How Health Benefits Work

The Basics

Everybody should have health coverage so that they can visit the doctor or get medications. It used to be that a lot of people, especially people with disabilities, couldn’t afford to get health coverage or couldn’t even qualify to get it. However, that’s changed. Now, there’s a health coverage option for almost everybody, even if you have a disability.

This article will introduce the health coverage options that are most likely for you:

  • Medicaid, a government program which is almost free if you have low income, whether or not you have a disability.
    • If you get Supplemental Security Income (SSI) benefits, you get Medicaid automatically.
    • If you are elderly or have a disability and you need the level of care typically offered by a nursing home or other institution, Medicaid Waiver programs may pay for services so you can live in your own home instead.
  • Medicare, which you get if you have a disability or are retired, if you or a family member has worked long enough while paying Medicare taxes.
  • Employer-sponsored coverage, which your employer or a family member’s employer helps you pay for.
  • Individual coverage, which you pay for yourself, possibly with the help of government subsidies.
Get covered

Don’t assume that coverage is too expensive or that you won’t qualify. You probably qualify for one of these programs and it may be a lot more affordable than you think.

You can use DB101's Finding the Right Coverage for You interactive guide to get an idea of which program might work best in your situation.

All of these types of coverage have:

  • Clearly defined services they will cover, including most of the physical and mental health needs you may have. For private insurance, all plans must cover Essential Health Benefits. Medicare’s coverage is comparable, while Medicaid offers some additional benefits, like personal assistance services if you need them.
  • Payments you must make. Typically, payments for private insurance are highest and the fees for Medicaid are lowest. Your payments may include:
    • Premiums, a monthly payment you must make whether or not you use any medical services. (Medicaid usually has no premium.)
    • Copayments, a set amount you have to pay for a medical visit or service. The amount of the copayment depends on the service you get.
    • Co-insurance, a set percentage of the cost of a visit or service that you must pay.
    • A deductible, a set amount of money that you pay out of your own pocket each year before the insurance company will begin to pay for certain services. Once you have paid the deductible, you do not have to pay it again until the next calendar year.
  • An out-of-pocket maximum, which is an annual cap on how much you have to spend on copayments, co-insurance, and deductibles. That means you will never have to spend more than $9,450 if you’re single or $18,900 for a family on these expenses.
    • Medicare is an exception: It does not always have an out-of-pocket maximum.

None of these types of coverage:

  • Have annual or lifetime limits on how much you can get in benefits. No matter how much medical care your insurance has to pay for, they can’t stop paying for care you need.
  • Can discriminate against you because you have a disability. They cannot deny you coverage, charge you more, or refuse to pay for certain types of treatment because you have a pre-existing condition.

This article looks at these types of coverage to help you understand which is right for you and how to sign up.

Get help with prescription drug costs

The Kentucky Prescription Assistance Program (KPAP) helps Kentucky residents find and apply for free or low-cost prescription drugs offered offered by drug manufacturers, discount drug programs, and discount pharmacy programs. Learn more about KPAP. To find a KPAP site near you, call 1-800-633-8100.

Note: DB101 keeps track of changes to health coverage and related laws. DB101 has been and will continue to be updated to reflect any changes. For news related to health coverage, visit the Kaiser Family Foundation.

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