Medicaid provides coverage to eligible low-income adults, children, people who are pregnant, elderly adults, and people with disabilities. Some states have expanded their Medicaid programs under the Affordable Care Act (ACA) to cover other adults below a certain income threshold. Specific eligibility requirements and benefits vary by state.
Medicaid is administered by the state, according to federal requirements, and is funded jointly by state and federal governments.
States may offer Medicaid benefits on a fee-for-service basis, through managed care plans, or both.
Medicaid Managed Care provides for the delivery of Medicaid services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs). The state pays MCOs a set fee per person enrolled in the plan (capitation payment), and the plan pays providers for the Medicaid services provided to these beneficiaries.
The majority of Medicaid enrollees (largely non-disabled children and adults under 65) are in managed care plans.
Medicaid fee-for-service (FFS) is a model in which the state pays providers directly for each covered service provided (as opposed to the fixed per member payment of managed care). Most states are moving away from FFS models towards managed care.
Medicaid Alternative Benefit Plans are Medicaid plans for the expansion population (in states that expanded Medicaid under the ACA to include more low-income adults). States have the option to provide alternative benefits specifically tailored to meet the needs of certain Medicaid population groups, target residents in a certain area of the state, or provide services through specific delivery systems instead of following the traditional Medicaid benefit plan.
The Children’s Health Insurance Program (CHIP) provides low-cost health coverage to children (up to age 19) in families with incomes too high to qualify for Medicaid but too low to afford private coverage. In some states, CHIP also covers pregnant individuals.
To see if you qualify for these plans or to get help with Medicaid and CHIP, contact your state Medicaid agency.
Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease.
Original Medicare includes Part A (Hospital Insurance – i.e., inpatient care in hospitals) and Part B (Medical Insurance – i.e., doctors’ services and outpatient care). This covers most, but not all, of the costs for approved health care services and supplies. Medicare beneficiaries can purchase supplemental plans (Medigap) from private insurers to help with out-of-pocket costs and provide coverage of other services. Medicare Part D are separate plans, offered by private insurers, that cover prescription drugs.
Medicare Advantage (also known as Part C) bundles Parts A, B, and D coverage into one plan. Some plans may offer extra benefits that Original Medicare does not cover. Medicare Advantage plans are offered by private companies.
To get help with Medicare, contact the Social Security Administration.
TRICARE provides coverage to current and retired military service members and their families.
Many companies offer health insurance to their employees. Companies with more than 50 employees offer large group plans, while companies with up to 50 employees offer small group plans.
Plans can be fully insured (employers pay a fixed premium to a third-party commercial insurance carrier that covers the medical claims) or self-funded (employers pay for medical claims and fees out of current revenue, but the plan is typically administered by a third-party commercial carrier).
Those who do not qualify for programs like Medicare or Medicaid and who do not have employer-sponsored insurance can purchase private coverage through health insurance Marketplaces. Subsidies are available for many individuals and families.
Most states use the federal Health Insurance Marketplace (HealthCare.gov), but some states operate their own Marketplaces.
See the federal Marketplace, or find your state’s Marketplace.
Some employers offer health coverage to employees when they retire.
Non-federal governmental plans provide coverage to state and local government employees.
These plans provide coverage for church employees and employees of church-affiliated entities.
Federal Employee Health Benefits (FEHB) plans provide coverage for current and retired federal government employees.
Short-term, limited duration insurance is primarily designed to fill temporary gaps in coverage when an individual is transitioning between plans. It is generally not subject to federal protections and requirements for comprehensive coverage that other plans are.