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Public Insurance

Medicaid and CHIP (Children's Health Insurance Program) are joint federal and state public health insurance programs that cover roughly 1 in 5 Americans, including low-income families and individuals, children, parents, pregnant women, seniors, and some people with disabilities. In addition, it is the nation’s largest provider for long-term care coverage. For the majority of people enrolled, these programs are the only option for affordable health coverage, largely because it drastically limits an individual’s out-of-pocket costs.

Medicaid

Each state operates their own Medicaid program. While the federal government broadly defines the requirements and provides oversight, states have the flexibility in how they design and implement their programs. For example, a state can choose to offer additional services and extend the eligibility criteria. However, should a state choose to deviate from the federal regulations they must seek approval from the federal government. Collectively, these differences make each state’s Medicaid program different.

To receive federal funding, states must cover certain groups:

Children up to 18 in families with income below 138% of the federal poverty limit (FPL). The FPL changes each year.
People pregnant and with income below 138% FPL
Certain parents or caregivers with very low income
Most seniors and people with disabilities who receive cash assistance through the Supplemental Security Income (SSI) program

The ACA gave states the option to expand the populations they cover. Currently, 39 states (including Washington, DC) have adopted the Medicaid expansion, while 12 states have not. In states that expanded, nearly all adults (i.e., childless adults) with incomes at or below 138% of poverty level now are eligible for Medicaid. This means there are no categorically excluded low-income individuals in states that expanded their programs.

CHIP

Similar to Medicaid, CHIP provides health coverage to eligible children (up to age 19) either through Medicaid and/or a separate CHIP program. The program is an affordable way for kids get covered when the family’s income is too high for Medicaid but too low for affordable marketplace or other coverage. CHIP is a joint federal and state program that is administered by states, complying with federal requirements. States have broad flexibility to define their program and the services provided.

Medicare

Medicare is federal health insurance program for people who are 65 or older and certain younger people with specific disabilities. It also covers people with end-stage renal disease (ESRD). To get Medicare you must be a U.S. citizen or lawfully present in the U.S. for five continuous years.

Parts of Medicare:

Part A (Hospital Insurance) helps cover:

Inpatient care in hospitals
Skilled nursing facility (SNF) care
Hospice care
Home health care

Most beneficiaries are enrolled in Part A automatically.

Part B (Medical Insurance) helps cover:

Services from doctors and other health care providers
Outpatient care
Home health care
Durable medical equipment (DME) (like wheelchairs, walkers, hospital beds, and other equipment and supplies)
Clotting factor therapies
Many preventive services (like screenings, shots, and yearly wellness visits) Most beneficiaries are enrolled in Part B automatically

Part C (also known as Medicare Advantage (MA)):

An “all-in-one” alternative to Original Medicare. These “bundled” plans include Part A, Part B, and usually Part D.
May have lower out-of-pocket costs than Original Medicare.
Plans may offer extra benefits that Original Medicare doesn’t cover—such as vision, hearing, dental, and more.

Part D (Prescription drug coverage):

An optional benefit available to all people with Medicare
Run by private companies that contract with Medicare and follow rules set by Medicare
Provided through
- Medicare Prescription Drug Plans (PDPs) (work with Original Medicare)
- Medicare Advantage Prescription Drug Plans (MA-PDs)
- Some other Medicare health plans (like Cost Plans)
Options
- Can add to Original Medicare
- Usually included in Medicare Advantage (MA)

Enrollment

When you first enroll in Medicare, and during certain times of the year, you can choose how you get your Medicare coverage. There are two main ways to get Medicare:

Original Medicare (Part A and B)

Includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance)
If you want drug coverage, you can join a separate Part D plan (note: everyone should consider getting a Part D plan)
To help pay your out-of-pocket costs in Original Medicare (like your deductible and 20% coinsurance), you can also shop for and buy supplemental coverage

*Please note that Medicare Supplement Insurance (Medigap) policies only work with Original Medicare

Medicare Advantage (MA)

An “all-in-one” alternative to Original Medicare. These “bundled” plans include Part A, Part B, and usually Part D.
May have lower out-of-pocket costs than Original Medicare.
Plans may offer extra benefits that Original Medicare doesn’t cover—such as vision, hearing, dental, and more.

Original Medicare vs. Medicare Advantage: Coverage

In general, you can only enroll in coverage during the specified open enrollment period. Marketplace open enrollment for states that do not operate their own marketplace (using healthcare.gov) begins November 1 and goes through December 15. If you plan to sign up for a plan through the marketplace, be sure to complete your application and select your plan before the deadline. If you miss the deadline, you must wait till the next open enrollment period.

However, if you experience certain changes in circumstances during the year, meaning have a qualified life event (i.e., birth, marriage, divorce, lost job-based insurance, etc.), you may qualify for a special enrollment period (SEP). If you qualify you must enroll within 60 days. This is a firm deadline.

It is important to note that loosing coverage because you didn’t pay your premiums or voluntarily dropped your coverage, does not qualify you for an SEP. You must meet the specific criteria used by the marketplace to qualify.

If you are buying non-group coverage for yourself and/or your family outside of the marketplace, you still can only enroll in coverage during the open enrollment period, provided you do not qualify for a special enrollment period.