Health Care Questions & Answers
An ounce of prevention is worth a pound of cure.
Q. What is the purpose of health insurance?
A. The purpose of health insurance is to help you pay for the high cost of health care and protect you financially from unexpected medical expenses in the event of a serious illness or injury. Also, with health insurance, you are more likely to get routine and preventative care, have a regular doctor, and have access to health care when you need it.
Q. Is it legal for insurance companies to refuse to sell someone health insurance?
A. In many cases, yes. Health insurance is provided by private companies, and like most private companies in the United States, the bottom line is to make a profit. The idea behind insurance is the transfer of risk – the insurer accepts the larger financial risk in exchange for a smaller periodic premium. Insurers are allowed to consider their financial risk when accepting or denying insurance coverage to an applicant, which is based on a person’s medical history. While insurers’s are often allowed to discriminate based on medical history and pre-existing conditions, they cannot discriminate on certain factors such as race, gender, and national origin.
In some states, laws have been passed which mandate that insurers offer coverage to people with pre-existing conditions within a certain period of time. Just because they have to offer coverage, however, does not guarantee that the coverage will be affordable.
If you have been denied coverage and think you are being discriminated against, you should contact your state’s insurance commission and find out whether or not what the company is doing is legal.
Q. Are employers legally required to provide group health insurance for employees?
A. There is currently no federal law requiring employers to provide their employees with group health insurance. This is one aspect of health care reform that has been considered by Congress, however, as one of the possible solutions of making health care insurance more affordable and accessible to working individuals.
Q. What options do I have if I have a pre-existing condition and cannot get health insurance?
A. Over 30 states have established a program, known as a high-risk pool, that offers health insurance to people who don’t have access to coverage through group insurance or cannot purchase private health insurance due to a pre-existing medical condition. Most states that offer the program fund the risk pool through premiums as well as tax revenues or assessments on health insurance companies doing business in that state. To find out if your state operates a high-risk pool, contact your State Insurance Commissioner, Contact information should be listed in the government section of your local telephone book.
Q. What options do I have if I cannot afford health insurance?
A. If you cannot afford health insurance, you may qualify for one of the government-sponsored programs for low-income individuals and families, such as Medicaid and the State Children’s Health Insurance Program (SCHIP). You should contact the social services office in your area to discuss eligibility and available services. In the event of a medical emergency, you will not be turned away for treatment at a hospital due to lack of health insurance.
Q. What is Medicaid?
A. Medicaid is a joint federal-state program operated at the state level that provides health care coverage for qualifying people with limited income. Medicaid helps many individuals and families who cannot afford to pay for health care by covering some or all of their medical expenses.
- In 2006, 12.6% of health care coverage was provided by Medicaid.
To receive coverage from Medicaid, you must first qualify. Medicaid is only available to people with limited income, but not all people with a limited income will qualify. Some of the other eligibility requirements considered are age, pregnancy, disability, blindness, other assets and resources (such as bank accounts and real property), and citizenship status.
If you need assistance with health care expenses, you should contact the social services office in your area to see if you qualify. Telephone numbers and locations are usually listed in the government pages of the telephone book. You will want to talk to a qualified caseworker in your state, as each state has it’s own rules for eligibility and covered services. For more information on the Medicaid program, visit the government website at www.cms.hhs.gov/MedicaidGenInfo.
Q. What is SCHIP?
A. State Children’s Health Insurance Program (SCHIP) is a joint federal-state program similar to Medicaid, which was created by Congress in 1997. The purpose of SCHIP is to provide health insurance to low-income children whose parents earn too much money to be eligible for Medicaid but not enough to purchase private health insurance.
SCHIP eligibility varies from state to state, but in most states uninsured children 18 years of age or younger with a family income up to $34,100 a year for a family of four will be eligible. The insurance provides coverage for doctor visits, immunizations, hospitalizations, and emergency room visits, either at little or no cost.
To learn more about SCHIP, you may either contact the social services office in your area or visit the website at www.insurekidsnow.gov.
Q. What is Medicare?
A. Medicare is a federally funded health insurance program for American citizens and permanent residents who are 65 years or older. Generally, you are eligible if you or your spouse worked at least 10 years in a Medicare-covered employment. If you are under 65, you may also qualify if you have certain disabilities (many people with morbid obesity are categorized as disabled under the Social Security Act) or end-stage renal disease (permanent kidney failure that requires dialysis or a kidney transplant).
- Medicare is the nation’s largest health insurance program, covering nearly 40 million people. In 2006, 13.6% of health care coverage was provided by Medicare.
Medicare, which is administered by The Centers for Medicare & Medicaid Services (CMS), pays for many health care services and supplies. Sometimes it will pay the entire bill, at other times a co-payment will be required. Medicare has two parts: Part A is for hospital insurance, Part B is for medical insurance. Most people do not have to pay for Part A, while many pay a monthly premium for Part B. Some individuals may qualify for dual Medicare/Medicaid coverage. To learn more about the Medicare program, visit the Medicare site at www.medicare.gov.
Q. What is COBRA?
A. The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a law passed by Congress in 1986 that allows for a continuation of group health insurance in some situations where it otherwise might be terminated. When coverage is lost due to certain specific events, COBRA provides the right to temporary continuation of health coverage at group rates to qualifying former employees, retirees, spouses, former spouses, and dependent children. Usually, COBRA participants pay the entire premium without any employer co-pay, but the cost is usually less expensive than paying for individual health coverage.
COBRA eligibility is determined by meeting specific requirements of three factors: qualified health plans, qualified beneficiaries, and qualifying events. For more information on eligibility and coverage, visit the US Department of Labor website at www.dol.gov, then go to search/A to Z index and go to COBRA.