Getting and Keeping Getting and Keeping Health Insurance inHealth Insurance in

PennsylvaniaPennsylvania

The Center for Emerging Visual Artists February 28, 2013

Artists Health Insurance Resource CenterA program of The Actors Fund

Presenter: Jim Brown, Director of Health Services jbrown@actorsfund.org 212-221-7300 x265

http://www.ahirc.org

How can I get health insurance How can I get health insurance in Pennsylvania?in Pennsylvania?

Employment-related coverage

Private, direct-purchase plans

Government-subsidized programs

What are my protections and What are my protections and limitations?limitations?

Elimination riders permitted

Group market: ◦6 month look back period/ 12 month

pre-existing condition exclusion◦Credit for coverage if less than 63 day

lapse in policies

What are my protections and What are my protections and limitations?limitations?

No right to insurance

Right to receive care in a life-threatening emergency at any hospital regardless of insurance status

Individual market:◦5 year look back period/ 3 year pre-

existing condition exclusion◦No credit for prior coverage

Current healthcare reform Current healthcare reform protections protections

PCIP (for the uninsured with pre-existing conditions)

Children under age 19 can’t be denied coverage

Adults up to age 26 can stay under parents’ plan

Insurers can’t rescind coverage if you get sick

Current healthcare reform Current healthcare reform protections protections

Lifetime dollar limits on medical coverage are banned

Medicare and new private plans must cover certain preventive services for free

Medicare recipients in donut hole receive 50% off brand-name drugs

Words to knowWords to knowCo-payCo-insuranceDeductibleHMOPPOHSAFederal Poverty LevelPremiumReasonable & customary charges

Employment-related Employment-related optionsoptionsJob or spouse/domestic partner’s job

COBRA Guarantees right to continue coverage Must work for an employer with 20+

employees 18 months (sometimes more) 60 days to sign up (from date of letter) Full premium (at group rate)

Employment-related Employment-related optionsoptionsMini-COBRA

Guarantees right to continue coverage

For employees of small businesses (fewer than 20 employees)

9 months coverage 30 days to sign up (from date of

letter) Full premium (at group rate)

Employment-related Employment-related optionsoptionsSmall business insurance (2-50

workers)◦Guaranteed access to coverage◦Check with local Chamber of

Commerce◦http://www.ehealthinsurance.com

Self-employed: association plans◦e.g., Greater Philadelphia Cultural

Alliance (GPCA) www.philaculture.org

Employment-related Employment-related optionsoptionsUnions

◦Actors Equity◦Screen Actors Guild◦AFTRA◦Writers Guild (East)◦Directors Guild◦Society of Motion Picture and TV

Engineers

School-related options:School-related options:

I can afford private insurance, I can afford private insurance, but I don’t know what type of but I don’t know what type of plan to get.plan to get.

Consider your medical & financial risk limits

Choose carrier & type of policy HMO HSA + high deductible plan

Min deductible: $1200; max OOP: $5950

PPO Short-term insurance

Private insurance rates Private insurance rates https://www.ehealthinsurance.comhttps://www.ehealthinsurance.com

I’ll be traveling/going on tour. I’ll be traveling/going on tour. Will I be covered while on the Will I be covered while on the road?road?

Check with insurer

International travel http://www.medhealthinsurance.c

om/traveler.htm

I have a pre-existing condition. I have a pre-existing condition. What do I do?What do I do?

HIPAA◦18 mo prior coverage, last day of

which was through group plan◦Have exhausted COBRA

Not eligible for public programs or job-related insurance

◦Receive your HIPAA certificate!Medicaid, CHIP, Special

Pharmaceutical Benefits Program, COBRA

I have a pre-existing condition. I have a pre-existing condition. What do I do?What do I do?

PA Fair Care◦Must have been uninsured for 6 months◦Must have pre-existing condition◦Comprehensive; pre-existing conditions

covered immediately◦Premiums vary according to age, type

of plan, and deductible◦$283/mo premium, $1000 deductible◦Out-of-pocket max: $5950/indiv◦http://www.pafaircare.com

I can’t afford insurance. Are there I can’t afford insurance. Are there government programs I qualify for? government programs I qualify for?

Federal Poverty Levels 2012Federal Poverty Levels 2012

Government programsGovernment programsMedicaid

◦Comprehensive ◦Very limited income (36%-185% of FPL) and fit one of these categories: pregnant, blind, disabled, over 65, under 19, or be a parent living with kid under 19

◦No premiums◦No pre-existing condition waiting periods◦2 month application process◦https://www.humanservices.state.pa.us/C

ompass.Web/CMHOM.aspx◦

““Special Care” Special Care” Benefits: limited

◦ 4 office visits/year◦ Covered: maternity, surgery, ER,

chemo/radiation, hospital(21 days only), diagnostics ($1000 only)

◦ No coverage for: drugs, mental health, substance abuse treatment…

Prices vary: 1 person: $162/moEligibility:

◦ Cannot be enrolled in or eligible for private or government insurance

◦ Meet income guidelines: 1 person: $21,660◦1-866-282-2702

Government programs for Government programs for childrenchildrenCHIP

◦Must be under age 19◦Must be uninsured◦Comprehensive◦Premiums and co-pays vary according

to household size and income◦Example: 4 person household, $60,000

income: $60/mo per child◦http://www.chipcoverspakids.com

Non-insurance optionsNon-insurance optionsSliding-scale clinics

Health Center Program: http://findahealthcenter.hrsa.gov

◦ Be Well website: http://bewellpgh.org/category/freesliding-scale-clinics/

◦ PA Association of Community Health Centers: http://www.pachc.com/health_find.html

Retail clinics in pharmacies◦ Minute Clinic http://www.minuteclinic.com

Urgent care facilities ◦ Concentra Urgent Care

http://www.concentraurgentcare.com

I have a special health condition. I have a special health condition. Are there any programs that Are there any programs that cover it?cover it?

SelectPlan for Women◦ Free reproductive-related services

◦ Eligibility: age 18-44, not pregnant, no or limited insurance, income under 185% FPL

Special Pharmaceutical Benefits Program◦Covers HIV/AIDS medications & lab work◦Must have income below 337% FPL◦http://www.dpw.state.pa.us/foradults/

healthcaremedicalassistance/aidswaiverprogram/specialpharmaceuticalbenefitsprogram/S_000352

◦

I have a special health condition. I have a special health condition. Are there any programs that Are there any programs that cover it?cover it?

Healthy Woman Program◦Free mammos for women age 40+◦Free pap smears for women age 18+◦Must go to a participating provider◦Must be uninsured and have income

under 250% FPL◦http://www.pahealthywoman.com

I’m 65. Are there any I’m 65. Are there any programs for people my age or programs for people my age or

older?older?Medicare

◦Part A: hospitalization; automatic at age 65

◦Part B: outpatient services; monthly premium

◦Part D: medications

◦Medigap◦Medicare Advantage Plans (HMOs/PPOs)

replace traditional Medicare◦http://www.medicare.gov

I need mental health care but I I need mental health care but I don’t have insurance. Where can don’t have insurance. Where can I go?I go?SAMHSA mental health locator:

http://store.samhsa.gov/mhlocatorPMHCC: (215)-546-0300 www.pmhcc.org

I have dental problems but no I have dental problems but no insurance. What do I do?insurance. What do I do?

Dental clinics◦http://www.padental.org

University of Pittsburgh School of Dentistry

http://www.dental.pitt.edu/patients/index.php

Negotiate with your dentist

How can I get cheap or free How can I get cheap or free drugs?drugs?

The Partnership for Prescription Assistance◦http://www.pparx.org

$4 Generic Drug programs◦Walmart◦Target

PACE and PACENet◦ For low-income seniors

◦http://www.aging.state.pa.us

Links & Resources Links & Resources

Pennsylvania Department of Health◦Info on facilities, providers, insurers,

health care programs, diseases, etc…◦http://www.health.state.pa.us/

Families USA◦http://www.familiesusa.org

Federal Health Care Reform website◦http://www.healthcare.gov