What is health insurance and how does it affect me?
Health insurance is a formal agreement to provide and/or pay for medical care described in your health insurance policy. There are medical services that are not “covered” and will not be paid by your insurance company.
There are a variety of private and public health insurance programs. Most women obtain health insurance through their employer or as a dependent in a family plan. There also are public health insurance plans funded by the federal and state governments. However, there are 16 million uninsured women. As health insurance costs soar, employers cut benefits, or jobs disappear—millions of people slip through the cracks and lose their coverage. These are working Americans who make too much money to qualify for Medicaid, but don’t have enough money to buy health insurance. Uninsured women are more likely to suffer serious health problems, partly because they tend to wait too long to seek treatment or preventive care. The lack of health insurance can even be deadly as research has shown that uninsured adults are more likely to die earlier than those who have insurance.
What are my health care options?
Health insurance can be complicated and confusing. There are different types of plans:
Private Health Insurance
- “Fee-for-service.” The provider gets paid for each covered service. Most have a deductible amount that you must pay each year before the insurance company will begin to pay for medical services
- Health Maintenance Organizations (HMOs). They provide health services for a fixed monthly payment. The HMO Act of 1973 created this alternative to traditional health plans as a more affordable option.
- Preferred Provider Organization (PPO). This is another option that offers more choices than an HMO, but can be more costly for out-of-network services.
People who have private insurance either buy it themselves or get it through their employer. Insurance obtained through an employer typically requires the employee to pay a small portion of the overall policy cost.
| Employer-Sponsored |
Group policy paid in whole or in part (typically 75-85%) by employer |
Typically Fee-for-Service, HMO, or PPO |
| Individually Purchased |
Individual policy, more costly, benefits usually more limited |
Typically Fee-for-Service, HMO, or PPO |
Public Health Insurance
The government also provides health care coverage for qualifying women through Medicaid, Medicare, and special interest programs. These plans serve those who meet certain financial, age, or situational requirements. The following is a description of the different types of government health insurance programs:
- Medicare. This is the national health insurance program for people age 65 or older, some people under age 65 with certain disabilities, and people with permanent kidney failure. Medicare has two parts:
- Part A covers inpatient hospital, skilled nursing, home health, and hospice services. Everyone over age 65 is entitled to Part A.
- Part B covers outpatient hospital, physicians, lab, and other services. Part B is a supplemental policy that must be purchased.
- The Medicare Modernization Act of 2003 provided for improved benefits and prescription drug coverage through low-cost plans. For more information, call 1-800-MEDICARE or go to http://www.medicare.gov.
- Medicaid. This is a state-run health program that receives federal funding and must meet federal guidelines regarding specific benefits. Medicaid provides health care to qualifying low-income individuals and families with limited resources. You must be a U.S. national, citizen or permanent resident alien in order to apply for benefits. Each state defines its own eligibility rules and administers its own program services. Qualification in one state does not guarantee qualification in another state. For more information, call 1-877-0267-2323 or go to http://www.cms.hhs.gov/medicaid.
Note: Many states have become more flexible in their ability to serve families in need, especially if you fall into any of these categories:
- Pregnant—Both you and your child will be covered if you qualify.
- Children/Teenagers—May cover sick children or teenagers on their own.
- Aged, Blind, and/or Disabled—Nursing home and hospice care available.
- Leaving welfare—You may be eligible for temporary assistance.
Call your local social security office for more information.
- State Children’s Health Insurance Program (SCHIP). This is a joint state and federal program that provides insurance for children of qualifying families. Families who make too much money to qualify for Medicaid but cannot afford private health insurance, may be able to qualify for SCHIP assistance. Eligibility and health care coverage varies according to each state. For more information, contact http://www.insurekidsnow.gov or call 1-877-KIDS-NOW
What if you are currently uninsured?
America’s uninsured recently grew to more than 44 million people and most are in working families. To address to this problem, the government is looking for ways to provide more affordable health insurance and greater access to health care. Right now, there are a number of resources for women without health insurance. There are government-sponsored “safety net” facilities that provide medical services for those in need, regardless of ability to pay. “Safety net” facilities include community health centers, public hospitals, school-based centers, public housing primary care centers, and special needs facilities. The U.S. Department of Health and Human Services (HHS) recently awarded more than $19 million to expand and strengthen these facilities. For information on community health facilities, contact your local or state health department.
Other government-sponsored programs for uninsured women include:
- Special Supplemental Nutrition Program for Women, Infants, & Children (WIC). Provides supplemental foods, nutrition education, and referrals to health care for low-income pregnant, breastfeeding, and postpartum women, infants, and children up to age 5. Contact: http://www.fns.usda.gov/wic.
- National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Provides free or low-cost mammograms and pap tests for women over age 39 who cannot afford breast exams or Pap smears. Contact: http://www.cdc.gov/cancer/nbccedp/contacts.htm or 1-888-842-6355.
- Maternal and Child Health Services. State programs provide health care services for low-income women who are pregnant and their children under age 22. The federal government funds these programs and establishes general guidelines regarding services. Each state determines eligibility and identifies the specific services to be provided. For services available in your area, contact https://performance.hrsa.gov/mchb/mchreports/link/state_links.asp.
- Indian Social Services Welfare Assistance. Provides financial assistance for American Indians in need, living near or on reservations. Contact: http://www.doi.gov.
- Projects for Assistance in Transition from Homelessness (PATH). Federal grants are provided to states and territories that partner with local organizations to provide a variety of health services for homeless people who have serious mental illness. Contact: http://www.samhsa.gov.
What if I do not qualify for these government programs?
Some uninsured or underinsured women make too much money to qualify for government assistance but cannot afford to pay for health insurance or costly medical services. This is a difficult situation for women and their families. There are other options for women in this situation. The following are a few options to consider:
- Free clinics. In 1992, The Free Clinic Foundation of America was founded and published a National Directory of Free Clinics. These clinics provide services for the working poor and uninsured. For a list of clinics in your area call (540) 344-8242.
- Prescription drug assistance. Some states provide prescription drug assistance to women who are not covered by Medicaid. Also, many drug companies will work with your doctor or health care provider to supply free medicines to those in need. For prescription drug resources, go to http://www.disabilityresources.org/RX.html.
- Women with cancer. Women who are coping with cancer can find help through a variety of government-sponsored and volunteer organizations. For example, Cancer Care provides free support, information, financial assistance, and practical help to people with cancer and their families. Low-income and underserved women with breast and cervical cancers can obtain assistance from AVONcares Program for Medically Underserved Women. For more information and a list of more resources, contact the National Cancer Institute at http://www.nci.nih.gov/.
- Women with HIV. The federal Ryan White CARE Act funds services for those with HIV/AIDS who are without insurance or financial resources to pay for care. For information about the Ryan White Care Act, call 1-888-275-4772 or go to http://hab.hrsa.gov. Contact your local or state health department to locate a CARE provider in your area.
- Low-Cost Health Insurance Options. Some labor unions, professional clubs, associations, and organizations offer group health insurance to its members. These plans are usually less costly and may be an option to consider.
- State Temporary Insurance. Some who have been denied health insurance because of a medical condition may be able to obtain coverage through State “High Risk Pools.” Over 30 states provide this temporary insurance assistance. For more information, contact http://www.healthinsurance.org/riskpoolinfo.html.
How do you protect your health insurance benefits?
If you are losing your health insurance due to job loss or reduced hours, there are some important steps you should take. Women and their dependent children who lose their health insurance through divorce or death are also entitled to the following protection.
- Obtain proof of previous health insurance coverage from your employer. This guarantees certain protections and rights under the Health Insurance Portability and Accountability Act of 1996, or HIPAA. Basically, HIPAA protects employed individuals and their families who are insured by continuing access to health insurance when leaving or changing jobs. For more information about HIPAA and how it affects you and your family, go to http://www.cms.gov/hipaa/hipaa1/content/more.asp.
- You may be eligible for continuation of your health insurance coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985, or COBRA. Generally, employers with 20 or more employees qualify for COBRA and must allow you the opportunity to continue your health insurance benefits for at least 18 months after leaving your job. You will have to pay more than when you were employed because you must also pay the premium costs previously paid by your employer. But you will receive the same health benefits while you look for another job or until you purchase health insurance. In some cases, you can apply for health insurance continuance after exhausting COBRA coverage through your State-mandated “High-Risk Pool” Insurance.
- Consider your health insurance situation carefully before agreeing to certain terms and conditions. This is especially important in situations of separation or divorce. Also, you may not want to waive certain survivor or retirement benefits as this could impact your health insurance benefits.
- A court order can be obtained to provide coverage for children under a divorced parent’s health plan, even if that parent does not have custody. This court order is called a qualified medical child support order.
- In most cases, there are strict time limitations in which to apply for benefits. So act quickly to get the right information and file the forms required in order to protect you and your family’s health insurance.
For More Information…
For more information about health insurance contact the National Women’s Health Information Center at 800-994-WOMAN (9662) or the following organizations:
Center for Medicare and Medicaid Services, HHS
Phone: (800) 633-4227 (MEDICARE)
Internet Address: http://cms.hhs.gov
Employee Benefits Security Administration
Phone: (866) 444-3272
Internet Address: http://www.dol.gov/ebsa
Health Resources Services Administration Information Center
Phone: (888) 275-4772
Internet Address: http://www.ask.hrsa.gov
State Children's Health Insurance Program, CMS, HHS
Phone: (877) 543-7669 (KIDS NOW)
Internet Address: http://www.cms.hhs.gov/schip
Social Security Administration Office of Public Inquiries
Phone: (800) 772-1213
Internet Address: http://www.ssa.gov
The Center For Women Veterans
Phone: (800) 827-1000
Internet Address: http://www.va.gov/womenvet
TRICARE/Military Health System
Phone: (888) DOD-CARE (363-2273)
Internet Address: http://www.tricare.osd.mil
America’s Health Insurance Plans
Phone: (202) 778-3200
Internet Address: http://www.ahip.org
National Association of Insurance Commissioners (NAIC)
Phone: (816) 842-3600
Internet Address: http://www.naic.org
The Commonwealth Fund
Phone: (212) 606-3800
Internet Address: http://www.cmwf.org
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