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Healthcare Resources, Part 1: Insurance
Volume 41, Number 2 - March/April 2017


Whereas Medicare is mainly for people older than 65 and is run by the federal government, Medicaid is for lower-income people and is overseen by the states. There are certain overarching guidelines and regulations that Congress has mandated (the “mandatory” benefits), but the details, such as income levels and exact specifications (the “optional” benefits”), are left to the discretion of individual states.

To quote its website, “Medicaid is a joint federal and state program that, together with the Children’s Health Insurance Program (CHIP), provides health coverage to over 72.5 mil lion Americans, including children, pregnant women, par ents, seniors, and individuals with disabilities. Medicaid is the single largest source of health coverage in the United States” ( This website gives insight into general eligibility requirements, effective dates, and terms such as the Modified Adjusted Gross Income (MAGI), which determines “income.”

The ACA expanded coverage starting in January 2014 for individuals younger than 65 years of age with incomes up to 133% of the federal poverty level (FPL). States are also per mitted—if their government chooses—to cover low-income adults who do not have children. Details of those changes, proposed rules/changes, general eligibility for foster children, and information on verification plans may all be found on the above-cited CMS’s general Medicaid website.

The CMS has compiled a profile on each state’s Medicaid plan, which includes each state’s individual eligibility levels, information on waivers, and links to data on applica tions and chronic conditions ( by-state/by-state.html). For data researchers, there are also monthly enrollment reports, state by state. Simply click on the map or use the drop-down menu to choose the state .

These state information summaries do not provide local contact information. There are two main sources to use in order to get this information. The first is the CMS website for Regional Contacts. There are 10 regions in the U.S., each covering multiple states. Boston, for example, is in Region 1, which covers the six New England states of Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. This makes the contact useful for general questions in the Northeast, but not as helpful for those “How many eyeglass pairs can I get each year?” types of questions.

To find out exactly what each person may be eligible for, he or she needs to visit each state’s individual website. The list of websites for each state and territory is located on another CMS website: state-page.html. The link will bring users to the contact information for each state, meaning email addresses and phone numbers, and sometimes an address to visit. There should be additional links on each site, however, to locate the detailed coverage data.

There is no one single database which includes all the de tailed Medicaid coverage plans for each state. Some states make changes each year on coverage. Some states update the plans as new products or technologies are available. Other states will only address technology changes every 3 years.

When researching coverage on a state website, look for materials (links, documents, databases) which contain terms such as Coverage Policies, Program Information, Reference Guides, Pharmacy Programs, Formularies, and Benefits. Not every site will use these terms, but these common words will bring you to documents designed to provide insight.

If there is a Frequently Asked Questions (FAQ) site, please visit it first! These sites are almost always the best place to start. There are two questions that show up on almost every website: “What health services are covered by Medicaid?” and “Will I have to pay copayments?”

Many states will post a chart which lists the family size and the maximum annual/monthly salary caps for eligibility. There are even exceptions for people who make more than the caps but have additional criteria/issues. The salary caps and exceptions are unique to each state.

If someone is eligible for Medicaid, the best action that person can take is to make an appointment at the nearest Medicaid facility, and sit down with a person to talk through coverage plans. Age, financial situation, family situation/members, and even living arrangements may affect how much coverage is available. Some services have copays that may be waived. Some services (wheelchairs, orthopedic shoes, for example) may require a prior authorization before Medicaid will cover the item.

If a local office is not available for a walk-in appointment, please call the toll-free numbers on each state website, usual ly marked as help lines. Have a list of questions ready, which may include the following:

  • Are eye exams covered? How often? Eyeglasses?
  • What prescription drugs are covered?
  • Is there is a list of service with copays that I can get?
  • Who would I contact with questions in the future about any bills?

For researchers, most states have online databases containing their coverage policies. It may be called a Reference Guide or Coverage Policies or be in an area marked Regulations. As each state refers to the documents in a different way, updates them at different times, and houses them in different parts of the state website (if policies are even online), there is no simple way to locate this information. If following directions on the website does not work, call the local office:

Researchers: Medicaid documents are not covered in the MCD database, which is where CMS houses the Medicare documents.

Children’s Health Insurance Program (CHIP)

According to the Medicaid website, “The Children’s Health Insurance Program (CHIP) provides health coverage to eligible children, through both Medicaid and separate CHIP programs. CHIP is administered by states, according to fed eral requirements. The program is funded jointly by states and the federal government” (

CHIP is for children, but much is covered under Medicaid. Almost every state lists both programs within the same department. The key difference: CHIP serves uninsured chil dren up to age 19 in families with incomes too high to qualify them for Medicaid, or up to 200% of the federal poverty level (FPL). Some, but not all, states have expanded coverage to 300% of the FPL.

Because CHIP is so loosely linked with Medicaid, many of the benefits in each state may be the same—with CHIP providing for more immunizations and childhood screenings. Twenty-one states had them linked as of May 2015, with another 11 states in the process of combining the programs.

Information on the broad mandates as well as links to locating CHIP programs by state is listed by the CMS: For loose categorizations of what is covered, visit the benefits section of the CMS CHIP website: To contact your local CHIP office, go to the individual state Medicaid websites and use the search function to find the CHIP services.

Veterans Administration (VA) Coverage

Those people who served in the active military, naval, or air service and are separated under any other condition than dishonorable may qualify for the Veterans Administration (VA) healthcare benefits. There are still a subset of requirements, such as serving for 24 continuous months or the full period of active duty, unless there was a discharge for a disability or the individual served prior to Sept. 7, 1980. There are also a few additional criteria, so the VA encourages all veterans to apply directly. Information on the process, timing, and additional eligibility is listed clearly on the website:

A person may have both VA coverage and Medicare. The VA will cover services provided in a VA facility/hospital. Medicare covers services in non-VA facilities. The patient being treated usually has the option of choosing the preferred location of the services. According to page 23 of the CMS report, “Medicare & Other Health Benefits: Your Guide to Who Pays First,” “Medicare can’t pay for the same service that was covered by Veterans’ benefits, and your Veterans’ benefits can’t pay for the same service that was covered by Medicare. Also, Medicare is never the secondary payer after the Department of Veterans Affairs (VA)” ( The above publication also clarifies when both may pay: “If the VA authorizes services in a non-VA hospital, but didn’t authorize all of the services you get during your hospital stay, then Medicare may pay for the Medicare covered services the VA didn’t authorize.” So, based on where the patient is treated (i.e., a non-VA facility), the patient may have both coverage types and still end up paying a deductible.

Just like most types of insurance coverage, the VA has co pay amounts, deductibles, and medication costs. The system is different in that rates are standardized and publically listed, but those veterans living in higher-cost areas may qualify for more reductions. Information on all this is located on the VA website:

Commercial/Third Party

Almost every American—about 50% of the country—who does not have Medicare or Medicaid is covered by a commercial payer, that is, a private health insurance company ( These are generally the employer-covered plans. Larger names in the space include (but are not limited to) Aetna, Cigna, UnitedHealthcare, and Humana. There are hundreds of these payer companies in the United States covering millions of lives.

Most payers have multiple types of insurance programs. Companies contracting with these payers to offer the services to the employees may select only a handful, however, so an employee’s access may in reality be restricted when compared to what that person may see on a payer’s website. Think of it as buying a car only from the selection at the local dealer lot (i.e., no special orders). The manufac turer of the car has many different models, including luxury vehicles, but your local dealer only sells a few of them, all in the low- to mid-range prices. No luxury models are available to you.

For the vehicles on the lot, each has a multitude of options. Before you are permitted to shop, however, the dealer then makes additional restrictions on the options. The group of cars on the right are cheaper in cost to you up front, but have limited options, and repairs will cost more out of your pocket. The cars on the left have cool features such as tinted windows, and repairs will cost less each time—but you have to pay more each month. Neither set of cars has all the options listed on the website. For example, no car available to you has tinted windows, Bluetooth, sunroof, satellite radio, self-parking, carbon fiber cup holders, blind spot warning, back-up cameras, heated steering wheels, remote starter, and is a convertible.

For the patient, this means looking at what is available and making tough choices. For a patient with back issues, while the website says that the payer will cover all chiropractic visits, in actuality the plan selected by the patient’s company does not have that covered item in one plan (e.g. an HMO). Does this mean the other plan (such as a PPO) is better if the patient can then see such a specialist for treatment?

Sometimes there is no choice. If a company chooses to work with a local payer and there is another company office in another state, the headquarter location may have selected the HMO or PPO option. The second office may only have the PPO option as it is “out of state.” If this happens, the price for the PPO is less expensive for the people in the second office than the PPO in the headquarter location, when there is no choice.

Health maintenance organizations, better known as HMOs, were developed in the 1970s and into the 1980s. The premise behind the HMO is to direct patients to a primary care physician (PCP) who triages a patient’s needs and helps him or her understand if specialized care is needed. If so, a referral is given to the patient, granting them permission to see a specialist. If there is no referral, any specialist visit must be paid for by the patient completely out of pocket (cash). In the HMO plan, the payer will not cover any of the costs.

The term PCP is an insurance term; it’s not indicative of a physician’s actual specialty. A person may choose a PCP who is a general practitioner in family medicine, an internist, or a pediatrician. Many HMOs have a list of physicians from whom members may choose. A doctor who is not on this list is not considered an authorized PCP by the HMO.

Not Done Yet

Just because you’ve got the right insurance, does that mean you’ve got the right treatment or right physician? Part 2 will take a closer look at the other factors at play in dealing with health crises.

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Tara Breton is the research services manager at Health Advances, an international strategic management consulting firm focused in the healthcare space. She has been at the organization for more than 14 years, working with the consulting teams to provide clients with innovative solutions based on deep industry insight, analytical rigor, and an objective perspective.


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