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An Artist's Guide to Accessing Health Care in the Philadelphia Area

2009

Funded through the generous support of LINC Philadelphia and The Ford Foundation.

Why do I need health insurance?

Access to quality health care is directly tied to having health insurance. Without health insurance or unlimited funds, you will have little or no control over the care you receive or in the choice of providers of that care.
The cost of care is so great that a surgery, a day or two in the hospital, treatment for a chronic condition, a prescription for ongoing drug therapy, or even several hours in a hospital emergency room can throw you into considerable, even ruinous debt, if you are uninsured.
People without health insurance frequently delay care, and are more likely to be sicker when they do seek care. Not surprisingly, the mortality rates for cancer and other diseases are higher amongst the uninsured.

What are my rights and protections?

You are currently not guaranteed the right to buy health insurance in the state of Pennsylvania. Private insurers can refuse to sell individual insurance because of one’s health status, exclude a pre-existing condition from insurance coverage, or charge a higher premium based on age, gender, or pre-existing condition. HIPAA does provide you with some protections that limit exclusions for pre-existing conditions.

You may be subject to a pre-existing condition exclusion period if you let your insurance lapse for 63 days or more. In that case your insurer can look back at the six months prior to the start of your policy to see if you received care for a mental or physical condition. If so, they can deny payment for any claims related to that condition for up to 12 months. In this situation, you can credit any previous continuous insurance coverage towards your exclusion period.

In the case of an emergency, federal law protects you from being denied care in an emergency room, regardless of your insurance status or ability to pay. If you do not have health insurance and it is not an emergency, hospitals are not required to treat you. However, some hospitals may see patients who are uninsured. For a list of hospitals in the Philadelphia region, visit www.pa-hospitals.com.

What if I have a pre-existing condition?

Pennsylvania does not offer a risk pool, which is a program offered in some states to help people with a personal or familial history of medical problems to purchase coverage, nor is guaranteed issue insurance available. If you meet certain low-income guidelines, you can sign up for adultBasic, a health insurance plan run by the state which does not exclude pre-existing conditions (see below).
All group health plans, usually obtained through an employer or union, must limit exclusions of pre-existing conditions, and prior coverage in a group plan can be used to reduce or eliminate the exclusion period. Employers are, however, permitted to impose a waiting period before you can sign up for benefits. You will receive a HIPAA certificate with your health plan, which is proof of your coverage. In the event that you move from one plan to another, keep this document at least 60 days after it is issued.

How can I get health insurance in the Philadelphia region?

You have three basic options for obtaining health insurance in the Philadelphia region:

Employment or other group coverage
Private, direct-purchase plans
Government-subsidized programs

What are my employment or other group related options?

A job that you hold or a spouse/domestic partner’s job may include access to health insurance.
This is how most people under 65 years old get health insurance. Typically the worker pays part of the cost and the employer/union pays the rest, although some employers require the worker to pay the full cost. This is called group insurance and can be the least expensive way to get health insurance. It is particularly useful to anyone who has a pre-existing condition, since the coverage will begin either immediately or, on average, 90 days after your start date. Some employers also offer Health Savings Accounts that allow you to pay for medical expenses with pre-tax dollars.
A union Many entertainment industry unions offer health insurance to eligible members. Eligibility is achieved through the amount of “union work” done by the performer and for which the employer contributes to the union health benefit.

The Greater Philadelphia Cultural Alliance (GPCA) currently offers individual artists who have Schedule C income the opportunity to enroll in a “group policy” through Independence BlueCross which does have a guaranteed issue policy. Visit www.philaculture.org for more information.

Options for freelancers There are some association plans for which you may be eligible to purchase health insurance at a lower rate. Additional requirements usually apply for insurance coverage. The following associations offer health insurance, though not at significant discounts; coverage is not guaranteed:

COBRA COBRA is a federal law that allows you to continue the group insurance you previously had through a job, parent, or spouse for 18 months (and in some cases up to 36 months). The cost can be high, but is often less expensive than buying insurance on your own. Employers who have more than 20 employees must offer you COBRA and it is optional for small employer groups.
You have 60 days from the date of your COBRA notification letter to decide if you want to continue your insurance through COBRA, and 45 days from the decision date to make your first payment. Call 1-866-275-7922 or visit The U.S. Department of Labor.

Federal COBRA subsidy Under the American Recovery and Reinvestment Act of 2009 (ARRA), the federal government will pay 65% of your COBRA premium for up to nine months. You are eligible if you have been offered COBRA and you were involuntarily terminated from your job between September 1, 2008 and December 31, 2009. If you were terminated after September 1st and did not elect COBRA, you have another 60 days to enroll. Pre-existing condition exclusion periods do not apply. Contact the Department of Labor for more information.

A school If you are a teaching artist you may be eligible for health insurance as an employee. If you are a student most colleges and universities offer health insurance at a greatly reduced cost, so you may want to investigate coverage through your school. If you are a full-time student and your parents claim you as a dependent you are eligible to remain on their plan to the age of 23 (and possibly up to 25 if their employer allows). Additionally, if you are a college graduate, the alumni association of your college may offer an affordable plan.

I can buy private insurance, but I don’t know which type to get based on my needs. How can I determine what product to buy?

First, consider the financial and medical risks you are willing to take. Then talk to your doctor or find doctors you are comfortable with and ask what insurance carriers they accept. Private, direct-purchase plans can be divided into 3 types:

HMO plans, which limit the providers you can see to those in their network.
PPO/POS plans, which have a network of participating providers but allow you to go outside the network at an increased cost, which you often pay directly and file for reimbursement.
HSAs (Health Savings Accounts), which combine tax-sheltered funds for health care with a high-deductible insurance plan.

Estimating your needs Plans vary widely in price and services provided, as costs can include premiums, co-pays, deductibles and co-insurance. Knowing how you use medical care will help you find the right coverage. Your personal history and needs are important in calculating these projected costs, especially if you have a chronic condition. It also helps to know what an average person consumes each year to help you estimate your possible out-of-pocket costs that are in addition to the premium cost.
On average, a person visits a physician 5.5 times a year — this includes annual visits to a gynecologist or a family practitioner as well as other specialists such as dermatologists, etc. Other statistics show that on average each person will have 12 prescription drugs filled a year and at least one lab or x-ray completed each year. In deciding whether you should take a higher or lower co-payment plan, add the estimated out-of-pocket costs (co-pays, coinsurance, etc.) for each plan to the yearly premium amounts. The expected total costs show which plan makes better sense for your budget. A plan with high premiums but low co-payments may cost you more than a plan with low premiums and higher co-payments.
Remember that averages do not reflect each individual’s distinct needs. It’s important to review your recent medical history to guide your decisions, although the past may not be a predictor of future risk.
Health Savings Accounts work best if you are young, healthy and make limited use of the health care system. High deductible plans such as these generally have lower monthly premiums, covering preventive care at 100% but requiring you to pay more for medical expenses up front.
For access to premium rates for private insurers in Pennsylvania, visit www.ehealthinsurance.com and www.ibx.com.

When traveling out of town, will I be covered if I get sick outside of Pennsylvania?

When traveling outside of the Philadelphia region, speak with your insurance carrier about your coverage. HMO plans generally pay claims for life-threatening emergencies only, and POS and PPO plans may pay out-of-network claims according to your contract. If you will be travelling internationally, consider buying travelers’ insurance. MedHealthInsurance has information on medical travel insurance policies

I am unable to afford private insurance. Are there any government-subsidized programs?

Eligibility for government health care programs is based on your income, figured as a percentage of the Federal Poverty Level (FPL). The 2009 FPL for one person is $10,830, for a household of two is $14,570, and for a household of four is $22,050. For more information on the FPL, visit 2009 HHS Poverty Guidelines.

adultBasic is a low-cost health insurance plan for adults subsidized by the state of Pennsylvania. The coverage is administered by private health insurance companies. In order to qualify, your family income must be below 200% of the Federal Income Guidelines, so the maximum income for one person is $21,660; for two people, $29,140; for three, $36,620; for four, $44,100; and for five people, $51,580.
There is a 28-month waiting list, but you should still apply if you believe you are eligible so that coverage can begin as soon as possible. The wait is determined by the date on which you filed a completed application and the rate at which the other enrollees leave the program. While on the waiting list, you can purchase temporary coverage through the private insurance company that covers your county on adultBasic. On average, this cost $313 a month in 2009 and is an option for coverage before adultBasic acceptance, but not a requirement. Choosing to not purchase this coverage will not affect your place on the program waiting list.
When accepted into adultBasic, you pay approximately $35 per month for basic insurance benefits. Modest co-pays are required for some services. There is a co-pay of $5 for doctor visits, $10 for specialist visits, and $25 for emergency room visits, which is later waived if the patient is admitted into the hospital.

CHIP is Children’s Health Insurance Program, a federal and state-funded program that offers comprehensive health coverage to children who are not otherwise enrolled in medical coverage. CHIP is administered by private health insurance companies, such as BlueCross, AmeriChoice, and Aetna. Children 1 to 19 years old are eligible and there is no waiting list to enroll. There is no family income requirement but coverage cost is determined by family size and income. Families must re-qualify for coverage every 12 months.

Medicaid is a publicly funded insurance program. You may be eligible if any of the following categories apply to you and you meet low-income guidelines: you receive Supplemental Security Income (SSI), are 65 or older, blind, disabled, pregnant, or the parent/caregiver of a child. Medicaid coverage is comprehensive and does not require premiums.

Medicare is health insurance for those age 65 and older and the disabled regardless of income, and is divided into different areas of coverage: Part A covers hospitalization, Part B covers outpatient and other medical services, and Part D covers prescriptions. Part A is free while Parts B and D require premiums and coinsurance or co-pays.

I am not eligible for employment-related coverage or government programs, and cannot afford private insurance. Are there any options?

Special Care is a low-cost, limited-benefit policy providing traditional fee-for-service health coverage for uninsured adults and children in southeastern Pennsylvania. No physical exam is needed to apply, and there are no annual deductibles. There are no claim forms with the Special Care participating network. There is also no waiting period, if eligible, to enroll. The monthly costs range from $125 for one adult, to $300 for a family.

Low-cost primary health care may be available through a local community health clinic. Clinics provide affordable health care through a sliding-scale financing system that sets fees based on an individual’s income. Check for a clinic near you or search for health services in your area at:

US Department of Health and Human Services, Health Resources and Services Administration

Pennsylvania Association for Community Health Centers

Philadelphia Health Care Center Locations

What about specific health conditions or issues?

PA Women Infant Children (WIC) is a federally funded program that provides healthy foods and nutrition services to low-income pregnant women, postpartum women, and their infants and children.

The Special Pharmaceutical Benefits Program (SPBP) for low and moderate income individuals and families helps pay for specific drug therapies for the treatment of persons with HIV/AIDS or a diagnosis of schizophrenia.

The PA Department of Health offers a list of HIV anonymous counseling and free testing sites

The HealthyWoman Program provides low-income, uninsured women access to screening and diagnostic services to detect breast and cervical cancers. Diagnosed women may be eligible for limited Medicaid to pay for the cost of treatment.

I am 65 or older. What are my options?

Medicare is a federal health insurance program for people age 65 and older and the disabled. Medicare is divided into different areas of coverage. Please see above for more information.

Pennsylvania Department of Aging aids older Pennsylvanians and provides resources to improve their health and quality of life. Visit the website or contact the APPRISE toll-free helpline at 800-783-7067 for free Medicare counseling.

I cannot afford my medications. Can I get them for less or for free?

PACE, PACENET, and PACE Plus Medicare are Pennsylvania’s prescription assistance programs for adults age 65 and older who meet the low-income criteria.
If you are a veteran, you may be entitled to prescription drug coverage through a VA medical facility.
The Partnership for Prescription Assistance provides information on over 150 pharmaceutical patient assistance programs that provide free or low-cost medications.
Some major retailers offer lower prices on commonly prescribed medications. Walmart and Target both offer over 300 generic medications for $4 for a 30-day supply or $10 for a 90-day supply.

I have mental health needs and do not have insurance. What are my options?

For a comprehensive listing of mental health providers across the state, visit The Mental Health Services Locator.
Some health clinics may also provide mental health services at a fee proportional to one’s income (see above section “I am not eligible for employment-related coverage…”).

I have a dental problem but no dental coverage. What are my options?

Private dental insurance may be purchased from various companies. Plan summaries, comparisons and applications are available at www.dentalinsurance.com.
To find Free or Reduced-Fee Dental Clinics in Pennsylvania by county, visit www.padental.org. In addition, many community health clinics may provide dental care to people who qualify (see above section “I am not eligible for employment-related coverage…”).

University of Pennsylvania Dental School offers an Emergency Care Clinic that is open Monday through Friday. An emergency evaluation, including x-ray, costs $40.00.

Temple University, Kornberg School of Dentistry operates clinics that provide services in every area of dentistry and oral health. Additionally, the school offers emergency service care Monday through Friday.

Kids Smiles is a non-profit dental center providing dental service and education for children. It provides care for children ages 1-15 and operates two Southwest Philadelphia locations.

Where can I find additional information on health-related issues?

Phillyhealthinfo.org is an online resource with a searchable directory and listing of health and medical organizations, events, and other resources for the five-county area.
The Pennsylvania Department of Health website is a comprehensive resource for health care information and services.

How do I find the health care facility I need in the Philadelphia area?

Community health clinics offering low-cost primary care are listed in the above section “I am not eligible for employment-related coverage…”

MinuteClinics are open 7 days a week and available without appointment, currently located inside select CVS Pharmacies.

Urgent Care facilitiesare alternatives to hospital emergency rooms for medical problems that are not life-threatening but should be attended to promptly. The following sites can be used to find Urgent Care Facilities:

Go Urgent Care

Find Urgent Care

Urgent Care Network

For a list of hospitals in the Philadelphia region, visit www.pa-hospitals.com.

The PA Dept. of Health offers a useful locator for many types of health care facilities, including hospitals, pediatric extended care centers, and portable x-ray facilities.

GLOSSARY

Co-insurance: The amount you must pay for your portion of medical fees, usually expressed as a percentage. For example, if you have an 80/20 plan, your insurance will pay 80% of the contracted charges and you are responsible for 20%.

Co-pay: A flat amount you pay for services, such as office visits and prescriptions.

Deductible: The sum of money you pay out of pocket for medical expenses before the insurer starts to pay its part.

Guaranteed issue insurance: Medical insurance that must be issued to a consumer regardless of the consumer's health. Currently in Pennsylvania insurers are not legally bound to provide guaranteed issue insurance to individuals.

HIPAA: The Health Insurance Portability and Accountability Act, which protects workers and their families from being denied access to health insurance coverage when they change or lose their jobs. For more information visit: www.dol.gov

HMO (Health Maintenance Organization): A type of insurance company or plan that provides services through a network of providers. In an HMO, your Primary Care Physician (PCP) is responsible for coordinating your medical care. An HMO does not cover services provided outside of its network.

Look-back period: The maximum length of time that can be examined for evidence of pre-existing conditions prior to enrolling in a health plan.

Network and non-network providers: Doctors and facilities that either work for or contract with an insurer are considered “network providers.” Those that do not are considered “non-network providers.”

Out-of-pocket maximum: The maximum dollar amount of covered health care expenses you could pay each year. Once you reach your out-of-pocket limit, the plan pays 100% of covered expenses for the remainder of the calendar year.

Pre-existing condition: A physical or mental condition which existed before applying for a policy, for which medical care was already recommended or received, and which may not be covered by insurance, or only after a period of time.

Premium: Money paid on a regular basis to an insurer for insurance coverage.

POS (Point-of-Service) /PPO (Preferred Provider Organization): A plan that allows members to use services in or outside of the insurer’s network of providers. Services outside of the network generally require payment of a deductible and co-insurance.

About The Artists’ Health Resource Center

The Health Insurance Resource Center was created in 1998 by The Actors Fund, with a grant from the National Endowment for the Arts, to help people in entertainment and the arts find affordable health care coverage. With in-person counseling in New York and Los Angeles, national telephone support, an Internet database of resources (www.ahirc.org) with over a half-million visitors each year, and more than a hundred Getting and Keeping Health Insurance workshops offered at arts, cultural and human services organizations throughout the country, HIRC works to reduce the number of uninsured artists and expand access to quality, affordable health care.

For more information, contact us at 212.221.7300 ext.265 or on the web at www.ahirc.org, or visit any of the websites listed in this guide.

The laws, regulations, rules and policies on which the information in this guide are based are subject to frequent change. The Artist Health Insurance Resource Center makes no representations or warranties, express or implied, as to the accuracy, completeness, or timeliness of the information in this guide. This guide contains references to companies, organizations, services, and health centers. Inclusion of this information is not an endorsement of the products, services, or care provided. Before commencing, terminating or changing coverage you should confirm the information herein with the appropriate company, organization, or government agency. This guide should not be used in place of consultations with qualified legal and/or medical professionals. In no event will AHIRC or The Actors Fund be liable for any decision made or action taken by anyone in reliance upon the information contained in this guide.