Policy & Health Systems
Explanations of healthcare policy and system-level terms that shape how care is covered, delivered, and accessed.
1.Medicaid Expansion - A policy that allows states to expand Medicaid eligibility to cover more low-income adults under the Affordable Care Act.
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2. Medicare vs. Medicare Advantage- Medicare is the traditional federal health insurance program, while Medicare Advantage is an alternative offered by private insurers that combines Medicare benefits and often uses provider networks and additional coverage rules.
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3. Coverage Exclusions- Services or treatments that an insurance plan does not cover, even if they are medically recommended.
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4. Formulary- A list of prescription medications that an insurance plan agrees to cover, often organized by cost tiers.
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5. Utilization Management- Insurance practices used to review and limit services to ensure care is considered medically necessary and cost-effective.
6. Essential Health Benefits- A set of services that ACA-compliant plans are required to cover.
7. Coverage Gap- A situation where a person does not qualify for affordable insurance coverage under existing rules.
8. Medical Policy- An insurer’s written rules explaining when specific services will be covered.
9. State-Level Variation- Differences in healthcare coverage or access depending on where someone lives.
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Medicaid Expansion States
Frequently Asked Questions
1.Why does my insurance cover some services but not others?
Insurance plans follow specific coverage rules, including exclusions and medical policies, that determine which services are considered eligible for payment.
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2.What does it mean when a service is “not covered”?
“Not covered” means the insurance plan has decided not to pay for that service, even if a doctor recommends it.
3.Why does where I live affect my health coverage?​
Healthcare coverage and access can vary by state due to differences in Medicaid expansion, insurance regulations, and provider availability.
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4. What is a formulary and why does it matter?
A formulary is a list of medications an insurance plan covers, and it can affect which drugs are affordable or require additional approval.
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5. Why does my insurance review or limit care my doctor recommends?
Insurers use utilization management to determine whether care meets their standards for medical necessity and cost-effectiveness.