Other Medical Help Programs

Approximately two-thirds of Americans are enrolled in employer-based health insurance programs. Experts have traditionally considered these programs to be the most attractive option for anyone to whom they are available.

This preference has been based on the fact that employers typically pay for a portion of the insurance as part of employees’ benefits packages. As a result, enrollees get more benefits than they would otherwise qualify for under the amount of money they themselves are paying for coverage.

Recent changes in America’s employment landscape have made employer-based plans less available and less affordable for many workers. The federal government took steps to mitigate these trends with the Affordable Care Act (ACA), which created subsidies and supports for low-income and high-risk groups. ACA plans create affordable alternatives for Americans who do not qualify for medical help under pre-existing programs such as Medicare or Department of Veterans Affairs health care.

The Affordable Care Act

The Affordable Care Act, also referred to as Obamacare, was passed in 2010. It has undergone a series of revisions since its initial adoption. Chief among these was the repeal of the individual mandate which goes into effect for the 2019 fiscal year. While the mandate, a legal requirement that all Americans be enrolled in qualifying health insurance policies, is being discontinued, ACA marketplaces, policies and subsidies all remain intact.

Obamacare was designed to make affordable health care and health insurance options available to individuals and families who:

  • Lack access to employer-based plans.
  • Are eligible for employer-based plans, but for whom such plans are not affordable.
  • Are not income-eligible for Medicaid and other low-income federal medical help programs.
  • Do not meet the disability, prior military service or other eligibility criteria necessary to enroll in veterans health insurance or other specialty federal medical help programs.

All Americans can apply for Obamacare health insurance plans, if they wish. Plans and enrollment are managed through online state and national healthcare marketplaces. During the enrollment process, applicants will be screened using a series of eligibility criteria.

  • Applicants with access to affordable employer-based plans are advised to take advantage of those options.
  • Applicants who lack access to affordable employer-based plans will be provided with plan options they can purchase directly online.
  • Applicants who meet Obamacare income limits will be permitted to purchase discounted or federally-subsidized plans. Subsidies and discounts are calculated using a sliding scale of family size, area of residence and annual household income.
  • Applicants with qualifying annual household incomes will be directed to Medicaid, CHIP and other low-income federal health insurance programs for which they qualify.
  • Some applicants may be eligible for additional cost reductions if they belong to high-risk or disadvantaged populations.

Consumers can apply for or change their ACA health insurance enrollment during annual open enrollment periods or any time they experience qualifying life events. All Obamacare health care plans offer federally-established minimum levels of insurance and care in key categories, putting quality care within reach for all Americans.

Medicare

Medicare offers low-cost health care to the elderly and individuals with qualifying disabilities. Many program enrollees also qualify for dual enrollment in Medicaid, and it is common for the programs to be used in conjunction with one another to fully cover the needs of individuals with serious or long-term health conditions. Medicare can also be combined with private health insurance.

Related Article: PACE

Americans reach “Medicare age” at 65, and may enroll up to three months prior to their 65th birthdays. Eligible seniors are required to enroll in Medicare Part A at that time, even if they do not intend to retire and begin collecting benefits right away. Seniors are not necessarily required to enroll in Medicare Part B immediately. They may, however, face financial penalties and coverage gaps later on if they elect to delay Part B enrollment.

Medicare Part A covers inpatient care. This includes hospital stays, short-term admittance to skilled nursing facilities, hospice facilities and, in some cases, short-term in-home health care. It does not pay for long-term or custodial care situations.

Medicare Part B covers primary and preventative care services. Medically necessary services and equipment, along with limited prescription drugs may also be funded by Part B. Occasionally, it funds enrollees’ participation in clinical research trials.

Medicare Part D is strictly prescription drug coverage. Medicare Part C, also known as Medicare Advantage Plans, allows qualifying individuals to enroll in privately administered managed care plans. Equivalent to private market HMO or PPO plans, Part C plans combine and integrate Medicare Parts A, B and D into single plans which may have different cost structures and internal rules than each part separately.

Medicare applications are handled by the Social Security Administration or, overseas, by embassies and consulates.

VA Health Care Benefits

The American Department of Veterans Affairs (VA) operates a diverse array of programs offering veterans health insurance and medical benefits. These programs seek to meet the needs of United States military veterans from all branches of the Armed Forces and their families. The VA operates its own facilities in nearly every state, but also funds services and care at other facilities or in veterans’ homes, where appropriate.

Former servicemembers are disqualified from receiving VA health care, insurance or benefits if they were dishonorably discharged. Although basic health care services are available to all honorably discharged veterans, some programs are open only to veterans or the families of veterans who served in certain theaters of war during specific periods of time. In the event that demand for services outstrips available supply, the VA may give preference to veterans who:

  • Are disabled.
  • Hold various medals of honor, indicating valor in service.
  • Meet low-income eligibility standards.

VA health care benefits are delivered in inclusive, supportive environments designed to meet the needs of all veterans. This includes conscious, informed care for female veterans and victims of trauma or sexual abuse. Changes in the law within the last several years have also caused the VA to revise its family medical benefits policies to recognize same-sex marriages and households. Veterans may now apply for VA health insurance for their families, even if they were previously denied benefits under former program rules.

Related Article: Health Insurance for Families

It might also interest you: