This guide is for customer support teams or patient representatives who need a better understanding of CMS and Commercial plan types in order to better assist patients.
Flexpa connects to healthcare insurers - the insurance carriers that patients use to pay for care. Healthcare insurers are often called “payers”, as they pay for care, and offer specific plans to patients based on geography, age, and finances. Patients may be confused and list their healthcare provider, the hospitals and clinics that they see their doctors at. While some providers offer insurance services, such as Kaiser Permanente, most do not.
Flexpa covers CMS-regulated plans - Medicare, Medicare Advantage, Medicaid, CHIP, and ACA. The sections below detail more information about these plans, their insurance cards, and finding the plan in Flexpa.
The full list of payers supported today by Flexpa is listed here.
As we identify issues, we add additional synonyms and abbreviations that are searchable in Flexpa Link. For instance, State of Missouri's Medicaid program is also known as MO Healthnet.
#Guiding the patient
The most straightforward way to identify a plan in the case that a patient does not know their insurance carrier is to ask them to show (or look at) their insurance card. The plan specific sections below show examples of insurance cards of different types, but generally the logo and name of the payer is located in the top left corner of the card.
In the event that they do not have their insurance card, you can narrow down the plan type by asking them:
- Their age. If they are over 65, they are on a Medicare or Medicare Advantage plan. They may also be on a Medicaid plan (see dual eligibles below)
- Their income bracket. If they are below the poverty line, they are likely on a Medicaid plan
- For any insurance-related emails, apps, or other documents they might have. This can be a good alternative way to identify the carrier
- Whether they have employer sponsored insurance. Good indicators of this are if they purchased their insurance through their employer or if their employer pays all of part of their monthly premiums. Flexpa does not cover employer based insurances today aside from Anthem and Kaiser Permanente.
#Flexpa Covered Plan Types
A program that covers 65 million Americans ages 65 and older, and those with End Stage Renal Disease (ESRD) or have received disability insurance payments for two years. It is our largest single health care program in terms of spending and our second largest in terms of enrollees after Medicaid/CHIP’s 82 million enrollees.
If the patient is on Medicare FFS, their insurance card would look something like this:
Medicare is the correct payer to select in Flexpa for all Medicare plans:
Learn more about Medicare here.
#Medicare Part A
Medicare Part A was designed for inpatient hospital insurance that will cover hospitalization, inpatient surgery (oftentimes requiring multiple day stays in a hospital), inpatient rehabilitation facility stays, skilled nursing facility care, home health care, and hospice care.
#Medicare Part B
Medicare Part B was designed as medical insurance. It covers doctor’s visits, outpatient care and surgeries that have short stays or no stay, home health care, durable medical equipment like wheelchairs, and preventative care like screenings and vaccines.
#Medicare Part C
See Medicare Advantage below. This replaces Part A, B and D.
#Medicare Part D
Prescription drug coverage that started in 2006 after implementation of the Medicare Modernization Act of 2003. Unlike Parts A and B, this program is not government run. Part D benefits are provided through private plans approved by the federal government. Enrollees must select a plan from a series of these regulated private providers.
#Medicare Advantage (MA)
Medicare Advantage is a privatized version of Medicare, created in its modern form by the Balanced Budget Act of 1997, that combines the coverage for Parts A, B, and D in a single plan. It can also cover comprehensive care for dental/vision/auditory care, and can supplement that basic care like Medigap does. This is all done in a single plan rather than keeping track of the different traditional Medicare programs. Additionally, while nearly all physicians and hospitals take traditional Medicare, Medicare Advantage uses HMOs and PPOs to create a narrower network of providers.
Medicare Advantage plans can be found in Flexpa with the name of the private insurer that runs the plan. For instance, in the examples below, the payer is listed in the top left (UnitedHealthcare and BlueCross BlueShield of New Mexico)
Medicaid is a voluntary federal-state partnership to cover poor Americans. Under the program, the federal government provided matching funds to states to enable them to provide Medical Assistance to residents who met certain eligibility requirements. Medicaid offers benefits not normally covered by Medicare, including nursing home care and personal care services. The main difference between the two main public programs in America is that Medicaid covers healthcare costs for people with low incomes while Medicare provides health coverage for the elderly.
Medicaid FFS programs run by the state will have simple insurance cards that look like this and only list the state:
Medicaid programs run by the state government can be found in Flexpa by searching, for example, “State of Nevada” or “Nevada Medicaid”.
#Medicaid Managed Care Organization (MCO)
Many people think of Medicaid as clearly public insurance, but that’s not quite the case. In the 1980s and 1990s, state governments started delegating the work of their Medicaid programs to private Managed Care Organizations (MCOs) with capitated payments to cover their beneficiaries. This was an attempt to use the private sector to curb cost growth, just like was later tried with private Medicare Advantage. As a result, about 7 in 10 Medicaid beneficiaries are covered with a private MCO plan rather than a traditional government Medicaid plan.
Learn more about MCOs here.
Medicaid programs run by private managed care organizations can be found in Flexpa with the name of the private insurer that runs the MCO. For instance, in the examples below, the payer is listed in the top left (Aetna and Anthem), and the state is listed in the top right (CardinalCare, Virginia's Medicaid Program)
Dually eligible beneficiaries generally describe low-income beneficiaries enrolled in both Medicare and Medicaid. The two programs cover many of the same services, but Medicare pays first for the Medicare-covered services that are also covered by Medicaid.
Dual eligibles can link either or both insurance they have by navigating to the correct Medicaid and Medicare portals.
Children's Health Insurance Program (CHIP)
CHIP provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. In some states, CHIP covers pregnant women. Each state offers CHIP coverage, and works closely with its state Medicaid program.
Learn more about CHIP here.
#Affordable Care Act
#Basic Health Plan
Under Section 1331 of the Affordable Care Act, each state has the option to establish a Basic Health Program (BHP) that provides affordable, comprehensive health coverage to residents who earn too much to qualify for Medicaid, but not more than 200% of the poverty level.
Congress envisioned Basic Health Programs as an in-between level of coverage for people whose income made them ineligible for Medicaid, but whose income was not robust enough to afford the premiums and out-of-pocket costs that go along with purchasing private coverage in the exchange.
Under the Basic Health Program model, the state contracts with one or more private insurance companies to provide coverage to eligible residents. Premiums are set at affordable levels (both NY and MN offer free BHP coverage to most eligible enrollees) and the coverage is robust, providing at least platinum-level coverage to people with income up to 150% of the poverty level, and at least gold-level coverage to people with income between 150% and 200% of the poverty level.
Like Medicaid, enrollment in a Basic Health Program is available year-round for people whose income makes them eligible, although states do have the option to implement open and special enrollment periods.
In contrast, enrollment in private individual market plans and employer-sponsored plans is limited to annual open enrollment periods and special enrollment periods triggered by qualifying life events.
It’s not clear if Basic Health Plans are covered by the CMS Patient Access Rule.
#Qualified Health Plan
The Qualified Health Plan (QHP) Application is available to issuers applying for certification to participate in the Federally-facilitated Marketplaces (FFMs). Health plans, including dental, must meet a number of standards in order to be certified as QHPs. As defined in the Affordable Care Act (ACA), a QHP is an insurance plan that is certified by the Health Insurance Marketplace, provides essential health benefits (EHBs), follows established limits on cost sharing, and meets other requirements outlined within the application process.
More detail on the ACA marketplaces here..
#Not Covered Plan Types
TRICARE is the uniformed services health care program for active duty service members (ADSMs), active duty family members (ADFMs), National Guard and Reserve members and their family members, retirees and retiree family members, survivors, and certain former spouses worldwide. Under the Military Health System (MHS)..
For service members who are entitled to Medicare Part A and B, TRICARE provides Medicare “wrap-around” coverage. Medicare is the primary payer for these beneficiaries. TRICARE serves as a supplement, paying the Medicare deductible and patient cost share.
Notably: A veteran is anyone who has served in the military. A retiree is someone who has either served long enough or has been wounded badly enough to get a pension.
#Veteran’s Health Administration
A single-payer health care system for veterans under the U.S. Department of Veterans Affairs (VA).
Learn more about the VA here..
Employer based insurance plans arose in the WWII era as wage growth was capped. These plans were a way to entice new hires without violating those wage laws.
The Employee Retirement Income Security Act (ERISA) is the main piece of legislation here (along with COBRA and HIPAA). It does not require that an employer provide health insurance to its employees or retirees, but it regulates the operation of a health benefit plan if an employer chooses to establish one.
In a fully-insured plan, the employer pays a per-employee premium to an insurance company, and the insurance company assumes the risk of providing health coverage for insured events.
In fully-insured arrangements, premiums vary across employers based on employer size,
employee population characteristics, and healthcare use. Premiums can also change over time within the same employer because of changes in the demographics of the employed group.
#Self-funded / Administrative Services Only (ASO)
Self-funded health care, also known as Administrative Services Only (ASO) or non-risk medical plans, is a self insurance arrangement in the United States whereby an employer provides health or disability benefits to employees using the company's own funds. This is different from fully insured plans where the employer contracts an insurance company to cover the employees and dependents.
In self-funded health care, the employer assumes the direct risk for payment of the claims for benefits. A recent study has reported that as of 2014, about 81% of workers covered by healthcare through an employer were in a partially or completely self-funded plan, which is up 21% since 1999.
#Federal Employees Health Benefits (FEHB)
The Federal Employees Health Benefits (FEHB) program is the largest employer-sponsored health insurance program in the world, covering more than 8 million Federal employees, retirees, former employees, family members, and former spouses.
FEHB is a system of "managed competition" through which employee health benefits are provided to civilian government employees and annuitants of the United States government.
FEHB is managed by the United States Office of Personnel Management, not the CMS.
When issues are encountered with Flexpa, such as errors, you can refer to the Troubleshooting tips guide to understand different issues.
The patient can submit to our support team directly from Flexpa Link, which will include relevant details about their session:
If all else fails, you can email our support team at firstname.lastname@example.org with specific issues.