I work at a busy community health center where no one is turned away for lack of insurance. When people come in for care, they are treated, and then sent upstairs to see me if they have no way to pay the bill. As social worker, I try to connect our uninsured patients with programs that may be able to offer them coverage.
Nearly 20 million Americans have gained access to health insurance coverage since 2010, thanks in large part to the Affordable Care Act. However, a coverage gap still exists in states that haven’t expanded Medicaid. I work in Kansas City — a city that straddles two states, Kansas and Missouri, that haven’t expanded their Medicaid programs. Without expansion, many low-income people can’t access Medicaid, and these are the clients I assist most often.
Thanks to Medicare, which provides health insurance for seniors, the uninsured rate among seniors is much lower than the general population — about 2 percent for those 65 and older, compared to 12.2 percent for the general population.
However, for seniors who haven’t had access to health insurance before — often after years of minimum wage jobs — understanding the system can be intimidating. I see lots of older people. Many of them assume they can’t afford insurance, even if they are eligible for financial assistance. They are confused by health insurance terms like “co-insurance” and deductible. And getting enrolled seems daunting. Here is how I walk my clients through the health insurance options available to them.
The first program I always look at for seniors in need of coverage is Medicare. Medicare is a federal health insurance program available to anyone age 65 or older. It is also available to disabled individuals who have received social security disability for at least 24 consecutive months.
Medicare includes several different parts broken down by coverage area. Part A covers hospitalizations. It is free for those who have been part of the workforce for at least 10 years, and may come with a premium, or monthly payment, for those who don’t have the appropriate work credits. Part B covers doctors visits and comes with a premium that is adjusted every year. For 2018 that monthly payment is $134 for Part B coverage. Prescription drug coverage is included in Part D, which is offered through private health insurance companies and may include a premium depending on the plan. Part C is known as Medicare Advantage and includes packaged plans from private health insurance companies that combine Parts A, B and D.
Understanding each of these parts, how they work together and what options are best for you or your loved one is no doubt a daunting process. I usually start by telling my clients to write down a list of their needs — what prescription drugs are they taking? Are they managing a chronic illness? Do they need any physical therapy? Starting with direct health care needs helps me narrow down the options available to them, and zero in on which plans will offer them the best coverage.
Although this process can be challenging, the good news is you don’t have to go at it alone.
Although this process can be challenging, the good news is you don’t have to go at it alone. Medicare assistance is available in every state as part of the State Health Insurance Program or SHIP. SHIPs offer local, personalized counseling for people with Medicare and can help answer questions about benefits, coverage, costs and joining or leaving Advantage or Part D plans. To find a SHIP counselor near you, visit www.shiptacenter.org.
For those worried about costs, whether that be Part B premiums, or out-of-pocket costs for co-pays or prescription drugs, Medicare-specific financial assistance programs are available. These programs vary by state, and are often administered through a state’s Medicaid office. Click here to learn more about Medicare costs and savings programs.
For low-income seniors, another program to consider is Medicaid. Medicaid is a health insurance program jointly funded by federal and state governments that provides coverage to low-income individuals and families as well as disabled adults. While the federal government sets general guidelines, each state determines Medicaid eligibility a little differently based on household size, income level and financial assets. Seniors who qualify for both Medicare and their state’s Medicaid program are considered to be dual eligible beneficiaries.
In this case, Medicare pays covered medical services first for dual eligible beneficiaries because Medicaid is generally the payer of last resort. In some cases, Medicaid may cover medical costs that Medicare does not or partially covers, such as nursing home care, personal care, and home and community-based services.
Health Insurance Marketplace
For those who don’t qualify for Medicare or Medicaid either because of age or income, I direct them to the health insurance marketplace. This is an option I typically explore for folks who own their own business or who work for very small employers that don’t offer health care coverage as a benefit.
The marketplace was created under the Affordable Care Act as a way for uninsured individuals who don’t have access to health care coverage through other programs or an employer to shop for private health insurance plans. For those who qualify based on household size and income, financial assistance is available to lower premium payments and out-of-pocket costs. For an individual, the income range to qualify for assistance spans from about $12,000 annually to about $48,000. This range varies depending on household size.
The health insurance marketplace, also called the exchange, varies a bit across states. Some states, like Oregon, have their own state-based exchange, while others, like Kansas, have a federal exchange. Despite the different appearances, they all do the same thing — allow consumers to apply for financial assistance, and then shop for, compare and ultimately choose a health insurance plan in their state.
Despite the different appearances, marketplace plans all do the same thing — allow consumers to apply for financial assistance, and then shop for, compare and ultimately choose a health insurance plan in their state.
The plans vary in their networks and prices, but all plans on the exchange cover the same 10 essential health benefits including preventive care, hospitalizations, prescription drugs, ambulatory patient services, emergency services, mental health and substance use disorder services, behavioral health treatment, rehabilitative and habilitative services and laboratory services.
The right plan for each person will vary depending on the consumer’s needs — which plans’ networks include their doctors, what kind of monthly premium they can afford and how often they think they will utilize their plan. Local, in-person marketplace assistance is available in every state, and the marketplace offers a 24/7 call center where consumers can ask questions and even apply over the phone. To learn more about how to find marketplace assisters, visit healthcare.gov or call the marketplace call center at 1-800-318-2596.
When it comes to health insurance options for seniors, it’s important to remember that assistance is available — both in applying and answering questions as well as paying for a health care plan. Navigating the world of health insurance and health care can be tricky, but with the right assistance and an understanding of options and needs, choosing a plan doesn’t have to be painful.
Erin Heger is a social worker and freelance writer based in the Kansas City area. Her work has been featured in The Atlantic, Rewire, Refinery29 and LearnVest.