Wellness should be your top priority when choosing health insurance. In the United States, where many have to use their private funds to get insured, understanding all of your options matters to find the best coverage you can afford, receive proper care when you need it and make a full recovery as soon as possible while keeping your medical costs low.
Unfortunately, comparing insurance products can be confusing. State-run marketplaces like Covered California make it easy to compare private health insurance plans, while the federal government’s exchange helps you determine whether you qualify for public health programs. Still, knowing where to begin and how to narrow down your options is challenging without a broker. Here’s a primer on public and private health insurance options in the U.S.
What Are the Different Public Health Insurance Programs?
American public health insurance programs typically apply only to specific demographic groups. Generally, their income, age and/or disability requirements determine your eligibility. The most common ones are as follows.
Medicare
Medicare is a federal program for people aged 65 or older. You may be eligible for it earlier if you have a disability or a specific medical condition, like Lou Gehrig’s disease. Medicare has four parts, each with its own separate eligibility rules and distinct coverage features.
Medicaid
Medicaid is a joint federal and state program for individuals with limited resources, qualifying applicants based on various factors, including income, disability, household size and family status. Inpatient and outpatient hospital benefits are mandatory, and states can offer additional coverage. If you live in a state that has expanded its Medicaid program, you may qualify if your household income is below 133% of the federal poverty level.
Children’s Health Insurance Program (CHIP)
CHIP is a joint federal and state program for children and pregnant women from households whose incomes are too high to meet Medicaid’s requirements but too low to afford private health insurance. CHIP’s comprehensive coverage includes routine checkups, doctor visits, immunizations, prescriptions and emergency care.
Indian Health Service (IHS) Programs
The IHS is a health care system that operates its own facilities and provides direct medical services to American Indians and Alaska Natives. This federal agency covers the costs of a broad range of services, including vaccination, inpatient and outpatient hospital care, dental and vision procedures, mental health and substance abuse treatments, prescriptions and others. It also funds trial and urban health programs.
TRICARE
TRICARE is the U.S. Department of Defense’s health care program for active-duty and retired service members, National Guard and Reserve members, their families, survivors and former spouses who meet eligibility criteria, like being married to a service member for at least 15 years. Its coverage includes health care services, a comprehensive pharmacy benefit and medical equipment.
VA Health Care
VA health care is an extensive health care program provided by the U.S. Department of Veterans Affairs (VA) to eligible veterans. Enrolled beneficiaries receive medical care through the Veterans Health Administration’s network of over 1,350 health care facilities, at least 170 VA medical centers and nearly 1,200 outpatient clinics.
State-Funded Programs
States run Medicare and CHIP programs independently and modify their features within federal guidelines.
Additionally, nonfederal government entities can establish their own health insurance programs to help fill the coverage gap for their residents. An excellent example is Washington, D.C.’s Health Care Alliance program. It provides medical assistance to adults aged 21 to 25 in the district who are ineligible for Medicare and Medicaid and whose income is at or below 133% of the federal poverty level.
What Are the Different Private Health Insurance Plans?
Private health insurers in the U.S. offer the following plans, primarily defined by network structures:
- Exclusive provider organization (EPO): This managed care plan covers services only if you receive care from health care facilities and providers within its network, except during emergencies.
- Health maintenance organization (HMO): This integrated health insurance plan focuses on prevention and wellness, covers medical care provided by its network, except in emergencies, and has geographic restrictions.
- Point of service (POS): This plan requires you to choose a primary care provider and get referrals to see specialists.
- Preferred provider organization (PPO): This flexible health plan allows you to receive services from health care professionals within and outside of its network without needing to select a main doctor to manage your general medical needs and to obtain referrals to consult secondary care providers.
The Affordable Care Act of 2010 introduced regulated health insurance exchange markets. These marketplaces help individuals and families find locally available plans, compare coverage features and make informed decisions.
How Do Covered California Plans Compare to Private Health Insurance? A Case Study
Coverage California, the Golden State’s health insurance marketplace, provides guidance on whether you qualify for Medi-Cal programs — the state’s version of Medicaid programs. It also features plans offered by private health insurance providers who voluntarily participate in the exchange. These plans pertain to cost sharing, not quality of care.
Covered California plans can offer more value compared to private health insurance products sold outside the marketplace, as you may receive financial assistance from the government.
Health for California, a licensed health insurance brokerage firm, helps shoppers navigate various health insurance options to maximize wellness coverage and minimize overall out-of-pocket costs. The agency’s certified enrollment counselors provide personalized guidance, enabling you to identify which plans make the most sense for you and/or your family’s needs.
The organization has been helping Californians compare, select and enroll in suitable health insurance plans since 2004. Health for California’s broker services are at no cost to consumers, allowing you to receive expert, impartial advice without inflating the cost of your chosen plan.
Both Public and Private Health Insurance Matter for Wellness
The most effective approach to get your health adequately insured in the U.S. is to take advantage of every public program you qualify for and enroll in a private health insurance plan that suits your individual needs. Combining the two is the winning formula to plug the gap in coverage, attain wellness and stay out of medical debt.
