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Understanding Health Insurance Coverage – Part 2

Understanding Health Insurance Coverage – Part 2

In Understanding Health Insurance Coverage – Part 1 we set a solid foundation for Part 2 of our series, where we’ll now begin to explore Medicaid, Medicare, and how these two very different types of coverage affect accident victims in various ways–not all of them beneficial. Here on the Blog, we provide our readers with the facts insurance companies don’t want those who have been injured to find out, but have a right to know!

We’ve already fully established an understanding of commonly used healthcare terminology within Part 1. We also looked at the use of authorizations and how this practice can delay patients’ much needed care, who is considered a beneficiary (hint: the policy holder!), and we established what a co-payment covers. We also explored HMO and PPO and offered our readers a look at their inherent differences to allow them to make more informed decisions together with their medical professionals.

While health insurance coverage is wrought with unfair practices for those who truly need it most (a subject we’ll explore in future articles), it’s most important to know what benefits are available in a time of need and how to navigate these to the best of the victim or their family’s ability to avoid falling prey to an insurance company more focused on saving money than providing the care a patient needs to recover.

Unforeseen circumstances such as an accident at the hands of another or an unexpected illness such as the diagnoses of cancer received by those who worked with Monsanto’s Roundup line of products happen by no fault of our own. If the time should come when serious medical issues arise, it’s best to have been well informed beforehand. The old adage “better to have it and not need it, than need it and not have it” can apply to knowledge of both Medicaid and Medicare benefits.

Medicaid, explained

Let’s start by looking at Medicaid benefits. Under normal circumstances, these benefits are approved for children from low-income families, disabled children, and adults who meet income requirements while employed. In special circumstances, a low-income applicant may become eligible for Medicaid benefits in the event they become disabled and qualify for SSI. SSI is also known as Supplemental Security Income and is granted by the Social Security Administration on a case-by-case basis.

In the event that an individual becomes disabled before they qualify for Medicare benefits (which we will explain further in the next section), they are awarded Medicaid benefits once they meet the criteria specified by the Social Security Administration.

Quick facts to know about Medicaid:

  • Medicaid is a public assistance program that must be qualified for under very specific circumstances
  • 1 in 5 Americans will have a qualifying condition to obtain Medicaid benefits in their lifetime
  • Services covered under Medicaid are not subpar to a private insurance plan (or “PPO”), contrary to popular belief. These covered services provided by Medicaid range from physician visits to major surgery in the event it’s determined to be medically necessary and/or lifesaving.
  • In some cases, though they vary (and should be thoroughly researched together with the victim’s physician and lawyer), Medicaid can potentially help accident victims who have become severely or catastrophically injured regain quality of life by allowing them to afford medical treatment that would’ve otherwise been out of reach.

Medicare, explained

Unlike Medicaid, the Medicare system is available to those who have worked a finite amount of years, thusly paying their taxes and ensuring themselves healthcare during their retirement years. However, there are other times that one may qualify for Medicare as well. Specific guidelines must be met, and the Social Security Administration outlines those as well.

The Social Security Administration separates Medicare into four distinct parts, making selecting a plan when the time comes a little more difficult without proper explanation. The four parts of Medicare are known as “A”, “B”, “C”, and “D”. These parts all encompass a different aspect of healthcare, and are not as straightforward as what we explained in our section on Medicaid.

Medicare Part A

  • Part A covers hospital insurance. In the event someone becomes ill or injured and requires an inpatient hospital stay, this portion of Medicare is what will cover them. However, like many insurance plans, Part A doesn’t cover hospital bills in full and the patient may be required to pay a co-pay alongside Medicare’s payout. Depending on the plan, Medicare may only pay up to a certain amount of inpatient hospital days. Every plan is different and it’s important to consult with doctors and health insurance experts to better understand the plan that fits.

Medicare Part B

  • Part B covers health insurance, the same way a health insurance policy (Blue Cross/Blue Shield, Humana, etc). This type of Medicare will cover (potentially with a co-pay or a deductible) X-rays, blood tests, doctor visits, and more. Part B is typically quite expensive until the patient’s deductible is met, but once it is, the plan will more than likely pay for future medical care in full until the next fiscal year, in which the cycle begins again.

Medicare Part C

  • Part C is, simply put, a package that combines both A and B also known as Medicare Advantage plans. These plans usually have a steep monthly premium but offer both hospital coverage and regular doctor visits, X-rays, lab tests, and yearly physicals. Most people prefer a Medicare Advantage plan so they don’t have to be burdened with the headache of wondering whether or not they’re covered. It’s again, important, to fully understand the coverage provided to the beneficiary so as not to fall prey to insurance company schemes that attempt to turn away accident victims from receiving the medical treatment they’re entitled to.

Medicare Part D

  • Part D is short and sweet: optional prescription drug coverage. For those on lifelong or longterm medications, this type of plan is necessary. However, patients may select not to have it. It is always at their discretion and they should consider their longterm needs before making a choice that could affect them physically and financially in the future.

Up next: private insurance and what they’re not telling accident victims!

In Part 3 of our Health Insurance series, we’ll explore private insurance coverage and what these plans can offer those who are able to afford them. However, we’ll also look more closely at the fine print to best provide our readers with the facts they need most: that is, what these insurance companies purposely try to keep those in need of medical treatment in the dark on!

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