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Getting and Keeping Health Insurance in Pennsylvania

Getting and Keeping Health Insurance in Pennsylvania. The Center for Emerging Visual Artists February 28, 2013 Artists Health Insurance Resource Center A program of The Actors Fund Presenter: Jim Brown, Director of Health Services jbrown@actorsfund.org 212-221-7300 x265.

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Getting and Keeping Health Insurance in Pennsylvania

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  1. Getting and Keeping Health Insurance inPennsylvania The Center for Emerging Visual Artists February 28, 2013 Artists Health Insurance Resource Center A program of The Actors Fund Presenter: Jim Brown, Director of Health Services jbrown@actorsfund.org 212-221-7300 x265

  2. http://www.ahirc.org

  3. How can I get health insurance in Pennsylvania? • Employment-related coverage • Private, direct-purchase plans • Government-subsidized programs

  4. What are my protections and 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

  5. What are my protections and 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

  6. Current healthcare reform 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

  7. Current healthcare reform 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

  8. Words to know • Co-pay • Co-insurance • Deductible • HMO • PPO • HSA • Federal Poverty Level • Premium • Reasonable & customary charges

  9. Employment-related options • Job 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)

  10. Employment-related options • Mini-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)

  11. Employment-related options • Small 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

  12. Employment-related options • Unions • Actors Equity • Screen Actors Guild • AFTRA • Writers Guild (East) • Directors Guild • Society of Motion Picture and TV Engineers

  13. School-related options:

  14. I can afford private insurance, but I don’t know what type of 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

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

  16. I’ll be traveling/going on tour. Will I be covered while on the road? • Check with insurer • International travel • http://www.medhealthinsurance.com/traveler.htm

  17. I have a pre-existing condition. What do I do? • HIPAA • 18 mo prior coverage, last day of which was through group plan • Have exhausted COBRANot eligible for public programs or job-related insurance • Receive your HIPAA certificate! • Medicaid, CHIP, Special Pharmaceutical Benefits Program, COBRA

  18. I have a pre-existing condition. 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

  19. I can’t afford insurance. Are there government programs I qualify for? Federal Poverty Levels 2012

  20. Government programs • Medicaid • 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/Compass.Web/CMHOM.aspx

  21. “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/mo • Eligibility: • Cannot be enrolled in or eligible for private or government insurance • Meet income guidelines: 1 person: $21,660 • 1-866-282-2702

  22. Government programs for children • CHIP • 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

  23. Non-insurance options • Sliding-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

  24. I have a special health condition. Are there any programs that 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

  25. I have a special health condition. Are there any programs that 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

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

  27. I need mental health care but I don’t have insurance. Where can I go? • SAMHSA mental health locator: http://store.samhsa.gov/mhlocator • PMHCC: (215)-546-0300 www.pmhcc.org

  28. I have dental problems but no 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

  29. How can I get cheap or free 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

  30. 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

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