There are several types of insurance coverage for health care services:

  1. Private insurance (including group health plans);
  2. Public assistance (Medicaid and Medicare); and
  3. State-funded health benefits plans.


Because the coverage and appeal rights differ based on the type of plan and by state, it is important to read both your member handbook and the governing state law to determine what type of coverage you have and your respective appeal rights.


Private insurance is either provided by your employer or obtained on your own. Though it depends on the issue, private plans are generally governed by state law and enforced by each state’s Department of Insurance.


Services and procedures covered under private plans vary widely. Some private plans may require referrals for special services, or may require you to use certain providers to receive coverage. Additional costs or copayments may be required if you elect to use providers outside of your plan’s network.


Public assistance programs include Medicaid (Individual State Plans, Early and Periodic Screening, Diagnosis and Treatment [EPSDT] program, managed care, or waiver programs) and Medicare coverage.


Medicaid is a federal-state entitlement program for low-income Americans. There are three basic groups of low-income people: parents and children, the elderly, and the disabled.


The eligibility rules for Massachusetts’s state Medicaid program, known as MassHealth, vary depending on the program. Think of MassHealth as a room with many doors. Not everyone enters the program through the same door, but once you get inside (i.e. become eligible), the available benefits are the same and are dependent on the necessity of the member.


One key difference to this notion is for people who need long-term care benefits. Long term care benefits consist of:

  1. Institutional or nursing-home level care
  2. Some community-based services
  3. Home and community-based waiver services which either prevent institutionalization or return members to the community from an institutional setting


To be eligible for Medicaid, there are income limits that vary depending on the program, and those income calculations are complex. For example, the MassHealth programs that require limited financial resources typically require applicants to have no more than $2,000 in countable assets.


Each state’s Medicaid State Plan provides the following mandatory services: in- and out-patient hospital treatment; lab tests and x-rays; EPSDT services; home healthcare; physician services; nurse midwives; family assistance; and nursing homes for those over the age of 21.


Additionally, each state may elect to include any of the following optional services:

  • Residential treatment centers
  • Optical appliances
  • Dental
  • Optometry
  • Chiropractic
  • Psychology
  • Podiatrist
  • Prosthetics & orthotics
  • Drugs during long-term care
  • Durable medical equipment
  • Hearing aids
  • Hospice
  • Transportation
  • Private duty nursing services
  • Personal care services
  • Clinic services
  • Therapies (ST, OT & PT) and intermediate care (ICF/MR)
  • In-patient psychiatric care for those under 21 and older than 65


Among the mandatory Medicaid services contained in the state Medicaid plan is the EPSDT Program. EPSDT services must be made available to every Medicaid-eligible child under the age of 21. Under EPSDT, the state must provide four types of screening services: medical, vision, dental, and hearing. The state is also required to provide coverage for medically necessary treatment.


EPSDT covers a wide range of treatment services, including all Medicaid mandatory and optional services when they are medically necessary to “correct or ameliorate defects and physical and mental illnesses and conditions,” regardless of whether such services are covered under the state plan.


Covered services under the EPSDT Program may include case management, home health care, personal care, private duty nursing, physical therapy and related services, respiratory care, hospice care, rehabilitation, durable medical equipment, hearing aids, eyeglasses, medically necessary orthodontic care, and personal care services.


In order to obtain and maintain coverage, your treating physician must provide written documentation that the requested service is medically necessary. The agency or individual that provides services should always keep precise notes on your condition and your continued need for the particular service. Without this documentation, medically necessary services are frequently reduced or terminated.


Many states offer home- and community-based Medicaid-funded waiver programs that provide disabled individuals with care both in the home and in the community as an alternative to institutional care.


In Massachusetts, we have a brain injury waiver, a Money Follows the Person (MFP) waiver—now called the Moving Forward Plan waiver—to return to the community from institutional care, a Katie Beckett (Kaleigh Mulligan) waiver for nursing services for medically fragile children, a brain injury waiver, a waiver for intellectually disabled adults, and a children’s autism waiver.


Medicare is a partner program to Social Security, which provides both a health and financial safety net to individuals 65 years and older, and to those who have been declared disabled for at least 24 months.


Medicare is divided into two parts. Part A covers hospital and limited nursing care. Part B, which requires an extra premium, covers physician services as well as a variety of therapies and other items. Medicare also has copayments and deductibles.


Self-Funded/Self-Insured Plans are insurance plans offered by a private employer, in which the employer (not an insurance company) assumes the risk of insuring its employees. Under such an arrangement, the employer hires an insurance company to administer the plan and handle all of the claims. Self-funded plans have greater latitude regarding what they do and do not cover under the plan.