INSURANCE 101

Health insurance is a contract between you and your health insurance provider. In a typical contract, providers pay a portion of your medical expenses if you get sick or hurt in return for your payment of a monthly premium. The health providers wager that they’ll take in more money in premiums than they have to pay out in benefits.

On this page you can find the various forms of health insurance. You also will find information on how to choose coverage and what to know during times of transition, such as a life event or a new job.

Types of Insurance

There are many different types of insurance payers, plans and programs in the United States, each catering to different populations with different needs.

Individual and Group Insurance

Individual or group insurance is a form of private health insurance offered by health insurance companies and other entities. Employers may provide health insurance to employees.You also can buy individual health insurance for yourself directly from an insurance company or through a health insurance marketplace, also called a health insurance exchange.

If you purchase insurance through a health insurance marketplace, you are guaranteed a minimum level of coverage for key services called essential health benefits. These plans may not discriminate against you if you have a pre-existing condition and may not cap annual benefits. You also might be eligible for financial assistance, depending on your income or other factors. When applying through a health insurance marketplace, you automatically are screened for Medicaid and/or Child Health Insurance Programs (CHIP) eligibility.

Public Insurance

Medicare

Medicare is a program run by the federal government that provides health insurance coverage if you are 65 and older, regardless of income level, or if you have been receiving Social Security Disability (SSD) assistance payments for a certain amount of time (usually two years). Medicare is broken down into four main parts: A, B, C and D. Learn more about Medicare.

Medicaid and CHIP

Medicaid programs are state programs that provide health insurance coverage based on income thresholds. Some states cover all individuals below a specified income limit. Other states only offer Medicaid coverage to low-income individuals who are disabled, an older adult, have children or are pregnant. Medicaid program names vary by state.

Child Health Insurance Programs, or CHIP, are state programs that provide low-cost health insurance coverage for your children if you earn too much income to qualify for regular Medicaid coverage, but can’t afford private health insurance.

If you have a child and need help finding health insurance, Insure Kids Now! offers resources for free and low-cost health insurance.

Military Plans

Military plans are designed to provide for and cover the costs of your medical services for active-duty military. That also applies to retirees, veterans and their families.

Veterans Affairs (VA) is responsible for providing federal benefits to veterans and their dependents. The VA provides coverage for basic and preventative care.

CHAMPVA is a health benefit program for the families of veterans with 100% service-connected disability and surviving spouses or children of veterans who die from service-connected disabilities. The VA determines eligibility and processes CHAMPVA claims.

TRICARE is the Department of Defense’s managed health care program for active-duty military, personnel, retirees and their families. PHA represents the needs of TRICARE beneficiaries affected by PH before the Uniform Formulary Beneficiary Advisory Committee.

Choosing Coverage

Choosing coverage often can be difficult. In some cases, you might be on your company insurance plan or a public plan such as Medicaid. But if you are choosing your own coverage or considering supplemental coverage such as Medicare Advantage, the information below offers help on how to select insurance coverage that is right for you and your family. Your medical team can be an important resource in this process.

Here are items to consider as you think about your coverage options:

  • The premium, or monthly cost, you would pay to maintain this health insurance. Plans with more expensive premiums may cover more services or cover them at a higher rate, making them a better deal in the long run.
  • If there is a deductible, or initial amount that you must pay before coverage begins.
  • The types of medical care you anticipate you might need in the coming year, such as routine tests or hospitalizations, and how much of those costs your plan will cover.
  • If prescription drug coverage is included or must it be purchased separately.
  • The medications you expect to take in the coming year, if they are included in the health plan’s formulary and what your out-of-pocket responsibility will be for each.
  • Whether the pharmacy network includes the specialty pharmacy that delivers your PH medications.

Maintaining Coverage During Times of Transition

It is important to keep insurance coverage in times of transition, such as changes in employment and when turning 18, 26 and 65 years old.

Change in Employment or Employer-Based Coverage

A gain, loss or change of employment can lead to a change in insurance coverage. If you lose your employee-based insurance, COBRA gives you and your family the right to continue group health benefits under your employer’s plan for a limited amount of time.

If your employer changes insurance carriers, be sure to read the new policy, and contact the new carrier to confirm it will cover your PH medications or therapies. If PH therapies or medications aren’t covered under your employer’s new carrier, you should file an appeal immediately.

Social Security offers a trial period for disability recipients to test their ability to work for nine months during a 60-month period while still receiving disability benefits. If your benefits stop because of substantial earnings, you have five years to request that your disability benefits be reinstated immediately if you stop working again. While your case is reviewed, you don’t have to wait to receive your benefits. If your disability benefits stop because of your earnings, free Medicare Part A coverage will continue for 93 months after the trial work period. After that, Medicare Part A coverage can continue through payment of a monthly premium.

Turning 18, 26 or 65 (for American Citizens)

At 18 years of age, children receiving Supplemental Security Income (SSI) must reapply as adults.

If you are 25 years old or younger, you can stay on your parents’ health insurance plan. That applies whether you live with your parents or independently and despite your marital status. Upon turning 26, you must leave your parents’ insurance plan unless you are receiving Social Security Disability benefits. After turning 26, you are eligible for COBRA, which allows you to keep your health insurance for a fee.

Once you turn 65, you are eligible for Medicare.

Other Life Changes

Marriage, divorce, retirement or the loss of a spouse carrying insurance may also change your insurance coverage. If you are approaching a transition, get support and explore your options early.

Additional Resources

Medline Plus provides information on health insurance and other health topics
from the U.S. National Library of Medicine.

Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI)

Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) both provide financial assistance to individuals with disabilities. SSI pays benefits based on financial need. SSDI pays benefits to individuals who have worked long enough and paid into Social Security taxes, regardless of income.

Learn More About SSI and SSDI