Government-Run Insurance: What Counts?

Government-run insurance, also known as public health insurance, is sponsored by the federal government, state government, or a combination of both. In the US, public health insurance programs include Medicare, Medicaid, the State Children's Health Insurance Program (SCHIP), the Department of Defense TRICARE, the Veterans Health Administration (VHA) program, and the Indian Health Service (IHS) program. These programs provide health care services to about one-third of Americans, including older persons, persons with disabilities, low-income mothers and children, veterans, active-duty military personnel and their dependents, and Native Americans.

Medicare, for example, provides health insurance to individuals eligible for social security who are aged 65 and over, those eligible due to a disability, and those suffering from end-stage renal disease. Medicaid, on the other hand, serves about 42 million people with low incomes who require health care services to achieve healthy growth and development or meet special health care needs.

Public health insurance is funded largely from taxpayer dollars and is available to some US citizens and permanent legal aliens. It is important to note that government-run insurance is distinct from private health insurance, which is marketed by the private health insurance industry and covers about half of the US population.

Medicare

Part A: Hospital Insurance

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, lab tests, surgery, and some home health care. Most people don't pay a monthly premium for Part A if they or their spouse paid Medicare taxes while working. If you don't qualify for premium-free Part A, you can buy it, with the standard premium being $505 in 2024.

Part B: Medical Insurance

Part B covers certain doctors' services, outpatient care, medical supplies, durable medical equipment, home health care, and preventive services. Everyone pays a monthly premium for Part B, with the standard premium amount in 2024 being $174.70.

Part C: Medicare Advantage Plans

Part C is a private insurance option that bundles Part A, Part B, and usually Part D into one plan. These plans may offer extra benefits not covered by Original Medicare, such as vision, hearing, and dental services. Costs and rules for how you get services can vary depending on the plan.

Part D: Prescription Drug Coverage

Part D helps cover the cost of prescription drugs, including recommended shots or vaccines. Each plan can vary in cost and specific drugs covered but must provide at least a standard level of coverage set by Medicare.

Original Medicare vs Medicare Advantage

With Original Medicare, you pay for services as you get them. You have the option to add a separate drug plan (Part D) and supplemental coverage, like Medigap, to help lower your share of costs. With Medicare Advantage, you get a bundled plan from a private company that includes Parts A, B, and usually D. These plans have yearly contracts with Medicare and must follow its coverage rules. You must decide how you want to get your Medicare coverage each year and can choose to add or switch drug coverage.

Medicaid

Eligibility for Medicaid is determined by both financial and non-financial criteria. Financially, Medicaid is designed for individuals with low incomes or limited resources. Non-financially, beneficiaries must be residents of the state in which they are receiving Medicaid and meet certain age, pregnancy, or parenting status requirements. Additionally, individuals must be either US citizens or certain qualified non-citizens, such as lawful permanent residents.

State Children's Health Insurance Program (SCHIP)

The State Children's Health Insurance Program (SCHIP) is a government-run insurance program that was formerly known as the Children's Health Insurance Program (CHIP). SCHIP is a partnership between the federal and state governments that provides matching funds to states for health insurance for families with children. The program was designed to cover uninsured children in families with modest incomes that are too high to qualify for Medicaid but too low to afford private coverage.

SCHIP was passed into law as part of the Balanced Budget Act of 1997 and is administered by the United States Department of Health and Human Services. The program is funded by both state and federal governments and is managed by states according to federal requirements. SCHIP provides low-cost or free comprehensive health coverage, including routine check-ups, immunizations, doctor visits, and prescriptions, as well as dental and vision care, and inpatient and outpatient hospital care.

Each state offers CHIP coverage and works closely with its state Medicaid program, but CHIP benefits vary across states. All states have an approved plan, and by February 1999, 47 states had set up CHIP programs. SCHIP typically covers children up to the age of 18 or 19 from families with incomes too high for Medicaid but below 200-300% of the federal poverty level. In some states, CHIP also covers pregnant women.

SCHIP has been reauthorized multiple times since its creation, including in 2009, 2015, and 2018, with the most recent reauthorization extending the program through 2027.

Department of Defense TRICARE

TRICARE is the health care program for service members, retirees, and their families worldwide. It is a government-managed health insurance program for the US military, managed by the Pentagon's Defense Health Agency. TRICARE is a registered trademark of the Department of Defense (DoD).

TRICARE provides comprehensive coverage, health plans, special programs, prescriptions, and dental plans. It brings together the health care resources of the Military Health System, including military hospitals and clinics, with a network of civilian health care professionals, institutions, pharmacies, and suppliers.

TRICARE offers different health care plans for different situations. There are plans for active-duty service members, their families, reservists, retirees, and more. The specific plans include Tricare Prime, Tricare Select, Tricare Reserve Select, Tricare for Life, Tricare Young Adult, and the Tricare Dental Plan.

Tricare Prime is a managed service healthcare program for service members, reservists, dependents, and some retirees. It is similar to a civilian health maintenance organization (HMO). Users are assigned a primary care manager and must get referrals to access specialty care. User costs depend on military service status. For example, an active-duty family enrolled in Tricare Prime pays no fees as long as they follow referral rules, but retiree families do pay out of pocket.

Tricare Select is a fee-for-service insurance plan available to family members, veterans, and retirees. It is similar to a civilian preferred provider organization (PPO). Users can select their own primary care manager and self-refer to specialists. While some provider appointments, such as well-child visits, carry no fees, others do. How much users pay and whether they face an enrollment fee depends on their service status.

Tricare Reserve Select is a plan for traditional Guard and reservists and functions like Tricare Select, with the difference that users must pay a monthly premium.

Tricare for Life is a program that provides supplemental health coverage for retirees and their spouses over the age of 65. To use this program, retirees must also be enrolled in Medicare Part B and pay Part B monthly premiums.

Tricare Young Adult is available in both Prime and Select versions for military dependents who are full-time students between the ages of 23 and 25 or non-students between 21 and 25. Users pay enrollment fees set by law.

The Tricare Dental Plan is managed by a contractor, United Concordia, and is available for purchase by active-duty family members and Guard and Reserve members and their families. Military retirees must purchase dental coverage through the Federal Employees Dental and Vision Insurance Program (FEDVIP).

Veterans Health Administration (VHA)

The Veterans Health Administration (VHA) is a component of the United States Department of Veterans Affairs (VA) that provides healthcare and healthcare-adjacent services to veterans. It is the largest integrated healthcare system in the US, with 1,321 healthcare facilities, including 172 medical centres and 1,138 outpatient sites of care, serving 9 million enrolled veterans annually.

The VHA provides primary care, specialised care, and related medical and social support services. This includes regular check-ups, appointments with specialists, home health and geriatric care, medical equipment, prosthetics, and prescriptions. The VHA also offers mental health services, with free and confidential counselling and treatment for mental and physical health conditions related to military sexual trauma.

The VHA is divided into 21 distinct service regions, called Veterans Integrated Service Networks (VISN), that provide funding and care to its medical centres and associated clinics. Funding for each VISN is based on the anticipated number of veterans enrolled in care within the covered region. The VHA has initiatives in place to provide a "seamless transition" for newly discharged veterans moving from Department of Defense healthcare to VA care for conditions incurred during service.

The VHA is the second-largest division in the entire federal government, employing over 350,000 employees. All VA hospitals, clinics, and medical centres are owned and operated by the Department of Veterans Affairs, and all staff are federal employees. As a result, veterans who qualify for VHA healthcare do not pay premiums or deductibles but may have to make copayments depending on the procedure.

Frequently asked questions