomes. Single 18-year-olds with eligible incomes may also apply. Income cannot exceed 160% of the FPL

Be younger than age 19

Must be a woman age 40 through 64


WIC: Reside in North Dakota, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL

Be without comprehensive medical coverage through Medicaid, Healthy Steps or a private insurance carrier

Four federally recognized tribal nations exist in North Dakota: the Turtle Mountain Band of Chippewa, Three Affiliated Tribes - Mandan, Hidatsa, and Arikara Nation, the Spirit Lake Nation, and the Standing Rock Sioux Nation. The state is also home to the Trenton Indian Service Area



Be a resident of the state of North Dakota Be a U.S. citizen or legal permanent resident

No health insurance, or unable to pay insurance deductibles and/or co-payments, or Pap smears and/or mammograms not covered by insurance plan


A client must be a resident of the United States for at least 30 days to be eligible for Women's Way

Eligibility

Income must be between 161% and 200% FPL


No documentation is required to verify residency

HS: Co-pays vary depending on




www.coverageforall.org North Dakota

Monthly Cost

service from $0-50

68

Demographic




Low income children and families

Children


COBRA/ Mini-COBRA


Healthy Families Medicaid

Healthy Start Medicaid

Program

800-234-1317

Group Health Ohio Association of Health Underwriters 330-273-5756 www.ohioahu.org/

Then convert to

HIPAA


800-234-1317

Individual Plans

800-324-8680 800-292-3572 TDD http://jfs.ohio.gov/OHP/

800-324-8680 800-292-3572 TDD http://jfs.ohio.gov/OHP/

Ohio Association of Health Underwriters 330-273-5756 www.ohioahu.org/


614-644-8006 800-755-GROW 800-755-4769 www.odh.ohio.gov/ odhPrograms/ns/wicn/wic1. aspx

or


Coverage

Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered with Some Limitations


Covers certain state mandated items




Annual open enrollment regardless of pre-existing conditions






GUARANTEED COVERAGE

GUARANTEED COVERAGE




Eligibility


HS: Comprehensive care including but not limited to doctor visits, mental, dental, prescriptions, hospitalization and more

GUARANTEED COVERAGE

GUARANTEED COVERAGE


Ohio resident or documented immigrant


Limited assets such as cash, savings, stocks and bonds AND...

HS: Uninsured children under age 19 and Pregnant women may have an income at or below 200% FPL


Uninsured children under age 19 and Pregnant women may have an income at or below 200% FPL

Families with Children under the age of 19 Income at or below 90% FPL

WIC: Reside in Ohio, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL

Disabled and elderly up to 64% FPL


Monthly Cost


69





HS & WIC: $0 or minimal share of cost

COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates, individual coverage may be less expensive, see next column

Ohio

800.234.1317

Women

Individuals with genetic disorders

Breast and Cervical Cancer Protection Program

Ohio Genetics Program

Services provided include mammograms, pap tests, office visits, clinical breast exams, colposcopies, breast utlrasounds, biopsies and other diagnostic procedures


Veterans

Medicare






877-222-8387 www.va.gov

800-633-4227

Ohio Genetics Program is not insurance, but is a system of clinics for individuals with genetic illnesses Genetic services include, but are not limited to genetic counseling, education, diagnosis and treatment for all genetic conditions and congenital abnormalities.





GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE











Coverage

If screened and diagnosed for breast or cervical cancer may be eligible for complete health coverage through Medicaid

614-728-4677 www.odh.ohio.gov/ odhprograms/cmh/genserv/ genserv1.aspx


Program

614-728-2177 (Ohio Department of Health) www.odh.ohio.gov/ odhPrograms/hprr/bc_canc/ bcanc1.aspx


Demographic


Genetic services are covered by most insurance companies & Medicaid Those who do not have medical coverage are billed based on their income level: No one is turned away from the genetics clinics for not having insurance

GUARANTEED COVERAGE Must be Ohio resident and have legal immigration status For mammograms must be between 50 and 64 years of age For pelvic and pap test must be between 40 and 64 years of age

$0

Individuals/families might benefit from genetic services if they have questions about: the cause of a medical condition or developmental problem; the chance of the same condition showing up in their children or other relatives; how to prepare for and have a healthy pregnancy; available choices based on an understanding of medical genetics, existing treatments, and other factors; recent genetic discoveries and current research about their condition; where to find medical specialists, community resources and parent support groups in their area or nationally.


www.coverageforall.org Ohio

Monthly Cost

There are different costs for the various services at genetics clinics. Most insurance companies and third party payers cover the costs of most services. Those who do not have medical coverage are billed based on their income level.


Eligibility

Must be uninsured or underinsured with income under 200% of FPL

Anyone can call and get information regarding genetic disorders

70

Demographic




COBRA/Mini-COBRA

800-234-1317

Program

Group Plans

Oklahoma Association of Health Underwriters 703-276-0220 www.osahu.org

Insure Oklahoma

Coverage

HIPAA


888-3-OK-EPIC 888-365-3742 www.insureoklahoma.org

HMOs cannot look-back at or issue exclusions for pre-existing conditions. Other carriers can impose a 6-month look-back/12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered

COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE






Oklahoma Health Insurance High Risk Pool

Medicaid SoonerCare

800-234-1317

Individual Plans

Oklahoma Association of Health Underwriters 703-276-0220 www.osahu.org

800-987-7767 www.okdhs.org/ programsandservices/health/ med or www.ohca.state.ok.us/ about.aspx?id=32

877-793-6477 www.okhrp.org

Family Planning

Insure Oklahoma

405-271-4476 www.okdhs.org/ programsandservices/health/ famplan

888-3-OK-EPIC 888-365-3742 www.insureoklahoma.org

GUARANTEED COVERAGE


Eligibility

and then





Lifetime maximum of $1,000,000

All carriers must guarantee issue coverage to all individuals with at least 12 months of prior coverage

Comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, home health visits, transplants, rehabilitation, durable medical equipment, and mental health and substance abuse, among other services

Except for those with 12 months of prior coverage, there is a 36-month look-back and 12-month exclusionary period limit for pre-existing conditions Benefits will vary depending on plan chosen Pre-Existing Health Conditions Covered with Some Limitations

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for an Oklahoma Health Insurance High Risk Pool plan, see next column Insure Oklahoma: US citizen or legalized alien, resident of Oklahoma age 19-64. Not currently on Medicare or any Medicaid program, employer must be located in Oklahoma and have 99 or fewer employees, income level cannot exceed 200% FPL

Applicants are subject to a 12-month pre-existing condition exclusion

Monthly Cost

71


Oklahoma



GUARANTEED COVERAGE

Resident of Oklahoma for at least one year and turned down by at least two insurance carriers

SoonerCare: Pregnant women and children ages 0-19: 185% FPL

Cannot be eligible for group coverage or COBRA, or government programs (must have exhausted this option)

Working Parents: 48% FPL Non-Working Parent: 32% FPL

Designated as a “guaranteed” option for those who are HIPAA-eligible

Aged, blind and disabled: 100% FPL Supplemental Security Income Recipients: 74% FPL Medically Needy couple: 34% FPL Medically Needy individual: 36% FPL

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs Costs depend on employer contribution and ± 25% of the insurance company’s index rate

Family planning, home health inpatient, laboratory and x-ray nurse-midwife, nursing facility outpatient, physician, ambulatory surgical center, hearing, chiropractic, dental durable medical equipment, prescription drugs, prosthetics mental health, rehabilitative services, transportation services, dental and vision for some people …and more

Legal OK residents; asset limits for some people Family Planning: Income 100% or below Federal Poverty Level (FPL).

Costs for individual coverage varies Insure Oklahoma: Premiums vary according to income level,

Costs vary based on applicant and plan; cannot be more than 50% higher than standard rates

Both: $0 or share of cost

Co-pays range from $5-50 depending on service

800.234.1317

Children


Child and Adolescent Health Clinical Services


405-951-3820 www.ihs.gov/FacilitiesServices/ AreaOffices/oklahoma/index. cfm



Veterans

Medicare






877-222-8387 www.va.gov

Program

405-271-4471 www.ok.gov/health/Child_ and_Family_Health/index.html


800-633-4227

405-271-4676 888-OKLAWIC 888-655-2942 www.ok.gov/health/Child_ and_Family_Health/WIC/index. html

Demographic


Senior’s Health Insurance Counseling Program (SHIP) 800-763-2828 405-521-6628 www.oid.state.ok.us

7 Indian hospitals and 40 outpatient health centers located throughout Oklahoma


26 are totally managed by tribes under compact/contract, 12 are operated directly by the IHS, and 2 are operated under contract with Indian organizations



Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D SHIP is a Medicare counseling service





Coverage

CAHCS: Well child care and treatment for minor acute illnesses



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

CAHCS: Children and adolescents at or below 185% of Federal Poverty Level (FPL) who are uninsured or underinsured for health care services

American Indians residing in Oklahoma

Medicare: Disabled or age 65 and older or people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)



WIC: Reside in Oklahoma, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL

Not enrolled in certain state plans See OHIHRP


Eligibility





www.coverageforall.org Oklahoma

Monthly Cost

CAHCS & WIC: $0 or minimal share of cost


72

Demographic


Individuals recently covered by an employer plan



COBRA


Program

800-234-1317 www.coverageforall.org

Group Plans

Oregon Association of Health Underwriters 877-412-OAHU 877-412-6248 www.orahu.org

Or

HIPAA


800-234-1317 www.coverageforall.org

Individual Plans Oregon Association of Health Underwriters 877-412-OAHU 877-412-6248 www.orahu.org



OMIP

Oregon Health Plan

(Oregon Medical Insurance Pool) 503-225-6620 800-848-7280 TTY: 800-375-2863 (Regence Blue Cross Blue Shield of Oregon is the plan administrator) www.omip.state.or.us

(OHP/Medicaid) 503-945-5772 800-527-5772 TTY: 800-375-2863 www.oregon.gov/DHS/ healthplan

Or

State Continuation Coverage

Coverage

Up to $2M lifetime maximum, assorted deductibles Under Oregon law, newborns and adopted children are automatically covered under parents’ fully insured health plan for the first 31 days, if the plan provides dependent coverage Pre-Existing Health Conditions Covered


Up to $2M, assorted deductibles depending on age and residence zone Pre-Existing Health Conditions Covered with Some Limitations


Max lifetime benefit is $2 million per covered person. Choose from 4 policy options In some cases benefits will not be provided during the first six months of enrollment for expenses resulting from a preexisting condition

Provides diagnosis, physician services, check-ups (medical and dental), family planning, maternity, prenatal, and newborn care, prescriptions, hospital services, comfort care, hospice, dental services, drug and alcohol treatment, mental health services Pre-Existing Health Conditions Covered


GUARANTEED COVERAGE

GUARANTEED COVERAGE

Company size 2-50


Two employees must work 17.5 hrs/week for coverage Owner can count as an employee

Monthly Cost

Eligibility


73

Credit for pre-existing conditions apply for individuals with no more than a 63 day break in coverage

Costs depend on plan choice and the Modified Community Rate

If you are denied coverage for a medical condition, you may be eligible for OMIP, see next column



Oregon


Costs depend on age and county If you are self-employed and buy your own insurance you can deduct 100% of the cost of the premium from your federal income tax

GUARANTEED COVERAGE

GUARANTEED COVERAGE


Child to Age 5: 133% FPL

Cannot be eligible for COBRA, or government programs

Child Age 6-18 or parent: 100% FPL Pregnant woman: 185%

Oregon resident


Have one of the listed medical conditions


Credit toward 6 month waiting period may apply for prior coverage


The plans offer a range of deductibles including $500, $750, $1,000 and $1,500

$0 to a share of the monthly premium for Standard or Plus plans

Similar to private rates if qualified for portability policy; 25% higher for the high risk pool rate

Oregon resident and documented immigrant

800.234.1317


Families

Women



Oregon Health Plan Plus

Family Health Insurance Assistance Program

Oregon Breast and Cervical Cancer Program



Healthy Kids

503-378-2666 877-314-5678 www.oregonhealthykids.gov

Coverage lasts for at least one full year or more as long as the child remains eligible

971-673-0984 877-255-7070 www.oregon.gov/DHS/ph/bcc

The program is currently not accepting new applications. If you would like to receive an application when the program reopens you may sign up; however, the wait list is approximately 1.5 to 2 years.

800-723-3638 http://oregon.gov/DHS/ph/wic/ about_us.shtml

Use FHIAP to buy the private health insurance plan you choose

BCCP: Some diagnostic services such as ultrasound, breast biopsy, surgical consultation, colonoscopy

If employer-sponsored plan is available then you must use FHIAP assistance to enroll in that plan

(Subsidy program) 866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)


Cancer treatment for some women qualified through Medicaid Referral to treatment services WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services


503-326-2020 www.ihs.gov/FacilitiesServices/ AreaOffices/Portland/

A number of services covered for eligible Native American Indians. Current areas of emphasis are: Infant Health, High Risk Maternal & Child Health, Tobacco Use, Intervention, Domestic Violence, Diabetes, Women's Health Care, and Cancer Screening. Pre-Existing Health Conditions Covered

Will cover COBRA if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Coverage is received through one of the four health plans OMIP offers. Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Both: Children under age 19

Oregon resident and legal immigrant

BCCP: Age 40-64



Health services from the Indian Health Service is that the individual is an enrolled member of a Federally recognized Tribe. Resides on tax-exempt land or owns restricted property

Oregon resident and legal immigration status (exceptions granted for certain groups)

Uninsured for at least 6 months unless coming off OHP


Savings less than $10k (including rental property)

Older than 64 and not eligible for Medicare Part B

Household income at or below 200% FPL

Not eligible for Medicare

WIC: Reside in Oregon, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL

Healthy Kids: Child must have been without health insurance for two months (though there are exceptions to this rule for special circumstances, like a parent’s job loss or a child’s serious medical need)

Must be uninsured for the previous two months, unless you are leaving the Oregon Health Plan (OHP)/Medicaid program and have income up to approximately 200% FPL


Eligibility

OHP Plus: Must be uninsured for 6 months

Coverage

Both: Coverage includes medical, dental and vision care regular checkups and preventive care, prescription medicines, medical equipment, mental health and chemical dependency services

(Subsidy program) 503-373-1692 888-564-9669 www.fhiap.oregon.gov

Program

(Apply through the Oregon Health Plan) 800-359-9517 (Applications) 503-378-2666 (Eligibility) www.oregon.gov/DHS/ healthplan/

Demographic


For free or low-cost coverage, household income cannot exceed 300% FPL If income exceeds 300% FPL, it is still possible to receive coverage, but share of cost may be higher

OHP Plus: No premium or co-pays

Both: $0 and share-of-cost sliding scale



www.coverageforall.org Oregon

Monthly Cost

Healthy Kids: Premiums vary depending on income level

Depending on family size and income FHIAP pays up to 95% of premium. FHIAP members are responsible for co-pays, deductibles and coninsurance.

74

Demographic






COBRA


Blue Cross Blue Shield

Program

800-234-1317

Group Plans

Pennsylvania Association of Health Underwriters 717-232-0022 www.pahu.org

and then

HIPP

Health Insurance Premium Payment 800-644-7730 or

800-234-1317

Individual Plans


866-542-3015 www.dpw.state.pa.us

(Contact regional carriers) 800-275-2583 www.ibx.com

For more information call your local county office:

Pennsylvania Association of Health Underwriters 717-232-0022 www.pahu.org

www.dpw.state.pa.us/About/ OIM/003670281.htm

HIPAA


Coverage



Assorted deductible and plan design options available for selection Limits on pre-existing health conditions may apply

Guaranteed issue coverage is available for five counties Philadelphia, Delaware, Chester, Montgomery, and Buck


GUARANTEED COVERAGE COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage


Eligibility



GUARANTEED COVERAGE

GUARANTEED COVERAGE

Been refused health insurance by other carriers


If you are denied coverage for a medical condition, you may be eligible for guarantee issue through Blue Cross Blue Shield, see next column

Children (ages 1-5): 133% FPL Ages 6-19: 100% FPL (also aged, blind and disabled) Parents with incomes up to 200% FPL can also apply for the Adult Basic program (which currently has a waiting list for coverage) SSI recipients: 74% FPL

HIPP: You may be eligible for HIPP if you have a high-cost health condition, and are on Medicaid

Medically Needy Individual: 59% FPL Medically Needy Couple: 46% FPL

Monthly Cost

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs Costs depend on employer contribution (also see HIPP) with rate variations allowed up to 300% of the base rate






Office visits, prescription drugs, immunizations, vision testing and eyeglasses, emergency room care, lab testing and X-rays, hearing testing and hearing aids, mental and substance abuse treatment

Exclusion period for pre-existing conditions for 1 year


GUARANTEED COVERAGE

Blue Cross/Blue Shield plans operating in the state voluntarily serve as the carriers-of-last-resort for people seeking coverage in the individual market through a year-round open enrollment for specified products


Prices based on age and several coverage options, applicant needs etc.

$0

COBRA & HIPAA: Premiums range from 102%-150% of group health rates; individual coverage may be less expensive, see next column HIPP: $0 or minimal share of cost

75

Pennsylvania

800.234.1317

Children

Women

Adults


Veterans

CHIP

Healthy Woman Program

adultBasic



800-215-7494 www.pahealthywoman.com

Healthy Baby Help Line 800-986-BABY 800-986-2229

Clinical breast examination, mammogram, pelvic examination and pap smear, education on breast self-exam, follow-up diagnostic care for an abnormal result Pre-Existing Health Conditions Covered

Hospitalization (unlimited days), physician services (primary care and specialists), emergency services, diagnostic tests (e.g. X-rays, mammograms and laboratory tests), maternity care, rehabilitation and skilled care (in lieu of extended hospitalization) Pre-Existing Health Conditions Covered


Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits

877-222-8387 www.va.gov


Coverage

CHIP: Immunizations; routine check-ups; diagnostic testing; prescription drugs; dental, vision, hearing services; emergency care; maternity care; mental health benefits; up to 90 days hospitalization in any year; durable medical equipment; substance abuse treatment; partial hospitalization for mental health services; rehabilitation therapies; home health care

800-GO-BASIC 800-462-2742 www.ibx.com/health_plans/ low_income/adultbasic.html or www.portal.state.pa.us/ portal/server.pt/community/ health_insurance/9189/ adultbasic/592645

Program

(Children’s Health Insurance Plan) 800-986-5437 www.chipcoverspakids.com

Demographic



Healthy Baby: Provides health insurance assistance information and referral service for pregnant women Pre-Existing Health Conditions Covered GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

CHIP: Must not be eligible for Medical Assistance or any other health insurance,

Women 40 to 64 years old (or under 40 if they are symptomatic of breast cancer, require follow-up for an abnormal Pap test, or have not been screened in the past five years for cervical cancer)

You are between the ages of 19 and 65


You do not have any other healthcare coverage (including Medicaid or Medicare); you have been without health insurance for 90 days prior to enrollment, except if you or your spouse lost health insurance coverage because you are no longer employed



Child must be under age 19 Must be a Pennsylvania resident and citizen

Must have no insurance or limited insurance that does not cover breast and cervical cancer screening services Must have income below 250% FPL

CHIP: Cost depends on whether your child qualifies for free, low cost, or full cost health coverage. Average Premiums

$0

range between $0-195 with co-payments of $0-50.




Your family income is below certain income limits (approximately 200% of FPL) You are a resident of Pennsylvania for at least 90 days prior to enrollment; and have U.S. citizenship or permanent legal alien status

$36 per month premium

payment if enrolled in the program or $600 per month premium payment if purchasing coverage while on the waitlist, Co-pays vary

premium


between $10-50

www.coverageforall.org Pennsylvania

Monthly Cost

Families with income below 200% FPL will receive free coverage, 200-300% FPL will receive discounted coverage, and 300% FPL or more will have to pay full cost


Eligibility

Covers all uninsured children under the age of 19 despite their families income level

76

Demographic




COBRA/Mini-COBRA and then

Program

800-234-1317

Group insurance carriers may not look-back at, issue exclusions for, or consider pre-existing conditions when issuing small group coverage Benefits will vary depending on the chosen plan

Coverage

HIPAA

Group Plans


Rhode Island Association of Health Underwriters 703-276-0220 www.nahu.org


COBRA or Mini-COBRA: Coverage available for 12 to 18 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered





Blue Cross Blue Shield of Rhode Island

RI Medical Assistance Program


Plan options vary based on applicant needs

All carriers must guarantee issue coverage to all individuals with at least 12 months of prior coverage


Family planning, home health inpatient, laboratory and x-ray nurse-midwife, nursing facility outpatient, physician, ambulatory surgical center, hearing, chiropractic, dental, durable medical equipment, ElderChoices, prescription drugs, prosthetics, psychology services, rehabilitative services for persons with mental illness, rehabilitative services for persons with physical disabilities, targeted case management, transportation services, ventilator equipment, visual services ...and more

800-234-1317

Individual Plans

Rhode Island Association of Health Underwriters 703-276-0220 www.nahu.org

(Medicaid) 401-462-5300 401-462-3363 TTY www.dhs.state.ri.us

800-639-2227 401-459-5000 401-831-2202 TTD www.bcbsri.com

Except for those with 12 months of prior coverage, there is a 36-month look-back and 12-month exclusionary period limit for pre-existing conditions Pre-Existing Health Conditions Covered with Some Limitations


GUARANTEED COVERAGE

GUARANTEED COVERAGE



Eligibility

Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage Owner name on business license must draw wages from the company Most small group carriers also require 75% employee participation and accept employees who sign a waiver indicating other coverage as counting towards the 75%

Eligibility is subject to medical underwriting If you are denied for a medical condition, you may be eligible for coverage through BCBSRI, see next column

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Resident of RI

Pregnant women and children ages 0-19: 250% FPL

Cannot be eligible for group coverage or COBRA, or government programs (must have exhausted this option)

Working Parents: 192% FPL Non-working Parents: 185% FPL Aged, blind and disabled: 100% FPL

Limited annual open enrollment period

Medically Needy individual: 69% FPL; Medically Needy couple: 87% FPL Supplemental Security Income Recipients: 74% FPL


Legal RI residents; asset limits for some people

Monthly Cost

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for any other public or private insurance programs

77




Costs vary based on applicant and plan; cannot be more than 50% higher than standard rates

$0


Rhode Island

800.234.1317


Adults

RIteShare/RiteCare

Women’s Cancer Screening

401-462-5300 401-462-3363 TTY www.dhs.state.ri.us

800-942-7434 401-222-5960 www.health.ri.gov/family/wic/ index.php

General Public Assistance

www.dhs.ri.gov/Adults/ GeneralPublicAssistance/ tabid/244/Default.aspx

Veterans

Medicare






877-222-8387 www.va.gov

Program


401-222-4324 401-222-1161 www.health.ri.gov/disease/ cancer/women-screening.php



Demographic


800-633-4227

Senior’s Health Insurance Program 401-462-0524 www.dea.state.ri.us

WCS: Offers pelvic exams, Pap tests, clinical breast exams, and mammograms (breast x-rays) to eligible women. Also covers diagnostic tests and possibly full treatment through Medicaid GPA: Covers primary care doctors’ office visits/ health centers visits and most generic prescription medications

Medicare offers two standard plans, A: Hospital Insurance and B: Medical Insurance, as well as several supplemental and advantage plans


SHIP is a Medicare counseling service





Coverage

RIteShare: Comprehensive coverage through different options. RIteShare is a premium assistance program that helps families get health insurance coverage through their employer (or spouse’s employer). RIteShare pays for all or part of the employee’s share of the health insurance premium. RIteShare also pays for co-payments in the employer’s health insurance plan WIC: Nutrition education and services; Breastfeeding promotion and education; A monthly food prescription of nutritious foods; and Access to maternal, prenatal and pediatric health-care services Pre-Existing Health Conditions Covered GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

RIteShare: Children and adolescents at or below 250% of Federal Poverty Level (FPL) who are uninsured or underinsured for health care services

WCS: Must be a resident of Rhode Island, have no health insurance coverage for the services provided by the program, have a family income less than 250% of the FPL and be between 50-64 years old. Women younger than 40 may receive services if they are found to have a palpable lump or a clinical finding of something suspicious for cancer. Women over 65 who are enrolled in Medicare but do not have Medicare part B may also be eligible for the program, as are undocumented women over 65









Eligibility

WIC: Reside in Rhode Island, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL


GPA: Must be a Rhode Island resident between the ages of 19 and 64, have an illness, injury, or medical condition, which is expected to last at least 30 days and prevents you from working, have a monthly income of $327 or less, have resources of less than $400 and an automobile with a value of less than $4,650. You must also not be eligible for any other federal assistance programs


Both: $0 or minimal share of cost

www.coverageforall.org Rhode Island

Monthly Cost

RIteShare: $0-92 per month depending on income

78

Demographic





COBRA/Mini-COBRA


Group Plans

HIPAA

and then

Program

800-234-1317

South Carolina Association of Health Underwriters 703-276-0220 www.scahu.org

Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov or

800-234-1317

Individual Plans

South Carolina Association of Health Underwriters 703-276-0220 www.scahu.org

Individuals with pre-existing, severe or chronic medical conditions SCHIP

South Carolina Health Insurance Pool 803-788-0500 x46401 (Columbia) 800-868-2500 x46401 (Outside Columbia) www.doi.sc.gov/consumer/ schip.htm


888-549-0820 803-898-2500 www.dhhs.state.sc.us

SC Healthy Connections Kids

877-552-4642 www.scchoices.com/ SCSelfService/en_US/kids.html

Conversion Plans

Coverage

All group health insurance carriers can impose a 6-month look-back/12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered

COBRA or Mini-COBRA: Coverage available for 12 to 18 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage

Assorted plans depending on medical needs There is a 12-month look-back and exclusionary period limit for pre-existing conditions in traditional individual market health insurance products Pre-Existing Health Conditions Covered with Some Limitations

Comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, transplants, durable medical equipment, mental health and substance abuse, physical, speech and occupational therapy among other services Pre-Existing Health Conditions Covered


GUARANTEED COVERAGE

GUARANTEED COVERAGE




Eligibility


Both: Hospitalization, well child/ adult appointments, lab and X-rays, doctor visits, vision, dental prescription drugs, family planning, medical equipment, hospice, ambulance, transportation, nursing facility, ICF for the mentally retarded, Inpatient psychiatric care, home health, physical therapy, speech therapy, mental health, family support services, targeted case management, behavioral health, home and community based LTC services and more Pre-Existing Health Conditions Covered

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for SCHIP, see next column

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Been refused health insurance by any insurer for health reasons;

Medicaid: Pregnant women and infants age 0-1: 185% FPL; Children age 1-19: up to 150% FPL; Working Parents: 97% FPL; Non-Working Parents: 49% FPL; Supplemental Security Income Recipients: 74% FPL; Aged, Blind & Disabled: 100% FPL; Low Income Medicare Benefeciaries: 120% FPL; Worked Disabled: 250% FPL; Family Planning Services: 185% FPL; Legal residents with asset limits for some people

Refused insurance except with a reduction or exclusion of coverage for a preexisting condition exceeding 12 months; Refusal of comparable coverage except at a rate exceeding 150 percent of the pool rate


Eligible for SCHIP with HIPAA

SCHCK: Children under the age of 19 must have a family income at or below 200% of the FPL

Several PPO coverage options with a $500 deductible and various coinsurance requirements


Monthly Cost

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or other public or group insurance programs

79





South Carolina

800.234.1317

Children with special health care needs

800-868-0404 www.scdhec.gov/health/mch/ cshcn/programs/crs/index.htm

BabyNet

803-734-0479 800-868-0404 www.scdhec.gov/health/mch/ cshcn/programs/babynet/ CRS: Covers nursing services, pharmacy, durable medical equipment, physician services, genetics, social work, nutrition, transition, and parent-toparent support


800-868-0404 803-545-4102 803-545-4145 www.dhec.sc.gov/health/ chcdp/cancer/bcn.htm

South Carolina Maternity/Prenatal Care Services 803-898-3432


Veterans

Medicare






877-222-8387 www.va.gov

800-633-4227

State Health Insurance Assistance Program (SHIP) www.aging.sc.gov/seniors/ ICare.htm

BCN: Program covers mammograms, clinical breast exams, Pap tests, pelvic exams, diagnostic procedures, case management, community education on breast/cervical cancer and early detection Maternity/Prenatal Care Services: Services are offered to women during their prenatal periods and emphasize primary and preventive care including health promotion and education

Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D SHIP is a Medicare counseling service





Coverage

BabyNet: Provides services to infants and toddlers with developmental delays or diagnosed disabilities

Best Chance Network


Program

South Carolina Children’s Rehabilitative Services

Women

Demographic





GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

CRS: To participate in the CRS program, a child must be a legal resident of the United States, live in South Carolina, be under 21 years old, be diagnosed with a covered medical condition, and must meet certain income guidelines

BCN: Must lack insurance or have insurance that only covers hospital care, Must be between the ages of 40 and 64, and have income at or below 200% FPL










www.coverageforall.org South Carolina

Monthly Cost


Eligibility

BabyNet: Infants and toddlers from birth to three years may be eligible for BabyNet services if they are developing more slowly

Maternity/Prenatal Care Services: Program available to pregnant women with incomes at or below 185% FPL. Pregnancy includes the 60-day postpartum period. The 60 days begin on the date of delivery or termination of the pregnancy


80

Demographic




COBRA/Mini-COBRA then

Program

800-234-1317

Group Plans

South Dakota Association of Health Underwriters 703-276-0220 www.nahu.org

Coverage

Up to $5M lifetime maximum, assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply Pre-Existing Health Conditions Covered

HIPAA





Low income families


South Dakota Risk Pool

South Dakota Medical Assistance

800-234-1317

Individual Plans

605-773-3148 www.state.sd.us/bop/ riskpool.htm

800-305-3064 www.state.sd.us/social

South Dakota Association of Health Underwriters 703-276-0220 www.nahu.org

Up to $5M, assorted deductibles depending on age and ZIP code Pre-Existing Health Conditions Covered with Some Limitations


Offers four health plan options

Full medical assistance coverage

Each plan offers similar benefits including daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, and out-of-hospital care including pharmaceuticals

Covered services include doctor appointments, hospital stays, dental and vision services, prescription drugs, rehab/ therapy, chiropractic, etc.



Medical coverage may begin three months prior to the application date Pre-Existing Health Conditions Covered


GUARANTEED COVERAGE



Two employees must work for at least 6 months out of the year, and work 20 hours per week for coverage Owner can count as an employee

Monthly Cost

Eligibility


81

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for the South Dakota Risk Pool, see next column



GUARANTEED COVERAGE

Be a resident of South Dakota

Families with or without private health insurance

Uninsured children under age 19 who have been denied or offered coverage by two insurance companies and have been without health insurance for the last 6 months may be eligible. Children enrolled under this eligibility criteria will have a 6 month pre-existing condition waiting period Individuals who have received notice from their insurance carrier that they are near or have reached their lifetime maximum benefit may be eligible for the program



GUARANTEED COVERAGE

Must apply within 63 days of losing your prior coverage and must have had at least 12 months of continuous creditable coverage

Family must consist of a parent or other adult caretaker relative (grandparent, brother, sister, stepparent, etc. ) and a dependent child Child under age 18: if a child is 18 years old and still a full time student in high school, the child is considered a dependent child if he or she is expected to complete school before reaching age 19 Ages 1-19 - 140% FPL Prengnant Women - 133% FPL Parents - 64% FPL

Must have used up COBRA or state continuation coverage Cannot be covered under any other form of health insurance and not had your most recent coverage terminated due to nonpayment of premiums or fraud Costs for individual coverage varies

Costs vary depending on age, region and program



South Dakota

800.234.1317

Children

Women

Refugees newly arriving in U.S.


CHIP

All Women Count

South Dakota Medical Assistance


800-738-2301 http://doh.sd.gov/ AllWomenCount/default.aspx

800-305-3064 www.state.sd.us/social

605-226-7582 www.ihs.gov/FacilitiesServices/ AreaOffices/Aberdeen

Or contact local department of social services


Medicare



Senior Health Information & Insurance Education (SHIINE)

800-738-2301 http://doh.sd.gov/WIC/default. aspx

Program

(Children’s Health Insurance Program) 800-305-3064 http://dss.sd.gov/ medicalservices/chip/


Demographic


800-536-8197 www.shiine.net


Covers pelvic exams, Pap smears, clinical breast exams, mammograms, and some additional diagnostic services Pre-Existing Health Conditions Covered

Covered services include doctor appointments, hospital stays, dental and vision services, prescription drugs, rehab/ therapy, chiropractic, etc. Coverage is limited to 8 months from a person's entry to the United States

Provide inpatient and outpatient care and conduct preventive and curative clinics. Pre-Existing Health Conditions Covered

Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D SHIINE is a Medicare counseling service


Coverage

CHIP: covers doctor appointments, hospital stays, dental and vision services, prescription drugs, mental health care and other medical services



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

CHIP: Children below 200% FPL who already have private health insurance may also be eligible for CHIP paying deductibles, co-payments and other medical services not covered by their private policy. If a child’s income puts the family over the income limit the family’s other children may still be eligible. A baby living with his or her teen parents may be eligible without looking at grandparents’ income

Women whose income is below 200% FPL are eligible for Pap tests if they are 30-64 and for mammograms if they are 40-64

Must be a refugee

Health services from the Indian Health Service is that the individual is an enrolled member of a Federally recognized Tribe.


Income limit is 62% FPL

Resides on tax-exempt land or owns restricted property

Eligibility

WIC: Reside in South Dakota, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL





www.coverageforall.org South Dakota

Monthly Cost

CHIP & WIC: $0 or minimal share of cost

82

Demographic

Private Health Insurance Individuals recently Small businesses covered by an (2-50 employees) employer health plan U.S. Uninsured Help Line 800-234-1317

Program

Group Plans

Tennessee Association of Health Underwriters 703-276-0220 www.tnahu.org

COBRA/Mini-COBRA and then

HIPAA






AccessTN

Medicaid

800-234-1317

866-268-3786 www.covertn.gov/web/ access_tn.html

Individual Plans

(TennCare) 866-311-4287 www.state.tn.us/tenncare

Families First

Tennessee Association of Health Underwriters 703-276-0220 www.tnahu.org

888-863-6178 www.state.tn.us/tenncare/

CoverTN

888-887-3224 www.covertn.gov

Coverage

(Effective December 1, 2009, new enrollment in CoverTN is suspended until further notice as a result of reaching budget capacity. Current members and participating businesses, as well as those who have been approved for coverage effective in January 2010, will be unaffected by the suspension)

Carriers can impose a 6-month look-back/12month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage (this may only apply to certain groups) Benefits will vary depending on the chosen plan Pre-Existing Health Conditions Covered




There is a 6-month lookback and a 12-month exclusionary period limit for pre-existing conditions


All carriers must guarantee issue coverage to all individuals


Three plans to choose from offering comprehensive health coverage similar to the benefits offered to state employees. Participants will be able to select the plan that is best for their situation. Refer to the benefit plan for more information on covered services. Pre-Existing Health Conditions Covered


Medicaid: Inpatient hospital services, outpatient hospital services, prenatal care, vaccines for children, physician services, nursing facility services for persons aged 21 or older, family planning services and supplies, rural health clinic services, home health care for persons eligible for skilled-nursing services, laboratory and x-ray services, pediatric and family nurse practitioner services, nurse/midwife services FF: Provides coverage to low income families with Children under age 19, Individuals who meet FF requirements, and Pregnant Women CoverTN: Limited-benefit health plan designed to cover the medical services needed by most people. Services include coverage for doctor visits, emergency treatment, inpatient and outpatient care, as well as pharmacy coverage. Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE



Eligibility

GUARANTEED COVERAGE

Must be a TN resident Individuals must pass medical underwriting so it is possible they can be turned down for pre-existing conditions If you are denied coverage for a medical condition, you may be eligible for AccessTN, see next column


Monthly Cost

83

COBRA or Mini-COBRA: With the 65% subsidy you are responsible for 35% of the monthly premium for the first 15 months. Once subsidy expires you are responsible for full premium COBRA, Mini-COBRA, HIPAA: Premiums range from 102%150% of group health rates; individual coverage may be less expensive

Tennessee

GUARANTEED COVERAGE

Must be a Tennessee resident, U.S. citizen or qualified legal alien.

Medicaid: Pregnant women & infants: 185% FPL; Children (ages 1-5): 133% FPL; Children (Ages 6-19): 100% FPL; All above must meet a medical eligibility test; Other infants and children with family incomes of 100% FPL are eligible; Working or non-working parents: 100%FPL; Qualified Disabled & Working Individuals: 200% FPL; Instituitionalized Individuals: $2022 Monthly Income; Medically Needy (Children up to age 18 or pregnant women): Family of 1, $241, Family of 2, $258; Family of 3, $317; Family of 4, $325; Family of 5, $392; Family of 6, $408; Family of 7, $467

Age 19 or older Uninsurable by medical or insurance determination No access to employersponsored health insurance (other than CoverTN) at the time of application Denial by two unaffiliated insurance carriers for individual coverage due to a health-related condition

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for any other insurance programs Costs depend on employer contribution and ± 35% of the insurance company’s index rate

GUARANTEED COVERAGE

Without health coverage six months, no access to insurance at time of application, exhausted continuation coverage including COBRA


Cost depends on age, tobacco use, etc. Premiums could be $284-1225, financial assistance for certain income levels could reduce price 30%-70%

FF: Family of 1, $1288, Family of 2, $1658; Family of 3, $1972; Family of 4, $2240; Family of 5, $2470; Family of 6, $2666; Family of 7, $2838 CoverTN: A U.S. citizen or qualified legal alien; 19-years-old or older; Tennessee resident for six months (employees at non-participating employers or self-employed); Earns $55,000 or less per year in adjusted gross income (employees at non-participating employers or self-employed); Works an average of at least 20 hours per week; Has not had health insurance in the previous six months (individual or group coverage)

Medicaid & FF: $0 or small share of cost CoverTN: Premiums are based on an individual’s age, weight and tobacco use. Must agree to pay one-third or two thirds share of premium depending on qualifications.

800.234.1317

Children

Women


TENNderCare

Breast and Cervical Cancer Screening Program


866-311-4287 http://state.tn.us/tenncare/ tenndercare/index.html

615-467-1500 www.ihs.gov/FacilitiesServices/ AreaOffices/Nashville/


Medicare





Program

CoverKids

888-325-8386 www.coverkids.com

(BCCSP) 877-96-WOMEN 877-969-6636 http://health.state.tn.us/BCC/ index.htm


Demographic


800-633-4227

Medicare Supplement Insurance Policy 888-486-9355

TENNderCare: A full program of check ups and health care services for children who have TennCare


A number of services covered for eligible Native American Indians by the Nashville Area clinics. Pre-Existing Health Conditions Covered

Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D The Department of Commerce and Insurance regulates providers of supplemental policies to help cover Medicare co-pays and deductibles

CoverKids: Preventive Care, Office Visits, Inpatient Hospital Services, Hospital emergency care, Urgent care services, Outpatient Facility Services and Outpatient Surgery, Prescription drug coverage, vision services


Coverage

These services make sure babies, children, teens and young adults receive the health care they need

Clinical breast exams, mammograms, and Pap tests



GUARANTEED COVERAGE

TENNderCare: Children with TennCare up to age 21

Must be uninsured or underinsured with income at or below 250% FPL

GUARANTEED COVERAGE








$0



www.coverageforall.org Tennessee

Monthly Cost

TENNderCare & CoverKids: $0 or significant share of premium cost and co-pays

GUARANTEED COVERAGE

Eligibility

CoverKids: Age 18 or younger, A Tennessee resident, U.S. citizen or qualified legal alien, Uninsured for at least three months prior to application, Not eligible for TennCare, No access to state employee health insurance, Income up to 250% of FPL, Maternity coverage available for pregnant women who meet eligibility criteria. Children above 250% can buy into the program.

GUARANTEED COVERAGE

84

Demographic



Program

800-234-1317

Group Plans

Individuals recently covered by an employer health plan COBRA then convert to

HIPAA

Texas Association of Health Underwriters 703-276-0220 www.tahu.org


Texas Employee Group Insurance Program (GBP)

and also



Individual Plans

Texas Association of Health Underwriters 703-276-0220 www.tahu.org

Individuals with Children with pre-existing, expensive medical severe or chronic conditions medical conditions Texas Health Insurance Risk Pool

TX Children with Special Needs

(Medical Expense Deduction Program) 888-398-3927 TDD 800-735-2989 www.txhealthpool.com

800-252-8023 www.dshs.state.tx.us/cshcn

Hospitalization, physician care, maternity, prescriptions, drugs, treatment for serious mental health illnesses and other services

There is a 12 month waiting period for people with preexisting health conditions where the policy will not pay any expenses for the condition. If you were covered by creditable coverage in place during the 12 months before your effective date your wait time will be reduced.

Ambulances, Ambulatory Surgery, Primary & Preventative Care, Inpatient rehabilitation and Outpatient Care, Speech and Hearing Services, Vision & Dental Care, Family Support Services, Mental Health Services, Diagnosis & Evaluation, Laboratory and Radiology Services, Equipment & Medical Supplies, Home Health Nursing, Hospice & Hospital Care, Meals, Lodging and Transportation when needed to obtain medical care, Medicines, Physician and Occupational Therapy, Orthotics and Prosthetics, Special Nutritional Products & Services and Insurance Premium Payment Assistance



GUARANTEED COVERAGE

GUARANTEED COVERAGE

Individuals with applicable pre-existing conditions should qualify

A person younger than 21 years of age who has a chronic physical, developmental, or emotional condition that will last or is expected to last for at least 12 months

Conversion Policies

877-275-4377 Austin: 512-867-7711 www.ers.state.tx.us

Coverage varies according to plan

Coverage

By law all insurers must offer at least one plan that includes coverage for state mandated benefits such as preventive care, mammograms etc. Pre-Existing Health Conditions Covered



GUARANTEED COVERAGE

GUARANTEED COVERAGE

Company size 2-50 employees (or self-employed)




Up to $5M, assorted deductibles depending on age and ZIP code


Insurance companies may require minimum participation

85

COBRA: Coverage available for up to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for the Texas Health Insurance Risk Pool, see next column


Texas

Renewable as long as you pay your premiums and continue to reside in Texas and meet other conditions: Ineligible for public or employer-based coverage If one family member qualifies then all are qualified

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA Costs depend on employer contribution and ± 25% of the insurance company’s index rate

5 plans to choose from including the new HSAQualified Plan.

Person of any age with cystic fibrosis Must have applied for Medicaid and CHIP and used those benefits

You must have had 18 months of continuous coverage with the last day in a group health plan


Premiums vary based on health plan chosen, age, gender and geographic zone

$0

Rates are limited to twice the amount a healthy person in a similar plan pays

800.234.1317


Low income families and adults

CHIP

Medicaid

In Texas: 2-1-1 800-252-8263 877-541-7905 www.hhsc.state.tx.us/ medicaid/index.html

State Kid Insurance Program (SKIP)


Breast and Cervical Cancer Treatment Program


(BCCTP) 512-458-7796 www.dshs.state.tx.us/ bcccs/default.shtm

Nashville Offices 615-467-1500 www.ihs.gov/FacilitiesServices/ AreaOffices/Nashville/

877-KIDS-NOW 877-543-7669 www.ers.state.tx.us/insurance/ skip/default.aspx

Both: Doctor and nurse care immunizations, preventive care, health clinics, laboratory tests, prescriptions, medical equipment, transportation, hospitalization, mental health services, well child visits, dental, vision and more

Albuquerque Area office 505-248-4500 www.ihs.gov/FacilitiesServices/ AreaOffices/Albuquerque/

Oklahoma City Area www.ihs.gov/FacilitiesServices/ AreaOffices/oklahoma/index. cfm Comprehensive health, dental, vision, and prescription coverage Pre-Existing Health Conditions Covered

Offers clinical breast examinations, mammograms, pelvic examinations, and pap tests at little or no cost to eligible women Referrals to treatment services

A number of services covered for eligible Native American Indians by the Nashville Area clinics. Pre-Existing Health Conditions Covered

Medicare



Employee Retirement System (ERS) Of Texas 877-275-4377 Austin: 512-867-7711 www.ers.state.tx.us

Medicare: Offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug coverage plan, known as Medicare Part D Pre-Existing Health Conditions Covered


GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Both: Children age 19 and younger at or below 200%FPL; Must be ineligible for Medicaid

Residents and some legal immigrants

Diagnosed with breast or cervical cancer

Retired or disabled people with low income and Medicare may also qualify for Medicaid assistance




No access to other health insurance including Medicare





range between $3 to $10.

SKIP: Ranges between $15 to

$25 per month

www.coverageforall.org Texas

Monthly Cost

family; most co-payments

Age 50-64 priority for breast screening


Texas resident and qualified resident

SKIP: Available to Children of employees in ERS' insurance program or Texas Employee GBP

$50 covers all children in

Women under age 65


Age 18-64 priority for cervical cancer screening if no Pap in previous years

No health insurance for the last six months at time of application

CHIP: $0 or share of cost;

GUARANTEED COVERAGE

Eligibility

CHIP: No limit on resources; Texas residents, qualified immigrants, and pregnant women can also qualify for CHIP; Must be ineligible for employer-based coverage

GUARANTEED COVERAGE

Coverage


CHIP: Children enrolling in CHIP for the first time after being covered by private health insurance will have a 90-day waiting period before benefits can be used


Program

(Children’s Health Insurance Program and Medicaid) 800-647-6558 877-KIDS NOW www.chipmedicaid.org

Women

Demographic


86

Demographic





COBRA and Mini-COBRA


Program

800-234-1317

Group Plans

Utah Association of Health Underwriters 703-276-0220 www.uahu.org

Utah’s Premium Partnership for Health Insurance (UPP)

888-222-2542 http://health.utah.gov/upp

Coverage

Assorted deductibles There is a 6-month look-back/12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage UPP is a program for adults and children who do not currently have health insurance or COBRA coverage. UPP will help pay for monthly insurance premiums for individuals enrolled in their employer’s health insurance plan or COBRA

Then convert

HIPAA


800-234-1317

Individual Plans Utah Association of Health Underwriters 703-276-0220 www.uahu.org

Or


Low income families and medically needy

HIPUtah

Medicaid

(Utah Comprehensive Health Insurance Pool) Application Help: 800-705-9173 801-442-6660 Member Services 800-538-5038 801-442-5038 www.selecthealth.org www.insurance.utah.gov/ hiputah/index.html

800-662-9651 801-538-6155 http://health.utah.gov/ medicaid

Coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, transplants, rehabilitation, durable medical equipment, mental health and substance abuse, physical, speech and occupational therapy, and preventive care, among other services

Inpatient hospital, outpatient hospital services, prenatal care, vaccines for children, physician, nursing facility services, family planning, rural health clinic services, home health care for persons eligible for skilled nursing services, laboratory and x-ray services, pediatric and family nurse practitioner services, nursemidwife services and more

State Conversion Policies COBRA or Mini-COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer

Up to $5M, assorted deductibles depending on age and residence zone Limits on Pre-Existing Health Conditions May Apply






GUARANTEED COVERAGE

Company size 2-50


Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage; owner can count as an employee

Monthly Cost

Eligibility


87

If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions- not counting birth or adoptionmay apply, (1-6 months respectively) UPP: Must be between the ages of 0-64; not be covered by other health insurance; be a U.S. citizen or legal resident; be able to get health insurance through an employer’s health plan; have your cost of health insurance be more than 5% of your income; meet income guidelines (Adults approximately 150% FPL, Children 200% FPL).

Costs depend on employer contribution and ± 30% of the insurance company’s index rate UPP: Up to $150 per adult and up to $120 per child in the family, every month

If you are denied coverage for a medical condition, you may be eligible for HIPUtah, see next column

GUARANTEED COVERAGE

Previous coverage terminated for reasons other than non-payment of premium or fraud or rejected for coverage within previous 6 months

Parents: 70% FPL

Cannot be eligible for COBRA, or government programs Must have resided in Utah for 12 consecutive months immediately preceding the date of application for HIPUtah (the 12 month requirement can be waived if moving from another state’s high risk pool)



Children Age 0-6 and pregnant women: 133% FPL Children Age 6-18: 100% FPL (also aged, blind and disabled) SSI Recipients: 74% FPL Medically Needy Individual: 53% FPL Medically Needy Couple: 48% FPL Working legally disabled 250% Parent or caretaker relative of a child 54% to 60%

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have preexisting conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or any other public or private insurance programs


Utah


GUARANTEED COVERAGE

Some services are based on age of member

Costs depend on age and county/zone

Premiums vary based on the plan, can be 150% of average rate

If you are self-employed and buy your own insurance you are eligible to deduct 100% of the cost of the premium from your federal income tax

Three available deductible options of $500 medical/$150 pharmacy, $1000 medical/$250 pharmacy and $2500 medical/$500 pharmacy

$0 or small share of cost; no copays

High deductible plan is also available with a $5,000 deductible

800.234.1317

Low income children

Women

Native American Indian


Veterans

Utah CHIP

Utah Cancer Control




800-717-1811 801-538-6157 www.cancerutah.org

(Navajo Area Office) 928-871-4811 www.ihs.gov


877-222-8387 www.va.gov

Program

(Children’s Health Insurance Program) 877-KIDS-NOW 877-543-7669 866-772-1261 866-435-7414 801-538-9004 www.utahchip.org

Demographic



877-WIC KIDS www.health.utah.gov/wic/ index.html Pap test, pelvic examination, clinical breast examination, referral for a free mammogram, education on breast self examination


Inscription House Health Center provides pediatrics, internal medicine and family medicine ambulatory care, services provided include laboratory, pharmacy, dental, public health nursing, mental health, health education, x-ray, and optometry care. As is true for other Navajo Area Indian Health facilities, leading reasons for outpatient visits include respiratory illness, preventive health activities, diabetes, well child exams and prenatal care







Coverage

Utah CHIP: Well-child exams, immunizations, health care provider visits, prescriptions, hearing and eye exams, mental health services, dental services for prevention and treatment of tooth decay

Can also use funds to purchase coverage through the State of Utah's Department of Workforce Services Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Utah CHIP: Must be a U.S. Citizen or legal resident, Under age 19, Not currently covered by health insurance, Income must be at or below 200% FPL

Women 50 - 64 years of age

Navajo indian, possibly others


WIC: Reside in Utah, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL

Do not have Medicaid or Medicare


Utah CHIP: $0-75 per quarter depending on income

$0


Uninsured or unable to afford insurance premium





Eligibility

Income at or below 250% of FPL



www.coverageforall.org Utah

Monthly Cost


Do not belong to an HMO (Health Maintenance Organization)

88

Demographic

Private Health Insurance Small business (1-50 Employees)



Low Income Families & Medically Needy

Low Income Children & Pregnant Women


COBRA


Medicaid

Dr. Dynasaur

Program

800-234-1317

Group Plans

Vermont Association of Health Underwriters 703-276-0220 www.nahu.org

Then convert to

HIPAA

Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov Or

State Conversion Policies

Coverage

Assorted deductibles There is a 6-month look-back/12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Pre-Existing Health Conditions Covered

COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered

800-234-1317

Individual Plans

800-250-8427 www.ovha.vermont.gov or www.greenmountaincare.org

National Association of Health Underwriters (To find and agent) 703-276-0220 www.nahu.org

Up to $5M, assorted deductibles depending on age and residence zone There is a 9-12 month look-back period limit on pre-existing health conditions Limits on Pre-Existing Health Conditions May Apply

(Children’s Health Insurance Program) 800-250-8427 www.ovha.vermont.gov or www.greenmountaincare.org


800-649-4357 802-863-7333 http://healthvermont.gov/ family/wic/wic_vt.aspx Doctor visits, prescriptions, hospital care (including emergency care), tests, x-rays, family planning, mental health services, substance abuse services, home health care, dental care, eye care, occupational therapy, physical and speech therapy, and more

Dr. Dynasaur: Doctor visits, checkups, dental care, immunizations, vision, hospital care, prescriptions, physical therapy, speech therapy, mental health care. Pregnant women receive doctor visits, hospital care, lab work & tests, prescriptions, prenatal vitamins and other services



GUARANTEED COVERAGE

GUARANTEED COVERAGE

Company size 1-50

COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage. Applies to businesses with more than 20 employees

Two employees must be present for half of the preceding calendar quarter and work 20 hrs/week for coverage Owner can count as an employee

Monthly Cost

Eligibility


89

If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions- not counting birth or adoptionmay apply, (1-6 months respectively)


GUARANTEED COVERAGE

GUARANTEED COVERAGE

Eligibility is NOT subject to medical underwriting

Children ages 0-18 300% FPL Pregnant Women: 200% FPL

Dr. Dynasaur: Provides coverage for children under 18 and pregnant women. Household income must be at or below 200% FPL for pregnant women, and up to 300% FPL for children. Cannot have had prior health coverage in the last month to be eligible, unless the coverage was dropped because of unemployment, death or divorce, or loss of dependent eligibility

Non-working Parents: 185% FPL Working Parents: 192% FPL Medically Needy Individual: 102% FPL (or 111% of the Federal Poverty Level for residents of Chittenden County only) Couple: 76% FPL (or 82% FPL for residents of Chittenden County only)

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA. You cannot be eligible for Medicare or any other public or private insurance programs


Vermont

GUARANTEED COVERAGE



$0 or small share of cost; no copays

WIC: Reside in Vermont, Nutritionally or medically at risk pregnant, postpartum or breastfeeding women, and children younger than 5 years old. Must be at or below 185% FPL

Dr. Dynasaur: $0 or $60 premium for children with family incomes between 200% and 300% FPL WIC: $0 to minimal share of cost

800.234.1317

Women

Ladies First

VHAP

(Vermont Health Access Plan) 800-250-8427 888-834-7898 TTY www.dsw.state.vt.us or www.greenmountaincare.org



Veterans

Medicare






877-222-8387 www.va.gov

800-633-4227

Program

800-508-2222 802-863-7200 TDD 800-319-3141 http://healthvermont.gov/ prevent/ladies_first.aspx

Adults

Demographic


State Health Insurance Assistance Program (SHIP) 800-642-5119 www.medicarehelpvt.net

Annual mammograms, clinical breast exams, pelvic exams, Pap tests, instruction in breast self-exam, and cardiovascular disease risk factor (cholesterol, high blood pressure, diabetes) screening

Full coverage for some women



Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D SHIP is a Medicare counseling service Pre-Existing Health Conditions Covered





Coverage

Repeat mammograms, ultrasounds, biopsies, and colonoscopies

Doctor visits, prescriptions, visits to specialists, emergency room care, inpatient hospital care - emergency and urgent admissions only, outpatient care, tests and x-rays, family planning, mental health services, substances abuse services, home health care

Can also use funds to purchase coverage through the Blue Cross Blue Shield of Vermont and MVP Health Plans Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Age 40 years or older without Medicaid, VHAP, or Medicare Part B

Must have income between 50185% FPL









Age 18-39 without Medicaid, VHAP, or Medicare Part B Income at or below 250% FPL

Must have been uninsured for 12 months or more – with exceptions for Vermonters who recently lost their insurance because of a life change such as a divorce or loss of a job


Eligibility

If you have breast symptoms or an abnormal Pap test, you are eligible for a limited membership. This includes breast and cervical screening and diagnostic tests, but not screenings for heart disease risk factors.

VHAP is a health insurance program for adults age 18 and older

In addition, all women who have been screened through Ladies First and need treatment for breast and cervical cancer may be eligible for full Medicaid benefits during treatment, including coverage for pre-malignant conditions

$7-$49

www.coverageforall.org Vermont

Monthly Cost

$0

90

Demographic





COBRA


Program

800-234-1317

Group Health

Virginia Association of Health Underwriters 703-276-0220 www.vahu.org

or

HIPAA


800-234-1317

Individual Plans Virginia Association of Health Underwriters 703-276-0220 www.vahu.org



Anthem

Medicaid

800-304-0372 www.anthem.com

804-786-4231 www.dmas.virginia.gov

CareFirst

866-520-6099 www.carefirst.com

Continuation and Conversion Policies Pre-existing conditions can be excluded for a limited time depending upon the type of group plan you are joining

Coverage



Plans will vary but insurers are required to offer certain benefits such as postpartum care and mammograms

Plans will vary but these two insurers offer plans to individuals denied coverage due to medical conditions



All insurers are required to offer certain benefits such as postpartum care and mammograms



HIPAA: Benefits are based on the program selected and there is no expiration of coverage State conversion plans offered through private health insurance market will vary Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE




Eligibility


Medical underwriting will determine eligibility If you are denied coverage for a medical condition, you may be eligible for coverage through Anthem or CareFirst, see next column

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Must not be eligible for any other insurance, including individual, group or public

Pregnant women, infants and children up to 133% FPL

Plan availability will depend on county residence Virginia resident

Medically needy couples up to 47% FPL Medically needy individuals 42% FPL Working parents up to 30% FPL Aged, blind, and disabled up to 80% FPL Non-working parents up to 24% FPL


High cost of medical conditions subtracted from income may make eligible

Monthly Cost

Must be a Virginia resident

91

Costs depend on employer contribution and for standardized plans, ± 25% of the insurance company’s index rate


Depends on plan selected

Each individual plan is priced differently depending on age and gender, no family rates



Virginia

800.234.1317

Children In Moderate Income Families

Women

Individuals with life-threatening illness or injury


Veterans

Family Access to Medical Insurance Security

Breast and Cervical Cancer Early Detection Program

Uninsured Medical Catastrophe Fund



866-395-4968 804-864-7761 www.vahealth.org/ breastcancer

(UMCF) 800-432-5924 www.dmas.virginia.gov


877-222-8387 www.va.gov


Program

(FAMIS) 866-873-2647 888-221-1590 (TDD) www.famis.org

Demographic


888-942-3663 www.vahealth.org/wic

FAMIS: Doctor visits, check-ups, immunizations, preventive care, dental, mental, hospitalization



Inpatient and outpatient hospital services and surgical centers, ambulatory care, laboratory and x-ray, physician, ambulatory care, medical care furnished by licensed practitioners, prescribed drugs and rehabilitative services to recover from medical treatment; the only organ and tissue transplant procedures covered are: kidney, liver, heart, lung and bone marrow

Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits



Coverage


If screened and diagnosed for breast or cervical cancer may be eligible for complete health coverage through Medicaid, including dental, prescriptions etc.


GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

FAMIS: Low income children under age 19, Uninsured and ineligible for Medicaid, Virginia resident, Income below 200% of FPL

Must be Virginia resident Women between 40-64 years of age. Women ages 18-39 can also qualify for tests but may need to pay for them

Citizen or a legal resident



Must be uninsured or underinsured, ineligible for Medicaid

Have a life threatening illness or injury, be uninsured for the needed treatment and not eligible for coverage for the needed treatment through private health insurance or federal, state, or local government medical assistance programs

WIC: Reside in Virginia, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL


Resident of VA Gross family income at or below 300% of the FPL





Eligibility

GUARANTEED COVERAGE

Identify a provider who is willing to accept the global fee established for the medical treatment plan





www.coverageforall.org Virginia

Monthly Cost

FAMIS: $2-5 co-pays, $0 for well-child and well-baby check-ups

92

Demographic





COBRA or


HIPAA

Individual Plans

Program

800-234-1317

Group Health Plans www.dol.gov/ebsa

Washington Association of Health Underwriters 206-623-8632 www.wahu-online.org


State Continuation Coverage

Coverage

Up to $2M lifetime maximum, assorted deductibles Under Washington law, newborns and adopted children are automatically covered under parents’ fully insured health plan for three weeks (60 days to notify carrier to add) if the plan provides dependent coverage. Pre-Existing Health Conditions Covered


Eligibility

Name on license must draw wages If uninsured for previous 64-90 days, a waiting period for coverage of pre-existing conditions- not counting birth or adoptionmay apply,; up to 3 months for 51+ employees; up to 9 mos. 20-50 employees, for HIPAA - up to 12 months

Costs depend on plan choice and + 375% of the Modified Community Rate

Healthy Options (Medicaid Managed Care Program) 800-562-3022 TTD: 800-848-5429 http://maa.dshs.wa.gov/ HealthyOptions

Medicaid

Up to $2M, assorted deductibles depending on age and county of residence Limits on Pre-Existing Health Conditions May Apply

Department of Social and Health Services 800-737-0617 800-562-3022 www1.dshs.wa.gov

Max lifetime benefit is $1 million per covered person

HO: Choose from several different plans

Choose from Medicare and Non-Medicare plans

Medicaid: Physician services, checkups (medical and dental), family planning, maternity, prenatal, and newborn care, prescriptions, mental health, hospital services, comfort care, hospice, dental services, drug and alcohol treatment, eye glasses, hearing aids

6 months pre-existing condition exclusion period. Exceptions apply. For example if applicant signs up through a portability policy Pre-Existing Health Conditions Covered

Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for WSHIP, see next column


GUARANTEED COVERAGE

GUARANTEED COVERAGE

Must be a Washington resident

HO: Low income families; Pregnant women; Children under age 19

Must have been rejected for coverage by an insurance carrier Cannot have any other health coverage Individuals who are eligible for Medicare may qualify for the WSHIP Medicare plan


Medicaid: Child age 0-19: 200% FPL Working parents: up to 77% FPL Non-working parents: up to 38% FPL Pregnant woman: 185% FPL Parent: 50% FPL with resource test



Washington

WSHIP

Washington State Health Insurance Pool 800-877-5187 www.wship.org

Washington Association of Health Underwriters 206-623-8632 www.wahu-online.org


Company size 2-50 eligible employees

Low Income Individuals & Families

800-562-6900 (Consumer Hotline)


GUARANTEED COVERAGE

Owner can count as an employee with proprietor

Monthly Cost


GUARANTEED COVERAGE

Two employees must work 30 hrs/week for coverage

93


800-234-1317


Washington resident and qualified immigrant

Costs depend on age and county/zone. If you are self-employed and buy your own insurance you are eligible to deduct 100% of the cost of the premium from your federal income (your taxable income)

Plan usually pays 80% of most benefits. Choice of annual deductibles $500-$1,500, subsidies for age 50+


800.234.1317

Individuals and Families

Children

Women


Washington Basic Health Plan

Apple Health for Kids (CHIP)

Washington Breast and Cervical Cancer Program

Indian Health Service

(Basic Health is no longer processing applications and has officially implemented a waiting list)

Washington Prescription Drug Discount Card

877-KIDS NOW 877-543-7669 800-562-3022 http://hrsa.dshs.wa.gov/ applehealth/index.shtml

888-438-2247 www.doh.wa.gov/wbchp

503-326-2020 (Portland-based) www.ihs.gov

Seattle Indian Health Board


206-324-9360 www.sihb.org

800-841-1410 www.doh.wa.gov/cfh/wic/ default.htm

Medicare



Program

(Subsidy program) 800-826-2444 800-660-9840 www.basichealth.hca.wa.gov


Demographic


877-208-1131 www.rx.wa.gov

Apple Health: Some children may qualify to have unpaid medical bills for the last three months covered

Some diagnostic services such as ultrasound, breast biopsy, surgical consultation, colonoscopy

Not all plans are offered in all counties

Full medical, dental and vision coverage

Comprehensive coverage including preventive care, office visits, pharmacy, emergency care, and maternity care


Cancer treatment for some women qualified through Medicaid

WPDD: Provides prescription drug discounts to all Washington state residents Pre-Existing Health Conditions Covered

Referral to treatment services


IHS: Programs vary depending on health center: primary & well child care, prenatal and post delivery care, family planning (birth control), minor surgical and orthopedic care, Pharmacy, dental and orthodontics, optometry, nursing, mental health, laboratory & radiology SIHB: multi-service non-profit community health center dedicated to improving the health and well-being of urban Indians living in the greater Seattle-King County area



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

BHP: 9 month waiting period of pre-existing conditions except of maternity care and prescriptions

Apple Health: Children age 18 and under who are Washington residents

Age 40-64

Member of a federally recognized tribe

Family income up to 300% (some children with higher incomes may still qualify)



$0 or sliding scale depending


Washington resident Not eligible for Medicare

Apple Health: $0-30 a month depending on income. No

WPDD: $0

family pays more than $60

$0 and share of cost sliding scale

on income


www.coverageforall.org Washington

Monthly Cost

BHP: Premiums vary depending on plan chosen


Eligibility

WPDD: Must live in Washington state. There are no income or age requirements to qualify for this prescription card.

WIC: Reside in Washington, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL


Coverage

BHP: Choose from plans from Kaiser Permanente, Columbia United, Molina, Community Health Plan of Washington

94

Demographic Program




COBRA

Group Health


Assorted deductibles

Coverage

Then

800-234-1317

There is a 6-month look-back/12-month exclusionary period for pre-existing conditions on enrollees that do not have prior creditable coverage Pre-Existing Health Conditions Covered

HIPAA





Low Income families & medically needy


Carefirst Blue Cross Blue Shield

Medicaid

800-234-1317

Individual Plans

At least three plans must be offered on a “guarantee issue” basis to all consumers

Comprehensive plans available depending on needs of applicant


D.C. does require all policies to cover certain benefits – such as mammograms, prostate cancer screening, and diabetes treatment


Two month waiting period Pre-Existing Health Conditions Covered

Doctor visits, immunizations (shots), school physicals, emergency care, hospital stays, prescriptions, prenatal labor and delivery, vision care and glasses, dental, family planning, transportation to doctor appointments, home health care, durable medical equipment, health education services, mental health services, drug and alcohol treatment and more Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Company size 2-50

COBRA: If you were involuntarily terminated between Sept 1, 2008 and May 31, 2010, you are eligible for a 65% COBRA subsidy from the Federal Government. If you become eligible for other insurance, you will no longer be eligible for the subsidy. Must have an income at or below $125,000 for individuals or $250,000 for couples. You have 60 days from date of termination to sign up for COBRA coverage. Applies to businesses with more than 20 employees

Eligibility is NOT subject to medical underwriting

If you are not HIPAA eligible and buy a GUARANTEED COVERAGE policy, CareFirst can impose a 10-month pre-existing condition exclusion period

Children Ages 0-19 and Pregnant Women may have an income up to 300% of the FPL

Eligibility

Most carriers require proof of the business or business owner, viability etc.

Monthly Cost

202-727-5355 202-442-5988 http://doh.dc.gov/doh



95

800-321-3497 www.carefirst.com

There is a 12-month exclusionary period limit for pre-existing conditions for HMOs, and a 10-month exclusionary period limit for pre-existing conditions for Carefirst Blue Cross Blue Shield (except for those qualified under HIPAA)

CareFirst is not required to credit your prior health coverage toward preexisting condition exclusion periods


Costs depend on employer contribution


CareFirst can exclude conditions for which you ever got care or for which the insurer thought you should have sought care; this is called the prudent person rule

Costs depend on age and county/zone

Aged, Blind and Disabled: 100% FPL SSI Recipients: 74% FPL Medically Needy Individual: 53% FPL Medically Needy Couple: 41% FPL Resource requirements for everyone but children or pregnant mothers

Premiums can vary due to age, gender, health status, family size, and other factors.

$0 or share of cost


Washington D.C.

800.234.1317


D.C. Healthy Families

Project Wish

(Breast and Cervical Cancer Early Detection Program) 202-442-5900 202-442-9128 (Spanish) http://doh.dc.gov/doh



Veterans

Medicare






877-222-8387 www.va.gov

800-633-4227

Choose one of three health plans: Unison Health Plan DC Chartered Health Plan Health Right







Coverage

Doctor visits, immunizations (shots), school physicals, emergency care, hospital stays, prescriptions, prenatal labor and delivery, vision care and glasses, dental, family planning, transportation to doctor appointments, home health care, durable medical equipment, health education services, mental health services, drug and alcohol treatment and more

Cancer education, screening, and diagnostic services

Program

202-639-4030 TTY: 202-639-4041 http://doh.dc.gov/doh

Women

Demographic




GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

For children, adolescents under age 19 who live alone, pregnant women, and parents/guardians

Must be a resident of Washington D.C.









Ages 50 and older are also eligible for a free annual mammogram

Up to 200% FPL for entire family, up to 300% for children only

Free transportation and interpreter services

$0 or share of cost

$0


Eligibility

Must be a resident of Washington D.C.

Monthly Cost

www.coverageforall.org Washington D.C.

96

Demographic





COBRA/Mini-COBRA


and then

Program

800-234-1317

All group health insurance carriers can impose a 6-month look-back/ 12-month exclusionary period for preexisting conditions on enrollees that do not have prior creditable coverage

Coverage

HIPAA

Group Plans


West Virginia Association of Health Underwriters 703-276-0220 www.nahu.org


800-234-1317

Individual Plans


Low income families

Access WV

Medicaid

(WV Health Insurance Plan) 866-445-8491 304-558-8264 www.accesswv.org

304-348-3365 888-483-0797 www.wvdhhr.org/bcf/family_ assistance/medicaid.asp

Physician's services, hospital inpatient care, outpatient hospital services, emergency room services, X-ray and laboratory services prescribed by an authorized practitioner, routine dental care for children and with approval some medically necessary special care such as braces, adult dental limited to removal of cysts or tumors, biopsies, treatment of fractures of the jaw bones and some emergency services, prescribed drugs, ambulance, artificial limbs, braces etc., vision, nursing facilities, family planning services, outpatient mental health services

West Virginia Association of Health Underwriters 703-276-0220 www.nahu.org


Assorted plans depending on medical needs There is a 12-month look-back and 24-month exclusionary period limit

Four plan options including doctor visits, hospital care, labs, prescription drugs, transportation, routine shots for children, mental health and substance abuse services



Annual benefit maximum $200K and lifetime $1M Must meet a 6-month waiting period for pre-existing conditions. This means that AccessWV will not provide benefits for services related to these conditions, including prescriptions, for 6 months after coverage is effective



GUARANTEED COVERAGE




Eligibility


Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for Access WV, see next column


GUARANTEED COVERAGE

GUARANTEED COVERAGE


Pregnant Women and infants (ages 0-1): 150% FPL



Must prove denial of coverage or offer of higher premium than Access WV


Supplemental Security Income Recipients: 74% FPL Working Parents: 34% FPL Medically Needy: 28% FPL Non-Working Parents: 19% FPL


Age limits for certain services

Monthly Cost


97




$0 or share of cost; no copays

$400-2,000 deductible for one person depending on the plan Premium prices vary based on family or single, region, age and plan selected


West Virginia

800.234.1317


Women

WVCHIP

Breast and Cervical Cancer Screening 800-642-8522 304-558-5388 www.wvdhhr.org/bccsp


Medicare






877-222-8387 www.va.gov

WVSHIP

304-558-3317 877-987-4463 www.wvship.org Mammograms for women age 50 and older Pap tests and pelvic exams for women age 25 and older Surgical breast consults, diagnostic mammograms, fine needle aspirations, breast biopsies, breast ultrasounds, and colposcopies with or without biopsies available if deemed necessary Pre-Existing Health Conditions Covered

Medicare offers two standard plans, Part A: Hospital Insurance and Part B: Medical Insurance, as well as several supplemental and advantage plans. It also offers a prescription drug program called Medicare Part D WVSHIP is a Medicare counseling service





Coverage


Veterans

800-633-4227

304-558-0030 http://ons.wvdhhr.org/

WVCHIP: Doctor visits, check-ups, hospital visits, immunizations, prescriptions, tests and x-rays, dental care, vision, emergency care, 24 hour nurse-line, mental health, diabetic supplies, urgent care or after hour clinic visits, case management for special needs and other services


Program

(Children’s Health Insurance Plan) 877-WVA-CHIP 877-982-2447 304-558-2732 www.wvchip.org


Demographic





GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

No health insurance, or your health insurance does not cover the services









Age restrictions for each service, 25-64 Income at or below 200% FPL


Eligibility

WVCHIP: Must be a West Virginia resident currently living in the state, Must be 18 or younger, Cannot have health insurance now and cannot have had it in the past six months (for the Basic CHIP plans) or the past twelve months for the CHIP Premium Plan. Also cannot be eligible for the West Virginia State Employee Health Insurance or Medicaid; Must have a family income at or below 250% FPL WIC: Reside in West Virginia, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL



www.coverageforall.org West Virginia

Monthly Cost

WVCHIP: $0-35 co-pays for drugs and services with a maximum of $0-750 annually depending on family size and income

98

Demographic





COBRA or HIPP


Program

800-234-1317

Group Health

Wisconsin Office of the Commissioner of Insurance 800-236-8517 608-266-3585 http://oci.wi.gov

Then convert to

HIPAA


800-234-1317

Individual Plans

Wisconsin Office of the Commissioner of Insurance 800-236-8517 608-266-3585 http://oci.wi.gov



HIRSP

Medicaid

(Wisconsin Health Insurance Risk Sharing Plan) 800-828-4777 608-221-4551 www.hirsp.org

800-362-3002 www.dhfs.state.wi.us/Medicaid

Or


Coverage


COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium HIPP: Benefits are the same as what you had with your previous employer, HIPP is a premium assistance program

Covers certain state mandated items, Annual open enrollment regardless of pre-existing conditions

HIRSP offers five plan options: Plan 1 is for people not eligible for Medicare and offers two deductible choices, and Plan 2 is only for people eligible for Medicare


Hospital and physician care, prescription drugs and insulin, maternity care and other services




HIPAA: Benefits are based on the program selected and there is no expiration of coverage Pre-Existing Health Conditions Covered GUARANTEED COVERAGE

GUARANTEED COVERAGE




Eligibility


HIPP: Pays employer premiums for families that have high cost medical conditions and are eligible for Badger Care

Eligibility is based on medical underwriting There is a 12 month look back period during first two years of coverage. If condition is deemed preexisting there can be a 24 month exclusionary period Must be resident of state or documented immigrant If you are denied coverage for a medical condition, you may be eligible for HIRSP, see next column

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Must be under age 65

Limited assets such as cash, savings, stocks and bonds AND...

Must be Wisconsin resident

Parents, children 1-19, pregnant women and infants at 185% FPL

Must demonstrate uninsurability Cannot be eligible for employeroffered group health insurance Cannot be eligible for comprehensive Wisconsin Medicaid services or BadgerCare Plus

Medically needy individuals up to 83% FPL Medically needy couples up to 61% FPL Wisconsin resident or documented immigrant


Automatically covered if on cash assistance or SSI

Premiums vary based on plan. Plan 1: Option A has annual deductible of $1000 and 20% co-pay with out-of-pocket max of $2,000; Option B has deductible of $2500 with $3500 out-of-pocket max and 20% co-pays Plan 2: $500 annual deductible and HIRSP pays 100%


Monthly Cost

HIPAA: After you have exhausted your COBRA benefits or if you had 18 months of continuous coverage and your company went out of business, you may convert to a HIPAA individual plan, even if you have pre-existing conditions. You have 63 days from the date you lost your previous coverage to sign up for HIPAA Costs depend on employer contribution and ± 30% of the insurance company’s index rate




99

Wisconsin

800.234.1317

Children

Women

Individuals with chronic health conditions

Adults


Badger Care Plus

Wisconsin Well Women Program

Wisconsin Chronic Disease Program

BadgerCare Core


800-362-3002 www.badgercareplus.org

(WCDP) 866-908-1363 http://dhfs.wisconsin.gov/wcdp

800-722-2295 http://dhs.wisconsin.gov/wic/ index.htm

BCP: Comprehensive care including but not limited to doctor visits, mental, dental, prescriptions, hospitalization and more (offers same as Medicaid)



The Wisconsin Chronic Disease Program (WCDP) offers assistance to Wisconsin residents with chronic renal disease, hemophilia and adult cystic fibrosis The WCDP is funded entirely by state dollars; the program pays health care providers for disease related services and supplies provided to certified Wisconsin Chronic Disease Program participants after all other sources of payment have been exhausted

Doctor visits, Hospital services, Emergency room visits, Emergency ambulance rides, Emergency dental services, Some prescription drugs, Physical therapy, Occupational therapy, Speech therapy, Cardiac rehabilitation, Durable medical equipment, Disposable medical supplies, Dialysis/ kidney-related services

Will cover 80% of your COBRA premium if employer contributes less than 50% (or spouses’ employer) Will cover individual insurance in which you were enrolled for last 30 days before TAA benefits Pre-Existing Health Conditions Covered


GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

BCP: All children under 19 years old without access to health insurance; Pregnant women with a monthly income up to 300% of the FPL; Parents and Caretakers up to 200% of the FPL

Must be Wisconsin resident and have satisfactory immigration status 45 to 64 years of age with no insurance Must be uninsured or underinsured with income under 250% of FPL

Wisconsin resident; U.S. citizen or legal immigrant; Age 19 through 64; Do not have children or dependent children, under age 19 living with you; Are not pregnant; Have family income at or below 200%; Do not have private health insurance or employer coverage 12 months before the application date; Do not currently have access to insurance from an employer; Are not getting BadgerCare Plus, Medicaid or Medicare.


WIC: Reside in Wisconsin, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL

Chronic Disease Program participants are responsible for certain co-payments and annual deductible determined by the program. Participants whose annual income exceeds 300% of the federal poverty level must pay a certain percent of out-of-pocket expense before becoming eligible to receive WCDP benefits. The state seeks repayment of WCDP benefits provided to Participants under the Estate Recovery Program

Both: $0 to minimal share of cost

$0




Coverage


If screened and diagnosed for breast or cervical cancer may be eligible for complete health coverage through Well Woman Medicaid

(Effective October 9, 2009, enrollment process for BadgerCare Plus Core Plan has been suspended because the total number of applications received is greater than the number of slots available. A waitlist has been created and those on the waitlist will be able to enroll as space becomes available)


Program


608-266-8311 800-218-8408 www.dhfs.wisconsin.gov/ womenshealth/wwwp

800-291-2002 http://dhs.wisconsin.gov/ badgercareplus/core/index.htm

Demographic




www.coverageforall.org Wisconsin

100

Demographic





COBRA


Group Plans

Conversion Plans

Program

800-234-1317


Up to $5M lifetime maximum, assorted deductibles If uninsured for previous 1-6 months, a waiting period for coverage of pre-existing conditions may apply

Or

and then

HIPAA

Health Insurance Portability and Accountability Act 866-4-USA-DOL www.dol.gov COBRA: Coverage available for 18 to 36 months depending on qualifying events, benefits are the same as what you had with your previous employer COBRA Subsidy: 15 months of partially subsidized COBRA premium

800-234-1317

Individual Plans



Coverage


Individuals unable to obtain private health insurance due to a medical condition


WHIP

Medicaid EqualityCare

Wyoming Health Insurance Pool 800-442-2376 307-634-1393 http://insurance.state.wy.us/ whip.html

The pool plan options provide comprehensive coverage of doctor visits, prescription drugs, outpatient and in-hospital care, maternity, ambulance, labs and x-rays, skilled nursing care, hospice, home health visits, rehabilitation, durable medical equipment, and mental health and substance abuse, among other services

800-251-1268 http://wdh.state.wy.us/ healthcarefin/equalitycare Contact local public or health services department

Offers health, dental, vision, hospitalization and prescription coverage Treatment for special health problems like breast cancer, kidney problems, nursing home needs, and AIDS Pre-Existing Health Conditions Covered

The pool provides enrollees with two plan choices, the Brown Plan and the Gold Plan


Effective January 1, 2010, the lifetime maximum paid for the Brown and Catastrophic Plan is increasing to $750,000. The Gold Plan’s life time maximum will also increase to $1,000,000 Pre-Existing Health Conditions Covered

GUARANTEED COVERAGE

GUARANTEED COVERAGE




Eligibility


Eligibility is subject to medical underwriting If you are denied coverage for a medical condition, you may be eligible for WHIP, see next column

GUARANTEED COVERAGE

GUARANTEED COVERAGE

Applicant has been refused coverage for health reasons by one insurer

Ages 0-5 and pregnant women up to 133% FPL

or Applicant has health insurance coverage more restrictive than the Pool or

Ages 6-18 up to 100% FPL Working Parents up to 52% FPL Non-Working Parents up to 54% FPL Live in Wyoming

Applicant has health insurance coverage at a rate exceeding the Pool


Must be a Wyoming resident Waiting periods may apply Applicants will be assigned to the proper eligibility level based on adjusted gross income. Level 2 is below 250% FPL, Level 1 is above 250% FPL

Monthly Cost

Church organizations may be excluded

101




Costs vary depending on age, region and program. Cannot exceed 200% of market rate



Wyoming

800.234.1317

Children

KidCare CHIP


Women

Pregnant Women


Children’s Special Health Program (CSH)

Breast and Cervical Cancer Screening

Best Beginnings Wyoming Baby


800-438-5795 307-777-7941 http://wdh.state.wy.us/ familyhealth/csh/index.html Contact local public or health services department

KidCare CHIP: Inpatient and outpatient hospital services, doctor visits, laboratory and x-ray services, well-baby, well-child and well-adolescent care, including age appropriate immunizations, prescriptions, mental health services, dental services (no braces, only preventive and some basic, services are covered) $750 maximum per benefit year, vision services (no contacts), physical therapy, other health benefits

Covered services include care coordination, specialty medical care, some equipment and medications, lab/X-rays related to diagnosis services, support services, and diagnostic evaluations There is an annual limit of up to $40,000 Pre-Existing Health Conditions Covered

307-777-7275 http://wdh.state.wy.us/ familyhealth/bestbeginnings/ index.html

406-247-7107 www.ihs.gov

Contact local public or health services department

Medical assistance is available for most women through Medicaid if their breast or cervical cancer exams were paid for by WBCCEDP and they were found to have breast or cervical cancer, including pre-cancerous conditions Pre-Existing Health Conditions Covered

Financial assistance for eligible women, pregnancy counseling and teaching, referrals to appropriate resources in the community, educational materials relating to pregnancy, smoking cessation assistance and referral, prenatal class/ support group, parenting classes for parents of newborns, home visits for moms and babies, breast feeding support

Comprehensive health care services available through a Service Unit located on the Wind River Reservation and three hospitals on the Blackfoot, Crow, and Fort Belknap Reservations Pre-Existing Health Conditions Covered

Coverage

800-994-4769 307-777-7494 http://wdh.state.wy.us/ familyhealth/wic/index.html

307-777-6006 800-264-1296 http://wdh.state.wy.us/phsd/ bccedp/index.html



Program

877-KIDSNOW 877-543-7669 http://wdh.state.wy.us/ healthcarefin/chip/index.html

Children’s special health

Demographic



GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

GUARANTEED COVERAGE

KidCare CHIP: At or below 200%FPL, A US Citizen or lived in the US for 5 years, A Wyoming resident, Age 18 or younger, No insurance within last 30 days

Your child must be a Wyoming resident under 19 years of age and suspected or known to have one of the medically eligible conditions, i.e. chronic illness or disability. Your child may also have insurance, KidCare CHIP, or EqualityCare (Medicaid).

Women age 50 to 64 years

Eligibility requirements vary from county to county

Member of a federally recognized tribe

Women age 18-50 with certain abnormal breast or cervical exams may also qualify Income must be at or below 250% of federal poverty guidelines Cannot have insurance coverage, including Medicaid

$0 or sliding scale share-of-

cost


$0



www.coverageforall.org Wyoming

Monthly Cost

KidCare CHIP: $3-5 co-pays with an annual family maximum of $200

Be sure to call your local office

Eligibility

WIC: Reside in Wyoming, Be a pregnant or recently pregnant woman, infant or child up to age 5 , Be determined to have a nutritional risk, Income must be: Family Income at or below 185% FPL

Women age 30-64 may be eligible if they have not had a pap test in past 5 years

102

Appendices

103

how to understand

The COBRA Subsidy Affordable COBRA For workers who were involuntarily terminated between September 1, 2008 and May 31, 2010, the government will subsidize 65% of their premiums under COBRA for fifteen months. This subsidy also applies to healthcare continuation coverage if required by the state. 2nd Chance for COBRA For workers who were involuntarily terminated between September 1, 2008 and the day the stimulus Law goes into effect, and who did not sign up for COBRA, will get an additional 60 days to do so and receive the subsidy. This special election period opportunity does not apply to coverage sponsored by employers with less than 20 employees that is subject to State law. Employer Notification Within 60 days of enactment, the Employer or COBRA Administrator shall provide an additional notification to any Assistance Eligible Employee who became entitled to elect COBRA before enactment of this Law. Tax Credit for Employers To offset the employer’s expense, the employer may take a full tax credit for its expenditures out of its payroll taxes including both income tax withholding and FICA. High Income Exclusion If the modified adjusted gross income (AGI) of a participant exceeds $125,000 a year, or a family’s AGI exceeds $250,000, their income tax will be raised by the premium reduction amount – effectively removing the subsidy. Plan Options Qualified Beneficiaries (QBs) under the stimulus will have the option to change plans to another product offered by the Employer with the following requirements: • Employer agrees to allow QBs to enroll in different coverage • The selected plan does not exceed the premium for coverage in which the individual was enrolled at the time the qualifying event occurred • Plan cannot be Dental, Vision, Counseling, Referral or FSA • Coverage is also offered to active employees

104

other services (by state) Alabama WIC (Women-Infant-Children) 888-942-4673 800-654-1385 www.adph.org/wic

Family Planning 800-545-1098

Vaccines for Children 800-469-4599

Alabama Department of Insurance 334-269-3550 800-433-3966 (in state) www.aldoi.gov

Alabama Department of Public Health 334-206-5300 www.adph.org

Alaska Anchorage Neighborhood Health Center 907-257-4600 www.anhc.org

Anchorage Community Health Services 907-343-4605

Women-Infant-Children (WIC)

907-465-3100 www.hss.state.ak.us/dpa/programs/nutri/wic/ default.htm

Alaska Division of Insurance 800-467-8725 (in state) 907- 465-2515 www.dced.state.ak.us/insurance

Alaska Health and Social Services 800-211-7470 907-562-3671 www.hss.state.ak.us

Arizona Women-Infant-Children (WIC) 800-252-5942 www.azwic.gov

Health Care Group of Arizona 602-417-6755 802-247-2289

Federal Emergency Services (FES)

(for people who cannot verify Citizenship or immigration) 800-352-8401 www.ahcccs.state.az.us

Arizona Department of Insurance 800-325-2548 www.id.state.az.us

Arizona Department of Economic Security 800-352-8401 www.azdes.gov

Arkansas Women-Infant-Children 800-445-6175 501-661-2905 http://www.healthyarkansas.com/ breastfeeding/wic_about.html

DDS Children’s Services 800-482-5850 x22277 501-682-8207 www.medicalhomear.org

Immunization Program 501-661-2793

AR Family Planning 501-661-2531

Women’s Health

Health Consumer Alliance

www.healthconsumer.org (13 different languages; information about programs and legal rights by county)

California Department of Health Services

916-445-4171 (English and Spanish) TTY 888-757-6034 www.dhcs.ca.gov (For information about Medi-Cal, Medicare, SSI, Food Stamps, Cash Assistance, CMSP, MISP, Healthy Families Program, CCS, MTP and more)

California Department of Insurance

800-927-4357 www.insurance.ca.gov (English and Spanish; general information on all types of insurance)

California Department of Managed Health Care

888-466-2219 www.hmohelp.ca.gov (English and Spanish; general information on all types of insurance)

BABY CAL

800-BABY-999 (800-222-9999)

WISEWOMAN

800-511-2300 www.dhs.ca.gov/cancerdetection


501-661-2480

888-WICWORKS 888-942-9675 www.wicworks.ca.gov

Arkansas Department of Insurance

Colorado

501-371-2600 800-282-9134 http://insurance.arkansas.gov

Arkansas Department of Human Services 501-682-1001 800-482-8988 www.arkansas.gov/dhhs

California Indian Health Services 916-930-3927 www.ihs.gov

California Children’s Services

www.dhs.ca.gov/pcfh/cms/ccs Or contact local county social services agency

Women-Infant-Children (WIC) 800-688-7777 www.cdphe.state.co.us/ps/wic

Colorado Indigent Care Program (CICP) 303-866-3513 (Denver Metro Area) 800-221-3943 www.chcpf.state.co.us

Colorado Division of Insurance

303-894-7490 www.dora.state.co.us/insurance/

Colorado Department of Human Services 303-866-5700 www.cdhs.state.co.us

105

Connecticut Women-Infant-Children (WIC)

Florida Office of Insurance Regulation

860-509-8084 www.ct.gov (Search “WIC”)

800-342-2762 www.floir.com

Connecticut Insurance Department

Florida Health and Human Services

Connecticut Department of Social Services

Georgia

800-203-3447 860-297-3900 www.state.ct.us/cid

800-842-1508 860-424-5016 www.dss.state.ct.us

Delaware Women-InfantChildren (WIC)

800-222-2189 www.dhss.delaware.gov/dph/chca/ dphwichominf01.html

Immunization Services 800-282-8672

Family Planning

http://dhss.delaware.gov/dhss/dph/chs/ chsfamilyplanning.html

Child Development Watch

http://dhss.delaware.gov/dhss/dph/chs/chscdw. html

Delaware Insurance Department 800-282-8611 www.delawareinsurance.gov

Delaware Department of Health and Social Services 800-464-4357 800-273-9500 www.dhss.delaware.gov

Florida Women-InfantChildren (WIC)

800-342-3556 www.doh.state.fl.us/family/wic

Florida Alzheimer’s Disease Initiative 850-414-2000

Florida AIDS Insurance Continuation Program

305-592-1452 www.doh.state.fl.us/disease_ctrl/aids/care/aicp. html

106

www.dcf.state.fl.us/ess www.doh.state.fl.us

Georgia Insurance Commission 800-656-2298 www.inscomm.state.ga.us

Immunization Program 404-657-3158

Idaho Indian Health Services 503-326-2020 www.ihs.gov


800-926-2588 http://healthandwelfare.idaho. gov/FoodCashAssistance/ WomenInfantsandChildren/tabid/92/Default. aspx

Idaho Department of Insurance 208-334-4250 www.doi.idaho.gov

Idaho Department of Health and Welfare

Tobacco Use Prevention

800-926-2588 www.healthandwelfare.idaho.gov

Emergency Food Assistance

Illinois

404-657-6611

404-463-2607 404-463-8042 404-657-3742

Georgia Department of Family and Children Services 404-656-4507 http://dfcs.dhr.georgia.gov

Georgia Department of Community Health http://dch.georgia.gov

Hawaii PACE Hawaii (age 55 and older) 808-832-6131

Hawaii Immunization Program 800-933-4832 808-586-8300 www.vaxhawaii.com

STD/AIDS Prevention Branch 808-733-9281


Oahu: 586-8175 Neighbor Islands: 888-820-6425 http://hawaii.gov/health/family-child-health/ wic/index_html

Hawaii Division of Insurance 808-586-2790 808-586-2799 http://hawaii.gov/dcca/ins

Hawaii Department of Health 808-586-4400 www.hawaii.gov/health

Health Benefits for Workers with Disabilities 800-226-0768 www.hbwdillinois.com

Women-Infant-Children (WIC) 800-843-6154 www.dhs.state.il.us/page aspx?item=30513

Illinois Department of Insurance 877-527-9431 http://insurance.illinois.gov

Illinois Department of Human Services 800-843-6154 www.dhs.state.il.us

Indiana Women-InfantChildren (WIC)

800-522-0874 www.in.gov/isdh/19691.htm

Indiana Department of Insurance 800-622-4461 317-232-2385 www.in.gov/idoi

Indiana Family and Social Services 317-232-4946 www.in.gov/fssa

Iowa

Louisiana


Louisiana KidMed

Iowa Insurance Division

Public Health Units

800-532-1579 www.idph.state.ia.us/wic/default.asp

800-325-2548 515-281-5705 www.iid.state.ia.us

Iowa Department of Human Services

800-259-4444 www.la-kidmed.com

(community care) www.oph.dhh.louisiana.gov/ophregions

Louisiana Department of Insurance

www.dhs.state.ia.us

800-259-5300 www.ldi.la.gov

Kansas

Louisiana Department of Health and Hospitals

Kansas Foundation for Medical Care 800-432-0770 785-273-2552 www.kfmc.org

225-342-9500 www.dhh.louisiana.gov

Maine

Senior Health Insurance Counseling of Kansas

Maine Genetics Program

Kansas Insurance Department

Maine Rx Plus

800-860-5260 www.agingkansas.org/SHICK/shick_index.html

207-287-4623 TTY: 800-606-6015 www.medicare.gov

785-296-3071 800-432-2484 http://ksinsurance.org

866-796-2463 TTD: 800-423-4331 www.maine.gov/dhhs/mainerx

Kansas Department of Social and Rehabilitation Services

Maine Bureau of Insurance

785-296-3959 888-369-4777 www.srskansas.org

Kentucky State Health Insurance Assistance Program

(counseling for seniors and disabled) 877-293-7447 http://chfs.ky.gov/dail/ship.htm

ICARE

877-422-7307 http://icare.ky.gov

Kentucky Office of Insurance 502-564-3630 800-595-6053 800-462-2081 (TDD) http://doi.ppr.ky.gov/kentucky

Kentucky Cabinet for Health and Family Services 800-372-2973 800-627-4702 (TDD) www.chfs.ky.gov

207-624-8475 800-300-5000 TTY: 888-577-6690 www.maineinsurancereg.org

Maine Department of Health and Human Services 207-287-3707 www.maine.gov/dhhs

Maryland

Maryland Department of Health and Mental Hygiene 410-767-6500 877-463-3464 www.dhmh.state.md.us

Massachusetts MASS Medline

866-633-1617 www.massmedline.com

MASSCare (AIDS)

617-994-9819 www.mass.gov/dph/fch/masscare.htm

AIDS Action Committee Hotline 800-235-2331 617-437-6200 617-437-1394 TTY www.aac.org

Massachusetts Division of Insurance 617-521-7794 www.mass.gov/doi

Massachusetts Department of Public Health 617-624-6000 617-624-6001 www.mass.gov/dph

Healthcare for Artists 617-784-4652 [email protected] www.healthcareforartists.org

Health Care For All Help Line 800-272-4232 www.hcfama.org

The Access Project

Family Planning

617-654-9911 [email protected] www.accessproject.org

Vaccines for Children

Michigan

410-767-6723 www.fha.state.md.us/mch/fp_home.cfm

410-767-6030 http://edcp.org/html/vaccine.html

Maryland AIDS Insurance Assistance Program

410-767-5227 800-358-9001 http://dhmh.state.md.us/AIDS/HIV_index.html

Maryland Insurance Administration

410-468-2000 800-492-6116 800-735-2258 www.mdinsurance.state.md.us

Family Planning 800-642-3195 866-501-5656 TTY

Children’s Special Health Care Services 800-359-3722

Michigan Department of Financial Insurance Services 517-373-0220 877-999-6442 www.michigan.gov/cis

107

Michigan Department of Community Health 517-373-3740 www.michigan.gov/mdch

Missouri Missouri CLAIM

800-390-3330 www.missouriclaim.org

775-684-3499

Nevada Department of Insurance

Disabilities Linkage Line

800-219-3224

775-687-4270 702-486-4009 http://doi.state.nv.us

Missouri Department of Insurance

Nevada Department of Health and Human Services

Family Planning

573-751-4126 www.insurance.mo.gov

775-684-4000 http://dhhs.nv.gov/

Missouri Department of Social Services

New Hampshire

Minnesota 866-333-2466 http://www.semcil.org/dll.html

800-78FACTS 800-783-2287 www.stdhotline.state.mn.us www.health.state.mn.us/divs/fh/mch/ familyplanning

Indian Health Services 218-444-0458 www.ihs.gov

Minnesota Department of Commerce 651-296-4026 TTD: 651-296-2860 www.commerce.state.mn.us

Minnesota Department of Human Services 651-431-2000 TTD: 800-627-3529 www.dhs.state.mn.us

Mississippi

Vaccines for Children

573-751-4815 www.dss.mo.gov

Montana

Montana State Auditor’s Office

New Hampshire Department of Insurance

800-332-6148 406-444-2040 http://sao.mt.gov

603-271-2261 800-852-3416 www.nh.gov/insurance

Montana Department of Public Health and Human Services

New Hampshire Department of Health and Human Services

800-551-3191 www.dphhs.mt.gov

www.dphhs.mt.gov

Mississippi Care For Yourself

Nebraska Health Insurance, Information, Counseling and Assistance Program

Donated Dental Services 601-368-9823 800-366-3640

Mississippi Department of Insurance 601-359 3569 800-562 2957 www.mid.state.ms.us

Mississippi Department of Health 866-458-4948 601-576-7400 www.msdh.state.ms.us

603-271-4517 800-852-3345 ext.4517 TTD: 800-735-2964

New Hampshire Medication Bridge Program

Nebraska

(Family Planning) 800-421-2408 www.msdh.state.ms.us/care

Family Planning

Montana State Health Insurance Assistance Program

Children's Medical Program (Chronic illnesses) 800-844-0898

603-225-0900

800-852-3345 www.dhhs.state.nh.us

New Jersey Special Child Health and Early Intervention Services

(for seniors) 800-234-7119 402-471-2201 TTD: 800-833-7352

609-984-0755 www.nj.gov/health/fhs/sch/ index.shtml

Nebraska Department of Insurance

800-356-1561

402-471-2201 TTD: 800-833-7352 www.doi.ne.gov

Nebraska Health and Human Services

Medicaid Dental Family Planning 609-292-8104

New Jersey Department of Banking and Insurance

402-471-3121 www.hhs.state.ne.us/index.htm

800-446-SHOP 800-446-7467 www.state.nj.us/dobi

Nevada

New Jersey Department of Human Services

Vaccines for Children 775-684-5900

108

AIDS Drug Assistance

609-292-3717 www.state.nj.us/humanservices/

New Mexico MEDBANK

(Emergency Prescription Drug Program) 800-432-2080 www.nmaging.state.nm.us/medbank2.html

New Mexico Health Policy Commission

North Carolina Health CARE LINE English/Español 800-662-7030 TTP: 919-733-4851

North Carolina Department of Insurance

505-827-6201 www.hpc.state.nm.us

800-546-5664 919-807-6800 www.ncdoi.com

New Mexico Public Regulations Commission

North Carolina Department of Health and Human Services

Chronic Disease Service

405-271-4072 http://www.ok.gov/health/Disease, Prevention,_Preparedness/Chronic_Disease_ Service

Family Planning

405-271-4476 www.health.state.ok.us/Program/whd/fpp. html

RX for Oklahoma 877-794-6552 www.RX4OKLA.com

888-4ASK-PRC 888-427-5772 505-827-3928 www.nmprc.state.nm.us/id.htm

800-662-7030 877-452-2514 (TTY) 919-855-4400 919-733-4851 (TTY) www.dhhs.state.nc.us/

Oklahoma Department of Business Regulation

New Mexico Human Services Department

North Dakota

Oklahoma Department of Health

505-827-3100 888-997-2583 www.state.nm.us/hsd/mad

New York Women-Infant-Children (WIC) 800-522-5006 www.health.state.ny.us/ prevention/nutrition/wic

Family Planning

800-541-2831 www.health.state.ny.us/health_care/medicaid/ program/longterm/familyplanbenprog.htm

Growing Up Healthy

Children’s Special Health Services 800-755-2714 TTY: 701-328-2436 www.ndhealth.gov/CSHS/

North Dakota Insurance Department 701-328-2440 800-247-0560 www.nd.gov/ndins

North Dakota Department of Human Services 701-328-2310 800-472-2622 www.nd.gov/dhs/

800-522-5006 (in state)

NY AIDS - HIV Counseling and Testing 800-541-AIDS 800-541-2437 (in state)

New York Insurance Department 212-480-6400 800-342-3736 www.ins.state.ny.us

New York Department of Health

Ohio Ohio Department of Insurance 800-686-1526 614-644-2658 www.ohioinsurance.gov

Ohio Department of Health www.odh.ohio.gov

Help Me Grow Program 614-644-8389 www.ohiohelpmegrow.org

866-881-2809 www.health.state.ny.us

HIV Drug Assistance Program

North Carolina

Oklahoma

Safety Net Dental Services

SoonerStart

919-707-5480 www.communityhealth.dhhs.state.nc.us/ dental/access_2.htm

614-466-6374

(child development) 405 522-5167 www.okdhs.org/programsandservices/dd/ss/

405-521-2828 800-522-0071 www.oid.state.ok.us

405-271-5600 800-522-0203 www.ok.gov/health

Oregon Oregon Insurance Division 503-947-7980 www.oregoninsurance.org

Oregon Department of Human Services 503-945-5944 www.oregon.gov/DHS/

Oregon Health Authority 503-947-2340 877-398-9238 www.oregon.gov/oha

Oregon Helps

(Program screener tool) http://oregonhelps.org

Pennsylvania APPRISE

(Medicare advice) 717-783-1550 www.aging.state.pa.us

Family Planning

877-PA-HEALTH 877-724-3258 www.dpw.state.pa.us/ServicesPrograms/ MedicalAssistance/003670181.htm

Women-InfantChildren (WIC) 800-WIC-WINS 800-942-9467 www.pawic.com

109

Pennsylvania Insurance Department 877-881-6388 www.ins.state.pa.us

Pennsylvania Department of Health 877-PAHEALTH 877-724-3248 www.dsf.health.state.pa.us

Rhode Island RI Early Intervention (child development) 401-462-2501 TTY 401-462-6353

Immunization Program 401-222-5960 www.health.ri.gov/immunization

Rhode Island Pharmaceutical Program for Elderly 401-462-3000 TTY 401-462-0740 www.dea.state.ri.us


605-226-7531 www.ihs.gov/FacilitiesServices/AreaOffices/ Aberdeen

South Dakota Division of Insurance

605-773-3563 www.state.sd.us/drr2/reg/insurance

South Dakota Department of Social Services 605-773-3165 www.state.sd.us/social

Tennessee Tennessee Health Options Services 888-486-9355


TX Children with Special Needs 800-252-8023 www.dshs.state.tx.us/cshcn

Texas Department of Insurance 800-252-3439 512-463-6464 www.tdi.state.tx.us

Texas Department of State Health Services 888-963-7111 www.dshs.state.tx.us

Utah RxConnect

866-221-0265 http://health.utah.gov/rxconnectutah

Health Insurance Information Program 800-541-7735

800-DIAL-WIC 800-342-5942 http://health.state.tn.us/WIC

Utah Insurance Department

Rhode Island Department of Business Regulation

CoverRX

Utah Department of Health

401-462-9500 www.dbr.state.ri.us

888-560-2649 866-268-3786 www.covertn.gov/web/cover_rx.html

Rhode Island Department of Health

Prescription Assistance

Vermont

Family Planning

Vermont Refugee Health Program

401-222-2231 www.health.state.ri.us

South Carolina South Carolina Family Planning Services 803-898-3432

888-486-9355

615-741-7353 http://health.state.tn.us/womenshealth/

Tennessee Department of Commerce and Insurance 615-741-2218 800-342-4029 www.state.tn.us/commerce/insurance

801-538-3800 www.insurance.utah.gov 801-538-6101 888-222-2542 801-538-9936 www.health.utah.gov

800-464-4343 802-863-7200

VScript

800-250-8427 TTD: 1-888-834-7898

Tennessee Department of Health

Vermont Department of Banking, Insurance, Securities & Health Care Administration

615-741-3111 http://health.state.tn.us/

802-828-3301 www.bishca.state.vt.us

803-737-6180 800-768-3467 www.doi.sc.gov

Texas

Vermont Agency of Human Services


800-942-3678 www.dshs.state.tx.us/wichd/default.shtm

South Carolina Health Insurance Assistance 800-868-9095

South Carolina Department of Insurance

800-868-0404 www.dhec.sc.gov/health/mch/wic/index.htm

South Carolina Department of Health and Human Services 888-549-0820 www.dhhs.state.sc.us

110

South Dakota


800-287-0589 802-241-2800 www.ahs.state.vt.us

Texas Family Planning

Virginia

Texas Vaccines for Children

Virginia Bureau of Insurance

512-458-7796

800-252-9152 www.dshs.state.tx.us/immunize/tvfc/default. shtm

804-371-9741 877-310-6560 www.scc.virginia.gov/division/boi

Virginia Department of Health www.vdh.virginia.gov

Washington Washington Office of the Insurance Commissioner 800-562-6900 www.insurance.wa.gov

Washington Department of Social and Health Services 800-737-0617 www.dshs.wa.gov

Washington D.C. D.C. Health Program for Refugees 202-442-9380

D.C. Healthcare Alliance 202-639-4030 TTY: 202-639-4041 http://doh.dc.gov/doh

Women-Infant-Children (WIC) 800-345-1942 202-442-9397 http://doh.dc.gov/doh

District of Columbia Department of Insurance, Securities and Banking

Wisconsin Wisconsin Office of the Commissioner of Insurance 800-236-8517 608-266-3585 http://oci.wi.gov

Wisconsin Department of Health Services 608-266-1865 http://dhs.wisconsin.gov

Wyoming Wyoming Seniors

307-856-6880 www.wyomingseniors.com

Wyoming State Health Insurance Assistance Program 800-856-4398 307-856-6880

http://wdh.state.wy.us

West Virginia

Department of Health and Human Services

West Virginia Health and Human Resources 304-558-0684 www.wvdhhr.org


Partnership for Prescription Assistance 888-4PPA-NOW 888-477-2669 www.pparx.org

Substance Abuse and Mental Health Services Administration

www.cfda.gov (Search tool for grants, loans and other benefits)

304-558-3386 888-TRY WVIC 888-879-9842 www.wvinsurance.gov


Wyoming Department of Health

202-727-1000 http://doh.dc.gov/doh

West Virginia Offices of the Insurance Commisioner

Medicare

www.mentalhelp.net/selfhelp (Search tool for people sharing information on hundreds of diseases, health conditions and other health care related situations)

Catalog of Federal Domestic Assistance

304-558-5388 800-642-8522 304-558-7164 (TTD) www.wvdhhr.org/mcfh/wvfp/index.asp

www.ihs.gov 301-443-3024 (Department of Public Health)

307 777-7401 800-438-5768 http://insurance.state.wy.us

District of Columbia Department of Health

WV Family Planning

Indian Health Services (IHS)

Self Help Clearing House

National Resources

800-642-8522 www.wvdhhr.org/birth23

Find a Health Center www.findahealthcenter.hrsa.gov

Wyoming Department of Insurance

202-727-8000 http://disb.dc.gov

WV Birth to Three

Health Resources and Services Administration

National Mental Health Information Center http://mentalhealth.samhsa.gov/databases/ (Mental Health Services Locator)

Veterans Health Administration 877-222-8387 www.va.gov

www.hhs.gov (Various health care search tools)

Employee Benefits Security Administration

www.dol.gov/ebsa (Official information and rules from the U.S. Department of Labor)

Government Benefits Finder 800-FED-INFO www.govbenefits.gov (Search tool for grants, loans and other benefits)

Health Coverage Tax Credit 866-628-HCTC 866-628-4282 www.irs.gov (key word HCTC)

111

state-by-state comparison State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

HighHighGuaranteed deductible deductible Coverage premium for premium for for Small 26-year-old 35-year-old Groups $50.00 $63.00 Yes $60.00 $80.00 Yes $46.00 $52.00 Yes $55.00 $60.00 Yes $47.00 $64.00 Yes $45.00 $54.00 Yes $41.00 $61.00 Yes $45.00 $55.00 Yes $58.00 $78.00 Yes $65.00 $90.00 Yes $50.00 $66.00 Yes $86.00 $113.00 Yes $33.00 $44.00 Yes $48.00 $67.00 Yes $46.00 $59.00 Yes $31.00 $40.00 Yes $60.00 $74.00 Yes $35.00 $43.00 Yes $32.00 $36.00 Yes $100.00 $148.00 * Yes $49.00 $66.00 Yes $334.00 $334.00 * Yes $57.00 $71.00 Yes $70.00 $80.00 Yes $54.00 $72.00 Yes $36.00 $46.00 Yes $75.00 $100.00 Yes $39.00 $52.00 Yes $55.00 $81.00 Yes $79.00 $102.00 Yes $157.00 $183.00 Yes $45.00 $70.00 Yes $279.00 $415.00 * Yes $64.00 $70.00 Yes $47.00 $60.00 Yes $52.00 $68.00 Yes $52.00 $64.00 Yes $65.00 $90.00 Yes $50.00 $59.00 Yes $100.00 $142.00 * Yes $50.00 $74.00 Yes $57.00 $74.00 Yes $50.00 $77.00 Yes $62.00 $70.00 Yes $60.00 $71.00 Yes $394.00 $394.00 * Yes $43.00 $59.00 Yes $57.00 $70.00 Yes $153.00 $168.00 Yes $40.00 $65.00 Yes $57.00 $69.00 Yes

Guarantee IncomeMedical Parental High Issue MiniCOBRA Based Underwriting Coverage Risk Employee Groups< 20 Options Buy-In for through Size Plan Individuals CHIP 2+ No Yes No Yes No 2+ No Yes No Yes No 2+ No Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 1+ Yes Yes No Yes No 1+ Yes Yes No Yes Yes 1+ No No No Yes No 2+ Yes Yes No Yes Yes 1+ Yes Yes No Yes No 2+ Yes No No Yes No 1+ No No Yes Yes No 2+ Yes No No Yes No 2+ No Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes Yes Yes No 2+ Yes Yes No Yes Yes 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 1+ Yes No Yes No No 2+ Yes Yes No Yes No 1+ Yes No Yes No No 2+ No Yes No Yes No 2+ Yes Yes No Yes Yes 1+ Yes Yes No Yes No 2+ No Yes No Yes Yes 2+ No Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes No No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No No Yes 2+ Yes Yes Yes Yes No 2+ Yes No Yes No Yes 1+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes Yes Yes No 2+ No Yes No Yes No 1+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 1+ Yes No Yes No No 2+ Yes Yes No Yes No 2+ Yes Yes Yes Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No 2+ Yes Yes No Yes No

Indian Health Services Yes Yes Yes No Yes Yes Yes No No Yes No Yes Yes No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes No No Yes No Yes Yes

Note: Premiums are based on the following information and may be subject to change — $2-5K deductible; male; nonsmoker; approximately 20% co-insurance; usually no office visits.. Plans were generated by ehealthinsurance.com using zip codes from major cities. In most cases the second least expensive plan is shown. * Coverage has serious limitations, short-term/12 months only or other restrictions.

112

The Uninsured in America How does your STATE compare to the rest of America? Source: US Census Bureau, 2002; BCBSA Analysis, Congressional Budget Office

State

Uninsured Population

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Total US

549,000 123,000 1,164,000 451,000 6,613,000 801,000 326,000 96,000 55,000 3,648,000 1,662,000 96,000 209,000 1,700,000 717,000 275,000 345,000 570,000 776,000 115,000 762,000 340,000 1,151,000 433,000 545,000 729,000 146,000 232,000 441,000 137,000 1,348,000 437,000 2,519,000 1,510,000 61,000 1,322,000 631,000 632,000 1,176,000 113,000 721,000 80,000 883,000 5,962,000 340,000 69,000 1,135,000 737,000 254,000 451,000 70,000 45,657,000

% of Uninsured Eligible for Government Programs 28% 30% 30% 33% 44% 23% 33% 52% 53% 28% 30% 56% 24% 30% 31% 38% 24% 39% 27% 42% 33% 60% 36% 41% 31% 40% 30% 36% 23% 25% 24% 28% 35% 31% 28% 31% 27% 46% 48% 55% 42% 33% NA 24% 26% 60% 25% 34% 38% 37% 23% 34%

% of Uninsured with Income $50K + 32% 32% 32% 32% 32% 32% 32% 32% 31% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 32% 33% 32% 32% NA 32% 32% 33% 32% 32% 32% 32% 32% 32%

% of Uninsured that is Short-term (Less than 1 Yr) 16% 15% 15% 14% 10% 18% 14% 7% 6% 16% 16% 4% 18% 15% 15% 13% 18% 12% 17% 11% 14% 3% 13% 11% 15% 12% 16% 13% 19% 18% 18% 16% 14% 15% 17% 15% 17% 9% 8% 5% 11% 14% NA 18% 17% 3% 17% 14% 12% 12% 18% 14%

% of Uninsured that is Long-term (More than 1 Yr) 23% 22% 22% 20% 15% 26% 20% 10% 9% 24% 23% 7% 26% 22% 22% 18% 26% 17% 24% 15% 21% 5% 19% 16% 22% 17% 22% 19% 27% 25% 26% 23% 20% 22% 23% 22% 24% 13% 12% 8% 15% 20% NA 26% 25% 5% 25% 20% 18% 18% 27% 20%

113

glossary of terms Agent

A person who has a license to sell insurance in California. He or she might work alone or with a large firm and may sell all kinds of insurance. Some agents work as an employee of an insurance company and sell plans just from that company.

Cal-COBRA

Cal-COBRA (also called MiniCOBRA) is simply “continuation coverage.” It is a law that helps people losing their employee health plan stay insured. It is for companies with 2 to 20 employees. (See COBRA.)

Carrier

Carrier is another name for insurance company.

CHIP

Sometimes this is called S-CHIP (State Children’s Health Insurance Plan). Every state has a plan for children who are not eligible for Medicaid because the family income is too high or they don’t have access to group coverage. The name of the program is usually called something like Healthy Families or Healthy Children and care is delivered by regular doctors through the state’s major insurance companies. In a handful of states, coverage is extended to the parents (as with Medicaid).

Claim

114

COBRA

COBRA is a federal law that helps an insured person keep their health insurance when they lose their employee health plan. It’s also called continuation coverage. COBRA stands for Consolidated Omnibus Budget Reconciliation Act. It applies to companies with 20 or more employees. Cal-COBRA is for companies with less than 20 employees.

Coinsurance

An arrangement under which the insured person pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, the insurance company might pay 80% of the allowable charge, with the insured person responsible for the remaining 20%, which is then referred to as the coinsurance amount.

Conversion Privilege

The right given to an insured person to change insurance without evidence of medical insurability, usually to an individual policy upon termination of coverage under a group contract.

Co-Pay

An arrangement where the insured person pays a specified amount for various services and the insurance company pays the remainder. The insured person usually must pay his or her share when the service is rendered. Similar to coinsurance, except that coinsurance is usually a percentage of certain charges where the co-payment is a dollar amount.

Coverage

Another name for “health insurance.” It refers to the scope of health benefits and financial risk protection provided under a contract of insurance.

A request for payment of benefits received or services rendered. A billing record is generated and submitted by a provider or subscriber using paper or electronic media.

Coverage Termination

The end of an insured person’s coverage due to loss of employment, reduction of hours, gross misconduct, covered employee and spouse divorce or become legally separated, or death of the covered employee.

Creditable Coverage

There are rules about when insurance companies have to start paying for your health benefits when you’re a new member or whether or not you get COBRA (continuation) coverage when your group plan ends. For example: to get COBRA, you have to have had insurance (creditable coverage) for 18 months.

Deductible

An amount which an insured person agrees to pay, per claim or per accident, before the insurance company has to pay their part.

Employee Contribution

The employee’s share of the monthly premium (payment).

Employer Based Coverage

Companies who offer health coverage at no or minimal charge to the employee.

Employer Contribution

The employer’s share of the monthly premium (payment).

Federal Poverty Level

This is a percentage level assigned based on the number of people and income per household. The percentages are created by the government, and then the public programs use those percentages in a chart to decide who can qualify for what programs.

Guaranteed Coverage

An underwriting term used to describe the fact that a small business group cannot be turned down for insurance because of poor health conditions either current or past.

Guaranteed Coverage for Individual Plans

This means that no one can be turned down for insurance because of a health condition, or in other words there is no “medical underwriting.” Only three states have guaranteed coverage for individuals: Maine, New York and Vermont.

High Risk Pool Insurance

This is health coverage for people who may have been denied access to a health insurance plan because of their serious medical conditions . In some states every insurance company must guarantee access to plans for these people. In other states there is an organization that oversees a program that involves a few plans from different insurance companies.

HIPAA

The right to transfer from a group health plan to an individual plan if the insured person is leaving the company or their group plan is being terminated. HIPAA is a law that has to do with both portability and privacy of medical records. It stands for Health Insurance Portability and Accountability Act.

Income Based Buy-In Plan

Some states have plans for people who have no access to group coverage and aren’t eligible for Medicaid or other public programs. Similar to public programs, the monthly premiums are determined by the applicant’s income level.

115


116

This is a federal organization that has medical facilities in states where there is a high populations of Native American or Alaskan Indians. Services range from full health care benefits to mobile clinics that cater to the needs of local tribes.

Individual Insurance

Health Insurance policies which provide protection to the insured person and/or his/her family (also called dependents).

Max out-of-pocket

The most an insured person will pay considering co-payments, coinsurance, deductibles, etc.

Medicaid

Medicaid is a state health coverage program that primarily covers emergencies, pregnancy-related services, kidney dialysis and treatment for breast and cervical cancer.

Medi-Cal

Medi-Cal is a California’s health coverage program that primarily covers emergencies, pregnancy-related services, kidney dialysis and treatment for breast and cervical cancer.

Medical Underwriting

Before you can buy a policy you must give the insurance company information about your health. This process is called underwriting. The company uses underwriting information to predict what the likelihood is that you will file claims against the insurance policy. Each company has its own underwriting standards, which means one insurance company could reject your application but another may be willing to accept it.

Pre-existing Conditions

When applying for health insurance, the insurance company requests the applicants medical history. A “pre-existing condition” is an illness, physical or mental, that was treated before getting insurance.

Premium

The payment an insured person makes to keep their insurance policy, usually monthly.

Provider

Your doctor, a hospital, clinic and anyone else that provides health care services to you is called a “provider.”

Qualifying Event

An occurrence (such as death, termination of employment, divorce, etc.) that changes an insured person’s protection under COBRA, which requires continuation of benefits under a group insurance plan for former employees and their families who would otherwise lose health care coverage.

Small Group or Small Business

A small group or business in most states is 2-50 employees, although some states consider a self-employed person or 1 employee to be a small group. Small groups or business are guaranteed health insurance coverage and can not be turned down for preexisting conditions.

Stop Loss

This is a special type of re-insurance that protects an individual or group who goes over their coverage limit.

For more information on your state’s health coverage options, we encourage you to utilize our other valuable health coverage resources.


800.234.1317

117

How to use this Directory: Use the Income Worksheet(page “v”) to determine the Federal Poverty Level percentage of you or the person whom you are trying to assist. This percentage usually determines if an individual is eligible for various public programs. Find your state’s Health Care Options Matrix for a complete list of private and public health coverage programs, along with additional valuable resources. Consult the Appendices for COBRA subsidy information, state-by-state program contact information, uninsured statistics for each state, as well as the glossary of terms found within this book.

Foundation for Health Coverage Education “Coverage for All Through Education” 101 Metro Drive, Suite 250 • San Jose, CA 95110 • www.coverageforall.org ISBN-13: 978-1-42432862-8 © Copyright 2010 by Philip Lebherz and the Foundation for Health Coverage Education All Rights Reserved. Printed in the U.S.A.

Printing for this version of the U.S. Directory of Health Care Options provided by the generous support of Pfizer, Inc.

Vol. IV, July 2010 The U.S. Directory of Health Coverage Options


FHCE

U.S. Directory of Health Care Options

Alternative Therapies: Expanding Options in Health Care

Economics of Health Care

Health Care

Consuming Health: The Commodification of Health Care

Essentials of Managed Health Care

Advocacy in Health Care

Sociology and Health Care

Primary Care Mental Health

Careers in health care

Sociology and Health Care

Health care career starter

Misadventures in Health Care

Health Care Financing and Insurance: Options for Design (Developments in Health Economics and Public Policy, 10)

Health Policy for Health Care Professionals

Essential environmental health standards in health care

Health Care Evaluation (Understanding Public Health)

The Ethics of Environmentally Responsible Health Care

Health and Medical Care of African-Americans

The Ethics of Environmentally Responsible Health Care

Principles Of Public Health Care Practice

Dictionary of Health Insurance and Managed Care

Ethics: The Heart of Health Care

Ethics of health care: an introductory textbook

Mental Health and Care Homes

Values, Ethics and Health Care

Qualitative Research in Health Care

Trust Matters in Health Care (State of Health)

U.S. Directory of Health Care Options

Alternative Therapies: Expanding Options in Health Care

Economics of Health Care

Health Care

Consuming Health: The Commodification of Health Care

Essentials of Managed Health Care

Advocacy in Health Care

Sociology and Health Care

Primary Care Mental Health

Careers in health care

Sociology and Health Care

Health care career starter

Misadventures in Health Care

Health Care Financing and Insurance: Options for Design (Developments in Health Economics and Public Policy, 10)

Health Policy for Health Care Professionals

Essential environmental health standards in health care

Health Care Evaluation (Understanding Public Health)

The Ethics of Environmentally Responsible Health Care

Health and Medical Care of African-Americans

The Ethics of Environmentally Responsible Health Care

Principles Of Public Health Care Practice

Dictionary of Health Insurance and Managed Care

Ethics: The Heart of Health Care

Ethics of health care: an introductory textbook

Mental Health and Care Homes

Values, Ethics and Health Care

Qualitative Research in Health Care

Trust Matters in Health Care (State of Health)

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