CHILDREN'S HEALTH INSURACE PROGRAE(CHIP) IN AMERICA

The Children’s Health Insurance Program (CHIP) provides health coverage to eligible children, through both Medicaid and separate CHIP programs.  CHIP is administered by states, according to federal requirements.  The program is funded jointly by states and the federal government.


Benefits

The Children's Health Insurance Program (CHIP) provides comprehensive benefits to children. Since states have flexibility to design their own program within Federal guidelines, benefits vary by state and by the type of CHIP program.

Medicaid Expansion Benefits

Medicaid Expansion CHIP programs provide the standard Medicaid benefit package, including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, which includes all medically necessary services like mental health and dental services.

Separate CHIP Benefits Options

States can choose to provide benchmark coverage, benchmark-equivalent coverage, or Secretary-approved coverage:

Benchmark coverage based on one of the following:
The standard Blue Cross/Blue Shield preferred provider option service benefit plan offered to Federal employees
State employee's coverage plan
HMO plan that has the largest commercial, non-Medicaid enrollment within the state
Benchmark-Equivalent coverage must be actuarially equivalent and include:
Inpatient and outpatient hospital services
Physician's services
Surgical and medical services
Laboratory and x-ray services
Well-baby and well-child care, including immunizations

Secretary-approved coverage: Any other health coverage deemed appropriate and acceptable by the Secretary of the U.S. Department of Health and Human Services.
Separate CHIP Dental Benefits

States that provide CHIP coverage to children through a Medicaid expansion program are required to provide the EPSDT benefit.  Dental coverage in separate CHIP programs is required to include coverage for dental services "necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions."


States with a separate CHIP program may choose from two options for providing dental coverage: a package of dental benefits that meets the CHIP requirements, or a benchmark dental benefit package. The benchmark dental package must be substantially equal to the (1) the most popular federal employee dental plan for dependents, (2) the most popular plan selected for dependants in the state’s employee dental plan, or (3) dental coverage offered through the most popular commercial insurer in the state.
States are also required to post a listing of all participating Medicaid and CHIP dental providers and benefit packages on www.insurekidsnow.gov.

Vaccines

Coverage for age-appropriate immunizations is required in CHIP. States with a separate CHIP program (including the separate portion of a combination program) must purchase vaccines to be administered to enrolled children using only CHIP federal and state matching funds. Vaccines for federally vaccine-eligible children (through the Vaccines For Children program) should not be used by children enrolled in separate CHIP programs, and funds available under section 317 of the Public Health Service Act are designated for the purchase of vaccines for the uninsured and may not be used to purchase vaccines for children who have separate CHIP coverage.

States have two options for purchasing vaccines for children enrolled in separate CHIP programs: (1) purchase vaccines using the CDC contract and distribution mechanism, or (2) purchase vaccines through the private sectsepara

The Children's Health Insurance Program (CHIP) serves uninsured children up to age 19 in families with incomes too high to qualify them for Medicaid. States have broad discretion in setting their income eligibility standards, and eligibility varies across states.

Income Eligibility

46 States and the District of Columbia cover children up to or above 200% of the Federal Poverty Level (FPL) ($44,700 for a family of four in 2011), and 24 of these states offer coverage to children in families with income at 250% of the FPL or higher. States may get the CHIP enhanced match for coverage up to 300% of the FPL ($67,050 for a family of four in 2011), which is higher than the Medicaid federal funding matching rate. See information on CHIP Financing.

States that expand coverage above 300% of the FPL get the Medicaid matching rate.  States have the option to provide continuous eligibility to children who remain eligible for CHIP.

New Medicaid & CHIP Coverage Options

Lawfully Residing Children and Pregnant Women
Many states have elected the option under CHIPRA to restore Medicaid and/or CHIP coverage to children and pregnant women who are lawfully residing in the United States.


Pregnant Women

CHIPRA created an explicit eligibility category for pregnant women to receive coverage through CHIP in certain circumstances. states have also chosen to provide prenatal care for pregnant women through the CHIP program through other available vehicles.

Children of Public Employees

The Affordable Care Act of 2010provides states the option to extend CHIP eligibility to state employees' children. Before enactment of the Affordable Care Act children of public employees were not eligible for CHIP, regardless of their income.

MEDICARE INSURANCE FOR AMERICAN CITIZENS

What is Medicare?

Medicare is a Federal health insurance program that pays for hospital and medical care for elderly and certain disabled Americans.

The program consists of two main parts for hospital and medical insurance (Part A and Part B) and two additional parts that provide flexibility and prescription drugs (Part C and Part D).


Medicare Part A, or Hospital Insurance (HI), helps pay for hospital stays, which includes meals, supplies, testing, and a semi-private room. This part also pays for home health care such as physical, occupational, and speech therapy that is provided on a part-time basis and deemed medically necessary. Care in a skilled nursing facility as well as certain medical equipment for the aged and disabled such as walkers and wheelchairs are also covered by Part A. Part A is generally available without having to pay a monthly premium since payroll taxes are used to cover these costs.

Medicare Part B is also called Supplementary Medical Insurance (SMI). It helps pay for medically necessary physician visits, outpatient hospital visits, home health care costs, and other services for the aged and disabled. For example, Part B covers:


Durable medical equipment (canes, walkers, scooters, wheelchairs, etc.)
Physician and nursing services
X-rays, laboratory and diagnostic tests
Certain vaccinations
Blood transfusions
Renal dialysis
Outpatient hospital procedures
Some ambulance transportation
Immunosuppressive drugs after organ transplants
Chemotherapy
Certain hormonal treatments
Prosthetic devices and eyeglasses.
Part B requires a monthly premium ($96.40 per month in 2009), and patients must meet an annual deductible ($135.00 in 2009) before coverage actually begins. Enrollment in Part B is voluntary.

Medicare Advantage Plans (sometimes known as Medicare Part C, or Medicare + Choice) allow users to design a custom plan that can be more closely aligned with their medical needs. These plans enlist private insurance companies to provide some of the coverage, but details vary based on the program and eligibility of the patient. Some Advantage Plans team up with health maintenance organizations (HMOs) or preferred provider organizations (PPOs) to provide preventive health care or specialist services. Others focus on patients with special needs such as diabetes.

In 2006, Medicare expanded to include a prescription drug plan known as Medicare Part D. Part D is administered by one of several private insurance companies, each offering a plan with different costs and lists of drugs that are covered. Participation in Part D requires payment of a premium and a deductible. Pricing is designed so that 75% of prescription drug costs are covered by Medicare if you spend between $250 and $2,250 in a year. The next $2,850 spent on drugs is not covered, but then Medicare covers 95% of what is spent past $3,600.


What about services that are not provided through Medicare?

Supplemental coverage for medical expenses and services that are not covered by Medicare are offered through MediGap plans. MediGap consists of 12 plans that the Centers for Medicare and Medicaid Services have authorized private companies to sell and administer. Since the availability of Medicare Part D, MediGap plans are no longer able to include drug coverage.

Who is eligible for Medicare?

To be eligible for Medicare, an individual must either be at least 65 years old, under 65 and disabled, or any age with End-Stage Renal Disease (permanent kidney failure that requires dialysis or a transplant.)

In addition, eligibility for Medicare requires that an individual is a U.S. citizen or permanent legal resident for 5 continuous years and is eligible for Social Security benefits with at least ten years of payments contributed into the system.

Who pays for services provided by Medicare?

Payroll taxes collected through FICA (Federal Insurance Contributions Act) and the Self-Employment Contributions Act are a primary component of Medicare funding. The tax is 2.9% of wages, usually half paid by the employee and half paid by the employer. Moneys are set aside in a trust fund that the government uses to reimburse doctors, hospitals, and private insurance companies. Additional funding for Medicare services comes from premiums, deductibles, coinsurance, and copays.

MEDICAID INSURANCE FOR AMERICAN CITIZENS

What is Medicaid?

Medicaid is a means-tested health and medical services program for certain individuals and families with low incomes and few resources. Primary oversight of the program is handled at the federal level, but each state:

Establishes its own eligibility standards,
Determines the type, amount, duration, and scope of services,
Sets the rate of payment for services, and
Administers its own Medicaid program.
What services are provided with Medicaid?
Although the States are the final deciders of what their Medicaid plans provide, there are some mandatory federal requirements that must be met by the States in order to receive federal matching funds. Required services include:

Inpatient hospital
Outpatient hospital services
Prenatal care
Vaccines for children
Physician services
Nursing facility services for persons aged 21 or older
Family planning services and supplies
Rural health clinic services
Home health care for persons eligible for skilled-nursing services
Laboratory and x-ray services
Pediatric and family nurse practitioner services
Nurse-midwife services
Federally qualified health-center (FQHC) services and ambulatory services
Early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21
States may also provide optional services and still receive Federal matching funds. The most common of the 34 approved optional Medicaid services are:

Diagnostic services
Clinic services
Intermediate care facilities for the mentally retarded (ICFs/MR)
Prescribed drugs and prosthetic devices
Optometrist services and eyeglasses
Nursing facility services for children under age 21
Transportation services
Rehabilitation and physical therapy services
Home and community-based care to certain persons with chronic impairment.


Who is eligible for Medicaid?

Each state sets its own Medicaid eligibility guidelines. The program is geared towards people with low incomes, but eligibility also depends on meeting other requirements based on age, pregnancy status, disability status, other assets, and citizenship.


States must provide Medicaid services for individuals who fall under certain categories of need in order for the state to receive federal matching funds. For example, it is required to provide coverage to certain individuals who receive federally assisted income-maintenance payments and similar groups who do not receive cash payments. Other groups that the federal government considers "categorically needy" and who must be eligible for Medicaid include:

Individuals who meet the requirements for the Aid to Families with Dependent Children (AFDC) program that were in effect in their state on July 16, 1996
Children under age 6 whose family income is at or below 133% of the Federal poverty level (FPL)
Pregnant women with family income below 133% of the FPL
Supplemental Security Income (SSI) recipients
Recipients of adoption or foster care assistance under Title IV of the Social Security Act
Special protected groups such as individuals who lose cash assistance due to earnings from work or from increased Social Security benefits
Children born after September 30, 1983 who are under age 19 and in families with incomes at or below the FPL

Certain Medicare beneficiaries


States may also choose to provide Medicaid coverage to other similar groups that share some characteristics with the ones stated above but are more broadly defined. These include:

Infants up to age 1 and pregnant women whose family income is not more than a state-determined percentage of the FPL
Certain low-income and low-resource children under the age of 21
Low-income institutionalized individuals
Certain aged, blind, or disabled adults with incomes below the FPL
Certain working-and-disabled persons with family income less than 250 percent of the FPL
Some individuals infected with tuberculosis
Certain uninsured or low-income women who are screened for breast or cervical cancer
Certain "medically needy" persons, which allow States to extend Medicaid eligibility to persons who would be eligible for Medicaid under one of the mandatory or optional groups, except that their income and/or resources are above the eligibility level set by their State.
Medicaid does not provide medical assistance for all poor persons. In fact, it is estimated that about 60% of America's poor are not covered by the program.

Who pays for services provided by Medicaid?

Medicaid does not pay money to individuals, but operates in a program that sends payments to the health care providers. States make these payments based on a fee-for-service agreement or through prepayment arrangements such as health maintenance organizations (HMOs).

Each State is then reimbursed for a share of their Medicaid expenditures from the Federal Government. This Federal Medical Assistance Percentage (FMAP) is determined each year and depends on the State's average per capita income level. Richer states receive a smaller share than poorer states, but by law the FMAP must be between 50% and 83%.

States may impose nominal deductibles, coinsurance, or copayments on some Medicaid beneficiaries for certain services. However, the following Medicaid beneficiaries must be excluded from cost sharing:

Pregnant women,
Children under age 18, and
Hospital or nursing home patients who are expected to contribute most of their income to institutional care.
All Medicaid beneficiaries must be exempt from copayments for emergency services and family planning services.