Insurance, Government Benefits & Community Resources
- Define the core terms related to health insurance.
- Describe the types of private and public health insurance and who may be covered by each.
- List federally funded benefits that CHWs may identify for their clients, including those provided by Medi-Cal.
- Name some community resources that CHWs may identify for their clients.
Introduction
Community health workers (CHWs) help people with their healthcare needs and support them in finding the right services. This lesson will explore the details of health insurance, government programs, and community resources that can help people get the care they need.
Why is health insurance so complicated?
In the last lesson we learned that healthcare in the U.S. is very expensive. Reasons for this include:
- Administrative expenses
- The involvement of companies that aim to make money
- Lack of government oversight
- A high rate of usage of expensive medical technology
Additionally, it's hard to know in advance how much someone's healthcare will cost because there are many different organizations and providers involved. It's also difficult to predict what specific care someone will need, especially if they have a serious injury or illness.
What is health insurance?
Health insurance protects patients from being responsible for large medical bills. When you have insurance, the plan pays for some or all of your medical costs for things like check-ups, illness, or injury. The health insurance system in the U.S. is complicated, but this lesson will give you a basic idea of how it works. It covers two main types of insurance: private insurance and public insurance.
Core insurance vocabulary
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Janice receives her private health insurance through her employer. Use her plan details to figure out what she actually pays out of pocket over the year.
- $3,000 yearly deductible
- $100 monthly premium
- $10 copayment for primary care doctor's visits
- 25% coinsurance for in-network hospital visits and specialty services
- At the start of the year, an in-network hospital visit that would cost $4,000 without insurance
- Monthly primary care visits — 12 times during the year
- A one-time specialty diagnostic test (covered) that would cost $1,000 without insurance
What are Janice's total out-of-pocket costs for the year?
Private Health Insurance
Private health insurance is when you get health insurance from a private company. There are two common ways people get private insurance: through their job (employer-sponsored), or by buying it themselves (individual).
Group plans
Employer-sponsored health insurance, also called group plans, is when your employer chooses and buys insurance for you and your family if you qualify. **Advantages:** Your employer pays part of the monthly cost, and the money you contribute can be taken out before taxes, which means you may pay less in taxes. **Disadvantages:** You can only choose from the options your employer offers, not all employees qualify, some employers don't offer insurance at all, and gig workers (like consultants or delivery drivers) may not be eligible.
Public Health Insurance
Government-funded (or public) health insurance is paid for by the government — local, state, or federal — and helps certain individuals cover their healthcare costs. The two main types are Medicare and Medicaid.
Medicare
Medicare is health insurance provided by the government for people who are 65 or older, as well as those with disabilities or End-Stage Renal Disease (ESRD). To be eligible, individuals need to have worked and paid Social Security taxes for 10 years and have been legal residents in the U.S. for the five years before applying.
The 5 components of Medicare
The 5 components of Medicare
Medicaid (Medi-Cal in California)
Medicaid is a government health insurance program that gives free or low-cost coverage to people and families who have limited income and assets. It is funded by both the federal government and individual states, but each state runs its own program — so eligibility and coverage differ by state.
Any resident of California can get Medi-Cal coverage if they meet the limits for income and assets, or if they meet other requirements. For example, residents whose income exceeds the threshold can receive coverage if they are age 65 or older, AND blind or disabled, AND have already spent a pre-determined 'share' of their healthcare costs in a given month. Monthly premiums vary based on income and family size; many individuals have no premium, no co-payment, and no out-of-pocket cost.
A client has an employer-sponsored plan. Which statement best describes an advantage of getting insurance this way?
Match each Medicare component to what it does.
Government Funded Programs
As a CHW, part of your job is to help people find public resources that can help them. It will be important to understand their financial status and sources of income in order to know what programs they might qualify for or benefit from.
Federally funded benefits and programs
1. Supplemental Security Income (SSI)
A federally funded program that provides income support to eligible individuals who are aged 65 or older, or who are blind or disabled, with limited income and resources.
Medi-Cal Funded Benefits
In addition to core healthcare benefits, Medi-Cal provides access to a variety of other services CHWs will encounter.
Medi-Cal funded benefits
In Home Supportive Services (IHSS)
Personal assistance and in-home services to Medi-Cal beneficiaries who are blind, disabled, or 65+. Helps them stay safely in their homes or continue working. Covers household chores, personal care, and paramedical services.
Community Resources
As a CHW, it's important to know about resources that can help the people we serve. We also need to build relationships with community partners.
Community-Based Organizations (CBOs)
CBOs are groups that help the community by providing specific services or support — finding housing, getting food, accessing healthcare. They can be government agencies or non-profit organizations. CBOs help fill in the gaps between medical care and other important needs that affect people's health.
CBOs include, but are not limited to:
- Aging and disability organizations
- Community health centers
- Home visiting programs
- Childcare providers
- Local domestic violence shelters and programs
- Adult protective services programs
- Homeless services providers
- Food banks
A CHW is helping a 70-year-old client with a low income who lives alone and struggles to afford food and get to appointments. Which programs might be worth exploring? Select all that apply.
What is the quickest way for a client to reach their local United Way chapter to find community resources?
🌟 Lesson takeaways
In this lesson, we discussed the complexities of the healthcare industry and explored the differences between private insurance (employer-sponsored and individual ACA plans) and public health insurance (Medicare and Medicaid — called Medi-Cal in California). We dug into the five components of Medicare, the additional services Medi-Cal offers (dental, transportation, and LTSS programs), and federally funded programs (SSI, VA, Section 8, and SNAP/CalFresh). Finally, we looked at community resources — CBOs, 211, and Area Agencies on Aging — that CHWs use to fill gaps in care related to income, housing, food, childcare, and disability services.
Great work! At the end of this module, you'll join a live discussion with your cohort and an instructor to explore how these resources are used throughout the CHW process. We'll see you there.