Montana Artists Guide to Individual Health Insurance and Health Care Reform
Since it began as a program of The Actors Fund in 1998 with a grant from the National Endowment for the Arts, the Artists Health Insurance Resource Center (AHIRC) has helped thousands of visual and performing artists and people in entertainment get health insurance.
Through seminars given in cities throughout the country, over 20 regional guides to finding affordable health care, a helpline (1-800-798-8447) staffed by experienced researchers and a website (www.ahirc.org) with over 6000 resources, we try to demystify this often confusing topic and clearly lay out the options available.
What are my rights and protections when buying health insurance?
In Montana, you can be denied health insurance coverage because of a pre-existing medical condition, or offered a policy that has limitations in coverage related to the condition, or charged higher premiums because of the condition, your age or your gender. The look-back period for a pre-existing condition is 36 months, and the maximum exclusion period is 12 months. This is one of the most important inequities addressed by health care reform. Because of the law, no person under 19 years old can now be denied insurance based on a pre-existing condition. Beginning in 2014, no one can be denied health insurance at any age, for any reason.
There are different rules for insurance obtained through an employer, a union, or as a small business. A comprehensive guide to how all of the different types of insurance function in Montana is available from the Georgetown University Health Policy Institute.
Note: in the case of an emergency, federal law protects you from being denied care in an emergency room, regardless of your insurance status and ability to pay.
How do I go about finding a health insurance plan?
The fastest way is to use an Internet-based broker such as www.ehealthinsurance.com. You’ll be asked your zip code, birth date, gender and that’s about it (in other words, you won’t be giving information that will result in dinnertime phone calls from insurance salespeople). As a test, I put in the zip code for Big Sky (I’m a native New Yorker – that’s what I think a town in Montana should be called) and said I was a 35 year old woman who doesn’t smoke. As it turns out, there are 31 plans available to me (if I’m healthy), ranging in cost from $92 a month (with a deductible – out of pocket cost paid before the insurance kicks in – of $10,000, and even after that, a co-insurance [your share] of 30% even after the deductible – ouch!) to $261.65 a month (with a deductible of $2500 but pays 100% of costs after that – much better!).
But I’m actually a 62 year old man. With that scenario, the least expensive premium is $255.21 a month (with an annual deductible of $5,950 and no costs after that) and the most expensive is $695 a month (with a $1000 deductible and 30% coinsurance after the deductible is met).
The amount of $5,950 is an interesting one. It will be the limit of an individual’s annual liability for health care starting in 2014, again thanks to the health care reform law. So there will no longer be medical debt reaching into the hundreds of thousands of dollars – and bankruptcies resulting from it. This particular product is a health savings account (HSA) which is a “catastrophic” insurance plan that you can combine with pre-tax deposits into a savings account (currently $3100). As long as the money is used for medically-related services, it remains untaxed. It rolls over from year to year and at 65 you can use any accumulations however you want. Many people who choose HSAs are surprised at how fast the savings are used by medical costs.
The word “product” used to describe an HSA should give you pause. Most of us don’t like to think of anything related to our health care as a product. But when you purchase health insurance, or health care, that’s what you’re purchasing – a product that has been created to make a profit. We are the only industrialized country that treats the health of its citizens this way.
You can see by all the parentheses and brackets in my exegesis of ehealthinsurance.com just how many factors are involved in your decision-making when you set out to buy health insurance. If you get lost, call us and we’ll explain what you’re getting for your money, and what you’re not. By the way, the only two insurers that came up for Big Sky were ClearOne and BCBS of Montana. Note: there may be others – these are the two paying to be listed on ehealthinsurance.com. Try other Internet-based brokers such as www.HealthCompare.com to find them.
I have a pre-existing condition and no insurer will sell me an affordable plan. Do I have any options?
Yes. An organization called Montana Comprehensive Health Association (MCHA) offers a number of different plans to “high-risk” individuals, or people who have been denied health insurance due to a medical condition. At one time there was a premium assistance program available but that is currently closed to new enrollments. A detailed description of the program, plans, premium rates, application and an online brochure that will guide you through the quite complex options are available at mthealth.org.
The Montana Affordable Care (MAC) Plan is new and part of the health care reform law. You will need to have a pre-existing condition (now it works for you!) and have been uninsured for the prior six months. There is a $2500 deductible and you will pay 30% of costs in network and 50% out of network. The out of pocket maximum (the most you can be liable for in any year) is $5950. Monthly premiums for the plan are based on age, and range from $171 (up to 17 years old), to $306 at 40 and $681 at 64. Go to The MAC website for the plan details and the application, or call MCHA at 1-800-447-7828, ext. 2128 for assistance.
I can’t afford private insurance. Are there any government-subsidized programs that can help me?
Well, there is Medicaid. Medicaid is a public health insurance program for those with very limited income and assets. In order to determine income eligibility, Medicaid adds all your sources of income and then subtracts certain deductions. Medicaid's coverage is comprehensive and includes prevention, primary care, hospitalization, prescriptions, and other services. There are no premiums. To be eligible, you must be very low income and fit into an approved group, such as pregnant women and people with disabilities. Single adults who do not fit into one of these categories, even if their income meets the eligibility requirement, are not eligible.
Here again, the health care reform will have a significant impact. Eligibility for almost all government health care programs, including Medicaid, is based on your income, figured as a percentage of the Federal Poverty Level (FPL), as well as other requirements. The 2011 FPL for one person is $10,890 and for a family of four is $22,350. In 2014 Medicaid eligibility will be expanded to include all people with incomes up to 133% of the FPL.
The best way to apply for Medicaid, and many other of Montana’s government-subsidized programs, is to apply on-line at Montana Connections.
Are there special programs for certain age groups?
Healthy Montana Kids (877-543-7669) is a free or low-cost health insurance plan for children under 19. Income eligibility depends on family size, e.g., a family of 2 has a limit of $36,775 while a family of five has a limit of $65,425. There can be some cost-sharing – e.g., co-payments – but it cannot exceed more than $215 a year for a family.
Montana WIC provides nutritional foods and many other services free of charge to pregnant women, breastfeeding and postpartum women, infants and children up to the age of five.
With health care reform, adult children under the age of 26 can enroll in their parent’s coverage. Those already on their parent’s coverage can stay on it up to age 26. Unlike some state plans that have permitted young adults to stay on their parents’ insurance but had to pay the full premium, this program treats the young adult as simply another dependent.
And there is, of course, Medicare for those 65 and older and the disabled. Medicare.gov is an excellent resource, and the Medicare Rights Center has an interactive website and a helpline: 1-800-333-4114.
I have a special health condition. Are there any public health programs that cover it?
Montana AIDS Drug Assistance Program (ADAP) provides HIV anti-retroviral drugs, medications to prevent opportunistic infection, and certain drugs to treat HIV-related disease for individuals who are uninsured or under-insured and who are unable to pay for such treatment. Eligibility is currently 330% FPL. For an application call the Montana AIDS Program at (406) 444-4744, or e-mail jnielsen@mt.gov.
Montana Cancer Control Programs (888-803-9343) offers free and low-cost screening services including mammograms, clinical breast exams, Pap tests and pelvic exams for the early detection of breast and cervical cancers and colonoscopies. The income guidelines range from a yearly income for one person of under $21,660 up to $74,020 for a family of 8. Women who are subsequently diagnosed with breast or cervical cancer may be immediately eligible for limited Medicaid.
I’m not eligible for employment-related coverage or government programs, and I can’t afford insurance. What should I do?
It is possible to get affordable health care for common conditions without health insurance by taking advantage of sliding-scale programs at public hospitals and community clinics, which set fees based on your income.
There are many community clinics which provide primary care and operate on a sliding-scale basis. The Partnership for Prescription Assistance has information on over 150 pharmaceutical patient assistance programs which offer low-income, uninsured or underinsured patients free or low-cost medications.
Some major retailers offer lower-cost medication. Wal-Mart and Target both offer over 300 generic medications for $4 for a 30-day supply.
I have mental health needs and I don’t have insurance. What should I do?
The Montana Suicide Prevention Crisis line is (800) 273-TALK (8255). Montana uses the National Suicide Prevention Lifeline as its primary suicide hotline number. The services are free and confidential. Callers are routed to the nearest crisis center in Montana – either Voices of Hope in Great Falls, or the Help Center in Bozeman.
The National Mental Health Services Locator offers a comprehensive database of mental health facilities, services, advocacy groups and resources. Substance abuse treatment facilities are also listed. Some clinics provide mental health counseling and set fees for services based on your income.
As an artist, will the health care reform law increase my access to health care?
Many of the changes created by the law are aimed at the individual and small business health insurance market where the majority of artists find themselves. The existence of a mandate to purchase insurance is accompanied by a series of mechanisms to make that insurance affordable, i.e., keep it near 8% of your income. With the creation of Exchanges where private insurers will compete for your business and a choice of plans on those Exchanges that will allow you to choose your level of cost-sharing, you should be able to find a quality, affordable health insurance plan for yourself and your family.
There will be more options starting in 2014, including special lower-cost, high deductible plans for adults under the age of 30 that will meet the mandate to have health insurance. Prevention benefits and 3 annual primary care visits will be exempt from the deductible.
There will be subsidies to help low and middle income people (artists!) pay monthly premiums so the percentage of their income they use for health insurance will be limited. Exchanges, or competitive, private insurance marketplaces that will offer plans that meet certain quality and affordability guidelines, will be created. The Actors Fund has published a booklet explaining Exchanges and other aspects of the reform law. It’s called EVERY ARTIST INSURED and is available as a pdf download here.
Because Montana legislators, many of whom opposed the health care reform law that benefits so many self-employed workers such as artists, refused to give the state the authority to set up these Exchanges, the federal government will create Montana’s Exchanges. It is a lost opportunity for the state to create a made-in-Montana solution that meets the unique needs of Montana’s population.
The goal of the Artists Health Insurance Resource Center (AHIRC) since it was created by The Actors Fund has been to have every artist insured. We’re not there yet, but we’re getting closer.