Service Tree

Affordable Care Act Insurance Information/Counseling

Organizations that provide consumer assistance for individuals and small businesses wanting to purchase private insurance through the marketplaces for themselves or, in the case of employers, for their employees. Their primary responsibility is to facilitate enrollment of consumers in health insurance plans offered through the marketplaces. The Affordable Care Act (ACA) requires the use of trained navigators to provide in-person education, and eligibility and enrollment assistance; and permits the use of trained in-person assisters and application counselors. The operator of the marketplace determines the process for establishing and managing the navigator program. Operations will vary depending on the model selected by the jurisdiction. Choices include a federally operated (or federally-facilitated) marketplace, a federal/state partnership or a state operated marketplace.

• Service code: LH-3500.0200
• 8 providers

Medicaid Information/Counseling

Programs that offer information and guidance for people who may qualify for Medicaid with the objective of empowering them to make informed choices. Included may be information about the eligibility requirements for Medicaid and how to apply; Medicaid Managed Care options, benefits covered (and not covered) by the program including long-term care and home and community-based services; the payment process for co-payments; Medicaid "spend-down" (the process of reducing income and/or assets an individual possesses in order to qualify for Medicaid); and information about Medicare and the linkages between the two programs. The program may also answer questions about Medicaid services available to individuals with disabilities; and some programs may help people who qualify with enrollment and provide referrals to providers who accept State Medicaid health insurance.

• Service code: LH-3500.4900
• 8 providers

Medicare Information/Counseling

Programs that offer information and guidance for older adults and people with disabilities regarding their health insurance options with the objective of empowering them to make informed choices. Included is information about benefits covered (and not covered); the payment process; the rights of beneficiaries; the process for eligibility determinations, coverage denials and appeals; consumer safeguards; and options for filling the gap in Medicare coverage (Medigap supplement insurance). Also available is information relating to an individual's eligibility for benefits and assistance with evaluating their options and enrolling in a Medicare plan (A, B, C, and/or D) that will best meet their needs. These programs also address coordination of benefits when beneficiaries have other types of health insurance in addition to Medicare (e.g. Medicaid, employer coverage or retiree insurance) and provide counseling and assistance regarding the subsidies that are available to low income beneficiaries enrolled in the Part D Prescription Drug Benefit (which help pay for Part D premiums and reduce the cost of prescriptions at the pharmacy) and the Medicare Savings Programs which help pay for Medicare out-of-pocket costs. They may also provide information about Medicaid and the linkages between the two programs, referrals to appropriate state and local agencies involved in the Medicaid program, information about other Medicare-related entities (such as peer review organizations, Medicare-approved prescription drug plans, Medicare administrative contractors), and assistance in completing related Medicare insurance forms.

• Service code: LH-3500.5000
• 11 providers