Health care has changed in many ways in recent years. Patients and families frequently come to us with questions about insurance coverage and the benefits to which they are entitled. The Department of Care Coordination has prepared this site to help you and your family understand some of the differences among various insurance programs. No insurance program covers everything. Even state or federally funded programs like Medicaid and Medicare have limitations. It is important for you and your family to know about your benefits so you can make good decisions about treatment and care.
Federal and State Programs
Medicare is a federally funded program for people 65 years or older, some disabled people less than 65 years of age, and/or people with end state renal disease.
It has two parts: Part A for Hospital Insurance and Part B for Outpatient medical services.
Traditional Medicare does not cover prescription medications that you need to take at home. Medi-Gap policies help cover costs not covered by Medicare. Some of these plans offer to pay for medications.
Medicare-Choice programs are Medicare HMO programs that may offer special services like prescription glasses or medications. You would need to choose a Primary Care Physician. If you have a Medicare-Choice program, you would not need a Medi-Gap policy.
Call Health Care Finance Administration (HCFA) and ask for your copy of the Medicare booklet (800-633-4227). This will include the latest information on deductibles, co-payments, Medi-Gap plans, and eligibility rules.
MassHealth is overseen by the Division of Medical Assistance and is funded by state and federal government.
This program is available for disabled people, pregnant women or adults with dependent children under age 19, and individuals who have been unemployed for the last 12 months.
MassHealth has different levels of medical coverage. With MassHealth, you are encouraged to choose a MassHealth managed care plan like Boston Health Net or Welfare Managed Care. If you choose such a plan, you select a Primary Care Physician who can get to know you and help you maintain or improve your health.
Employer Programs or Self-pay Insurance Programs
These programs refer to health insurance that you pay privately or have as a benefit from your employer. Always ask for an information booklet that explains your insurance policy and benefits.
HMO - Health Maintenance Organization
You will need to choose a Primary Care Physician (PCP) who helps to work with you to maintain or improve your health. If you want or need to see a specialist, you need to get a referral from your PCP.
If your PCP decides that you need to see a specialist for care, your choices might be limited to health care providers who work closely with your PCP. This is sometimes call in-network care.
Some HMO's offer a "point of service" option that allows patients to go out of network for an additional fee.
Most HMO plans cover the cost of medications with co-payments. Be sure you review the details of your plan.
PPO - Preferred Provider Organizations
A PPO is a managed care plan which allows greater choices of health care providers.
Usually, you still need to choose a Primary Care Physician.
Co-payments and deductibles are usually higher than HMO plans.
Often, you can have choices of physicians and/or hospitals.
This is a traditional insurance program. You do not need prior approval for care.
Usually, it does not pay for any preventative care such as yearly physical exams.
If this is offered from your employer, you might have higher weekly or monthly premium costs. You can have your choice of physician or hospital, but you might have other restrictions. Be sure to review the details of your plan.
If you have questions about your benefits or the services you can have, you may contact Brigham and Women's Hospital Care Coordination at 617-732-6469. Even if your insurance program does not require it, having a primary care physician is a good idea. A primary care physician can work with you so you can get the services you need to keep you healthy or to help you through an illness. If you would like information about connecting with a primary care provider, please let us know or call the BWH Physician Referral Service at 1-800-294-9999.