CHIP (State Children’s Health Insurance Program)
Congress enacted the State Children’s Health Insurance Program as part of the Balanced Budget Act of 1997. This created Title XXI of the Social Security Act. This program targets uninsured children under 19 with family incomes below 200% of poverty that are not currently eligible for Medicaid or covered by private insurance. There are a few states that have expanded coverage to parents of eligible children and other adults. States can expand coverage to uninsured low-income children through either a separate state program, or by broadening Medicaid eligibility, or both. States can have a separate plan, and expansion of Medicaid coverage, or a combination plan. Every state and the District of Columbia have an CHIP program in place. Although the coverage varies from state to state, a minimum standard of benefits the program must be offered.
Health Insurance Marketplace
The Health Insurance Marketplace and the state-based exchanges were established following the enactment of the ACA. The Health Insurance Marketplace is the name for the federally run exchange. States that have established their own exchanges have specific names for those exchanges (e.g. Connect for Health Colorado or Covered California in California). The Marketplace is a resource where individuals, families, and small businesses can: learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage. The Marketplace also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available through the Marketplace, and information about other programs, including Medicaid and CHIP. In some states, the Marketplace is run by the state. In others it is run by the federal government
A health insurance company that provides exchange coverage in a particular state.
Exchange plan name
An exact name of a health plan in the exchange (e.g. AmBetter Balanced Care 1)
Exchange portal name
The name of a state exchange (e.g. Connect for Health Colorado or Covered California in California), healthcare.gov, Obamacare
Indian Health Service
Members of federally recognized Indian tribes and their decedents are eligible for services provided by the Indian health Service (IHS). The IHS operates a comprehensive health service delivery system for approximately 75% of the nation’s American Indians and Alaska Natives. IHS services are provided directly and also through tribally contracted and operated health programs. Health services also include health care purchased from more than two thousand private providers.
Authorized under Title XIX of the Social Security Act (1965), Medicaid is a means-tested entitlement program financed by the state and federal governments and administered by the states. Federal financial assistance is provided to states for coverage of specific groups of people and benefits through federal matching payments based on the state’s per capita income.
The Medicare program was enacted in 1965. Today, virtually everyone age 65 and older is insured under Medicare. The Centers for Medicare and Medicaid Services (CMS) administers Medicare, the nation’s largest health insurance program. Medicare provides insurance to:
people who are 65 years old;
people who are disabled; and
people with permanent kidney failure.
Medicare has four parts:
Medicare Part A
Medicare Part A provides coverage for inpatient hospital services, skilled nursing facilities, home health services, and hospice care.
Medicare Part B
Medicare Part B helps to cover the cost of physician services, outpatient hospital services, medical equipment, supplies, and other health services.
Medicare Part C
The Balanced Budget Act of 1997 (BBA) created Medicare + Choice, Part C of Medicare, which expands the range of private health plans that may contract with Medicare to provide care to Medicare beneficiaries. A newer name for Medicare + Choice is Medicare Advantage. Medicare Advantage is intended to increase beneficiary participation in Health Maintenance Organizations (HMOs) and other private plans. Medicare Advantage options are: HMOs, HMOs with a Point of Service Option, Preferred Provider Organizations (PPOs), Provider-Sponsored Organizations (PSOs), Private Fee-for-Service, and Medical Savings Accounts (MSAs).
Medicare Part D
Medicare Part D offers prescription drug coverage to everyone with Medicare. Enrollment is offered twice a year however a penalty for late enrollment is enforced for those individuals who do not pick up the coverage when first eligible.
There are several types of health care coverage that are related to present or former military service. CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) was created in 1967. However, there has been care provided to dependents of military persons prior to this. In 1884, Congress directed that the “medical officers of the Army and contract surgeons shall whenever possible attend the families of the officers and soldiers free of charge.” There was very little change until WWII when in 1943 Congress authorized the Emergency Maternal and Infant Care Program (EMIC). This program was administered by the “Children’s Bureau,” through state health departments. In 1956, the Dependents Medical Care Act was signed into law. Amendments to this act in 1966 created CHAMPUS.
In response to the challenge of maintaining medical combat readiness while providing the best health care for all eligible personnel, the Department of Defense (DOD) introduced TRICARE. TRICARE is a regionally managed health care program for active duty and retired members of the uniformed services, their families, and survivors. TRICARE offers eligible beneficiaries many choices for their health care.
Used when Military Treatment Facilities are the principal source of health care. All active duty personnel must enroll in TRICARE Prime. Family members can choose to enroll in TRICARE Prime. There is no enrollment fee for active duty families enrolled in TRICARE Prime. There is an enrollment fee for retirees and their families.
This is a fee-for-service insurance plan that lets the TRICARE enrollee see any doctor. If an enrollee visits a network doctor they normally will only have to pay a small copay when they visit. This plan is available to military family members, veterans, and retirees. It is available worldwide. If the TRICARE enrollee visits a non-network doctor they may have to pay all charges up-front and file a claim with TRICARE for reimbursement.
TRICARE Extra was replaced by TRICARE Select on January 1, 2018. This choice offered a preferred provider option that saved money. Eligibility was limited to anyone who was CHAMPUS eligible. Active duty personnel were not CHAMPUS eligible.
TRICARE Standard was replaced by TRICARE Select on January 1, 2018. This was the new name for traditional CHAMPUS. Under this plan an enrollee could see the authorized provider of their choice. But having this flexibility meant that care generally costed more. Treatment was also available at a military treatment facility, if space allowed, and after TRICARE Prime patients had been served. Active duty personnel are not CHAMPUS eligible.
TRICARE for Life (TRICARE for Retirees)
This choice is a Medicare wrap around coverage available to Medicare-entitled uniformed service retirees, including retired guard members and reservists, Medicare-entitled family members and widows/widowers (dependent parents and parents-in-law are excluded), Medicare-entitled Congressional Medal of honor recipients and their family members, and certain Medicare-entitled un-remarried former spouses. To participate in the TFL program, the TRICARE enrollee must be entitled to Medicare Part A (either on the basis of age, disability, or end-stage renal disease) and enrolled in Medicare Part B. A Medicare-eligible beneficiary who is a family member of an active duty service member (ADSM) is NOT required to purchase Part B. However, when the ADSM retires, the Medicare-eligible beneficiary must purchase Medicare Part B in order to remain TRICARE-eligible.
TRICARE Young Adult
This is a plan that qualified adult children can purchase after eligibility for “regular” TRICARE coverage ends at age 21 (or 23 if enrolled in college). This plan provides comprehensive medical and pharmacy benefits and can be purchased by eligible children ages 21 – 26.
TRICARE Reserve Select and TRICARE Retired Reserve
These are additional TRICARE options that are available to specific groups.
US Family Health Plan
The US Family Health Plan is an additional TRICARE Prime option available through networks of community-based, not-for-profit health care systems in six areas of the United States. Active duty family members and other individuals are eligible for this plan. Active duty family members pay no enrollment fees and no out-of-pocket costs for any type of care as long as care is received from the US Family Health Plan. All others pay annual enrollment fees and network copayments. Under this plan, an individual does not get care at military hospitals and clinics or from the TRICARE network of providers.
Veterans Health Administration (VA)
The VA provides a broad spectrum of medical, surgical, and rehabilitative care to persons who are eligible to receive VA services. To be eligible for VA health care, a person must have been discharged from active military service under honorable conditions, service a minimum of 2 years (if discharged after September 7, 1980), and, if a National Guardsman or Reservist, served the entire period for which called to active duty (other than for training purposes). The VA emphasized prevention/primary care. Persons are assigned to a priority group depending on whether the veteran has a service-connected disability.
This is a health care benefits program for dependents (or survivors) of veterans who have been rated by the VA as having a total and permanent disability, or survivors of veterans who died from a VA-rated service-connected disability or survivors of person who died in the line of duty. In general, CHAMPVA covers most health care services and supplies that are medically and psychologically necessary.
Other State and Local Programs
These programs vary from state to state. Examples of these programs include: the Ryan White Act of 1990, which established funding for various programs at the state and local level to provide care and services to HIV and AIDS infected individuals, health insurance risk pools to enable persons to obtain private health coverage who would not be able to afford individual coverage; and special programs to provide health care coverage to farm workers and refugees are also include.
Private Health Insurance
The term health insurance covers a wide range of policies that cover the costs of doctors and hospitals and those that meet specific needs, such as paying for long-term care. The type of health insurance in which we are usually interested is comprehensive or major medical policies. Private health insurance also includes plans available through the Federal Health Insurance Marketplace and state-based exchanges.
Single Service Plans
Single Service Plans (SSPs) refers to health insurance coverage paid for by an individual or an employer that provides for only one type of service. Examples of SSPs are dental care, vision care, prescriptions, nursing home care, hospice care, accidents, catastrophic care, cancer treatment, AIDS care, and/or hospitalization.