Understanding health coverage

Being uninsured or underinsured does not mean there are no avenues to get health coverage.

Hospitals that accept federal money must provide a certain amount of free or reduced fee care. Check with the hospital's financial aid department to see if you qualify for reduced or charity care.

To start the process of getting care, meet with a caseworker at the hospital to gather relevant paperwork and begin applying for Medicare, Medicaid, and Social Security. Caseworkers or social workers are sometimes assigned by your hospital (though you may have to ask for one). They are there to assist you in managing your family member's care.

Health Insurance Marketplace

A Health Insurance Marketplace is defined as a new way to find quality health coverage. It can help if you don't have coverage or if you have it but want to look at other options.

With one Marketplace application, you can review lower costs based on your income, compare your coverage options side-by-side, and enroll.

The health reform law requires that all American citizens have the opportunity to shop online (or by phone) for the best available insurance coverage to fit their individual needs and budget.

Depending on a person's income, the coverage options provided through the Marketplaces may be a better choice than what is currently offered through an individual's employer, but they may not be. Of course, the Marketplaces will also offer the uninsured choices that may not have been privy to in the past.

Depending on where you live, the Marketplace in your state will be accessible through a website operated by either the federal or state governments.

Healthcare.gov will direct you to the Marketplace in your state, pretty seamlessly. It's certainly the best place to get started.

The Marketplace site will ask you basic questions about your income, your family size, where you live, and will provide an overview of the insurance options (both private and public) for which you qualify. But ultimately, you will have to make decisions based on your own needs, the needs of your family, and your budget.

Where can you get started?

Healthcare.gov will direct you to the Marketplace in your state, pretty seamlessly. It's certainly the best place to get started. The Marketplace site will ask you basic questions about your income, your family size, where you live, etc. and will provide an overview of the insurance options (both private and public) for which you qualify. But ultimately, you will have to make decisions based on your own needs, the needs of your family, and your budget.

Medicare

Medicare is a federal insurance program available to those:

  • 65 years and older (whatever their income)
  • Younger than 65 years with a disability and have received Social Security Disability Insurance (SSDI) for at least 24 months
  • Individuals of all ages who have end-stage renal disease (permanent kidney failure in need of dialysis or a transplant)

Medicare enrollees pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage.

If you're covered under Medicare, the following are some important things to remember:

  • Medicare isn't part of the Health Insurance Marketplace so, if you are already covered by Medicare, no action is needed.
  • Medicare's open enrollment period is October 15 – December 7. During this time, all people who have Medicare can make changes to their health plans and prescription drug coverage. To find out how to make such changes, visit medicare.gov, or call 1-800-MEDICARE.
  • The good news is, if you're on Medicare now, the ACA won't affect your choices, and your benefits won't be changing.
  • According to the Centers for Medicare & Medicaid Services (CMS), no matter how you get Medicare, whether through Original Medicare or a Medicare Advantage Plan, you'll still have the same benefits and security you have now, and you won't have to make any changes.
  • Note: the Marketplace does not offer Medicare supplement (Medigap) insurance or Part D prescription drug plans.

For more information on Medicare, including resources to help you compare coverage options and costs, check current enrollment, or enroll in coverage, you can call 1-800-MEDICARE.

Medicaid

Medicaid is a state-based assistance program serving low-income people under the age of 65. Patients usually pay no part of costs for covered medical expenses, although a small co-payment may be required.

Each state sets its own guidelines regarding eligibility and services so you should contact your local Medicaid office directly. Contact the relevant benefit offices to set up any appointments or interviews needed to expedite the process.

Be aware of any deadlines or important documentation that you may need to provide and keep accurate records of everyone you are in contact with. If you are unsure of your eligibility, it is best to apply and have a caseworker or legal aid office review your application before submission.

The Affordable Care Act (ACA) provided all states with the option to expand their Medicaid programs. Currently, 28 states have expanded their programs. For information regarding the Medicaid program in your state, you can call the Centers for Medicare and Medicaid Services (CMS) at 1-877-267-2323 or visit www.medicaid.gov.

Children's Health Insurance Program (CHIP)

If an individual is under 18 years of age, they may qualify for coverage under their state's Children's Health Insurance Program (CHIP). CHIP provides health coverage to nearly 8 million children in families with incomes too high to qualify for Medicaid, but can't afford private coverage.

Eligibility is determined by each state and is income and disability based. Each state's CHIP or SCHIP program may have a different name. It is important to note that your child may qualify for SCHIP coverage even if denied Medicaid.

Children may also be eligible for some disability benefits from Supplemental Security Income.

Additionally, under the Affordable Care Act, many young adults are now able to remain on their parents' health insurance plan until age 26.

Resources

If you are looking for more information on insurance or have a specific question, our information specialists are available business weekdays, Monday through Friday, toll-free at 800-539-7309 from 9am to 5pm ET.

Additionally, the Reeve Foundation maintains fact sheets on social security as well as Medicare and Medicaid with additional resources from trusted Reeve Foundation sources. Check out our repository of fact sheets on hundreds of topics ranging from state resources to secondary complications of paralysis.

We encourage you to reach out to spina bifida support groups and organizations, including:

  • Center for Medicare and Medicaid Service is part of the Department of Health and Human Services (HHS).
  • CHIP provides health coverage to uninsured children whose families earn too much to qualify for Medicaid, but too little to afford private coverage.
  • Disability.gov serves as the official government website on disability resources for the public. It was created by the federal government to serve as the single online point-of-reference for information and programs related to disability.
  • National Organization of Social Security Claimants’ Representatives (NOSSCR) provides representation and advocacy on behalf of persons who are seeking Social Security and Supplemental Security Income.
  • Social Security Disability Information is the largest of several Federal programs that provide assistance to people with disabilities.

This project was supported, in part by grant number 90PR3002, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.