How to Get Affordable Health Care in San Francisco and Oakland

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How to Get Affordable Health Care in San Francisco and Oakland

Funded through the generous support of Leveraging Investments in Creativity (LINC)/Ford Foundation, The California HealthCare Foundation and The Center for Cultural Innovation.



Why do I need health insurance?

  • Access: Access to quality health care is directly tied to having health insurance. Without health insurance or unlimited funds, you will have little or no say in the care you receive or in the choice of providers of that care.

  • Cost:  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 on-going drug therapy, or even several hours in a hospital emergency room can throw you into considerable, even ruinous debt, if you are uninsured.

  • Better Outcomes:  People without health insurance frequently delay care, and are more likely to be sicker when they seek care. Not surprisingly, the mortality rates for cancer and other diseases are higher among the uninsured.

What are my rights and protections?

If you are not insured through your employer, union, or some other type of group, you are currently not guaranteed the right to buy health insurance in California. Private insurers can refuse to sell you insurance because of your health status or charge you a higher premium based on your age, gender, or pre-existing medical condition. Insurers can define pre-existing conditions as those for which you received a diagnosis, treatment or medical advice during either a 6 or 12 month period prior to the start of your policy. (Time periods vary depending on the number of people insured under the policy). Coverage for pre-existing conditions can be excluded for a maximum of 12 months. However, the amount of time you were covered under your previous insurer may be credited toward your pre-existing condition exclusion period if you have not had a break in coverage of 63 days or more. This credit can cancel out or reduce the length of a pre-existing condition exclusion period. For those accepted by a plan, the premium (monthly payment) will be determined by several factors, the most important of which is age. If you are denied health insurance, you will have access to MRMIP, California’s high-risk plan (see below), but this is an expensive and limited alternative. You may also be eligible to buy an insurer’s HIPAA plan (see below). If you are HIPAA eligible, no pre-existing condition exclusion period can be imposed.

If you are insured through your employer, union, or some other type of group, you cannot be denied insurance because of your medical history.Insurers can count as preexisting conditions those for which you received medical advice in the 6 months prior to the start of your policy. Coverage for pre-existing conditions can be excluded for a maximum of 12 months. However, the amount of time you were covered under your previous insurer may be credited toward your pre-existing condition exclusion period if you have not had a break in coverage of 63 days or more. This credit can cancel out or reduce the length of a pre-existing condition exclusion period. If you lose coverage under a fully insured group plan, you may be able to buy a conversion policy. This type of policy cannot impose a pre-existing condition exclusion period, but benefits may be limited.

Please note that in an emergency, federal law protects you from being denied care in a hospital emergency room, regardless of your insurance status and ability to pay. For easy-to-understand information on your rights as a consumer, visit www.healthinsuranceinfo.net.


How can I get health insurance in the Bay Area?


You have three basic options for obtaining health insurance in the Bay Area:

  • employment or organization-related coverage
  • private, direct-purchase plans
  • government-subsidized programs


What are my employment-related options?

A job or a spouse/domestic partner’s job. This is how most people under 65 years old get health insurance. The worker usually pays part of the cost and the employer/union pays the rest. This is called group insurance. Coverage of pre-existing conditions may be excluded for a period of time. A waiting period may be imposed before you can sign up for coverage.
A union Entertainment industry unions offer health insurance to eligible members. For performers, eligibility is achieved through the amount of “union work” in which an employer contributes towards the union health benefit.

Small business insurance In California, small employers (with 2 to 50 full-time employees) are guaranteed the right to buy group coverage regardless of their employees’ health status. (This is what is referred to as guaranteed issue insurance). This type of coverage can be an option for those who might otherwise be rejected for individual insurance. For comprehensive information on small business insurance visit www.HealthCoverageGuide.org.

COBRA/Cal-COBRA are laws that let you keep the same insurance you had through an employer or union after you’ve left your job or become ineligible for benefits. You will pay the full premium, i.e. both your share and the amount your employer or union was paying on your behalf. COBRA/Cal-COBRA can be quite expensive, but may be cheaper than buying an individual policy; it may also be your only option if you have a pre-existing condition. California allows you to keep your insurance beyond the usual 18 months for up to 36 months (with an increase in the monthly cost). One important reason to choose COBRA is that once you’ve exhausted it, you’re eligible to purchase a “HIPAA” plan regardless of your health status. This is an important protection.

A school Most colleges and universities offer health insurance at greatly reduced cost to full-time (and in some cases part-time) students. If you are considering taking courses, you may want to investigate this option. For example, San Francisco State University offers health insurance to registered students with at least nine credit hours.


What if I have a pre-existing condition?

If you have a pre-existing medical condition look for guaranteed issue insurance. This means you are guaranteed acceptance into a health plan regardless of your medical status. Some options for buying guaranteed-issue health insurance are:

TEIGIT The Entertainment Industry Group Insurance Trust administers health insurance plans for members of participating arts and entertainment associations. Coverage for members and their dependents is guaranteed if they meet eligibility requirements.

 MRMIP The Major Risk Medical Insurance Program is California’s insurance program for people with serious health problems who are unable to buy individual health insurance. Premiums are more expensive than comparable open-market plans. You may continue to participate in MRMIP as long you qualify.

HIPAA Plans HIPAA is a law that guarantees you access to insurance coverage if: 1) you had at least 18 months of continuous insurance coverage, the last day of which was under a group plan, 2) you have exhausted any COBRA coverage which was available to you, and 3) you are not eligible for any public or group health plans. Once you enroll in a HIPAA plan, you cannot change insurers and premiums are generally higher. Contacting an insurance broker may be the simplest way to compare and choose a HIPAA plan.


I’m a freelancer.What’s available to me?

If you are a sole proprietor you do not have the right to guaranteed issue insurance. However, you may be able to join a professional association which will allow you to purchase health insurance at a reduced rate. Some associations and arts organizations offer discount plans; be wary of these plans, as they only promise discounts on health services and are not comprehensive insurance plans. For a listing of associations, visit www.ahirc.org.


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

Private, direct-purchase plans can be divided into 3 types:

  • HMO plans, which offer a wide variety of health services but limit coverage of care to doctors who work within their network
  • PPO plans, which pay for care in or outside a network of providers. If you go to an out-of-network provider, you often pay that doctor’s fees directly and file for reimbursement from the insurance company.
  •  HSAs (Health Savings Accounts) which combine tax-shelteredfunds for health care with qualified high-deductible plans.


Plans vary in services provided. Costs include premiums, co-pays, co-insurance, and deductibles. High-deductible plans generally have lower premiums, but require you to pay more for medical expenses up front before your benefits kick in. Health Savings Accounts work best if you are healthy and make limited use of the health care system. Health insurance brokers (listed in the yellow pages) or online brokers (such as www.ehealthinsurance.com) can help you weigh your options. Online brokers make it easy to compare plans, but list only those insurers who have paid to be on their site. Some insurance companies sell short-term insurance, which covers you for a limited period of time. This can be useful if you are between jobs or waiting for another policy to begin. However, you may not be able to renew it.


I will be traveling.Will I be covered if I get sick while I’m on the road?

If you plan on traveling outside the Bay area, speak with your insurer about coverage. PPO plans may pay out-of-network claims according to your contract. Generally, HMO plans pay claims for emergencies only.


Am I eligible for government-subsidized health care programs?

Eligibility for almost all government health care programs 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.

Medi-Cal is California’s Medicaid health insurance program. You may be eligible if any of the following categories apply to you and you meet low-income and asset guidelines: you receive SSI/SSP, are 65 years or older, blind, disabled, pregnant, or the parent or caregiver relative of a child under 21. To determine your income, Medi-Cal adds all your sources of income and then subtracts certain deductions. Medi-Cal’s coverage is comprehensive and includes primary care, hospitalization, prescriptions, and other services. There are no premiums.

Medicare is health insurance for people age 65 and older and the disabled. Medicare is divided into different areas of coverage: Part A covers hospitalization, Part B covers outpatient and other medical services, and Part D covers medications. You don’t have to pay a premium for Part A; both Parts B and D require premiums, and all parts require co-insurance or co-pays.
Free individual counseling about Medicare is available through the Health Insurance Counseling and Advocacy Program (HICAP). Visit their website for office locations.

Healthy Families is insurance for children up to age 19. It provides comprehensive health, dental and vision coverage to children in low-income families who are uninsured and don’t qualify for Medi-Cal. Income limits are based on family size and the ages of the children. Benefits are administered by insurance companies. Premiums and co-payments are low.

Healthy Kids is comprehensive, low-cost insurance for children up to the age of 19. Healthy Kids is similar to Healthy Families. Healthy Kids is public insurance for children up to age 19 who live in San Francisco county. It provides comprehensive coverage to children in low income families who are uninsured. Income limits are higher than for the Healthy Families program. Benefits are administered by insurance companies. Premiums and co-payments are low.

San Francisco Health Plan is a managed care plan that provides medical, dental, and vision benefits to participants in four government-subsidized health care programs. The benefits and eligibility requirements vary depending on which program you qualify for. Eligibility depends on annual income, family size, and in some cases, an applicant’s age.


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

The AIDS Drug Assistance Program (ADAP) and CARE/HIPP help HIV+ uninsured or underinsured individuals access medications, treatments, and insurance. ADAP makes medications available to those who do not qualify for Medi-Cal. CARE/HIPP pays health insurance premiums for people at risk of losing their insurance coverage. Income and asset limits apply.

The AIM Program offers comprehensive, low-cost health care to pregnant women. AIM is for uninsured middle-income families who don’t qualify for Medi-Cal. It is also available to women who have health insurance, but whose deductible or co-payment for maternity services is more than $500. If you qualify for AIM, your baby will automatically qualify for Healthy Families.

The National Breast and Cervical Cancer Early Detection Program provides low-income, uninsured women access to screening and diagnostic services to detect breast and cervical cancers. Women who are subsequently diagnosed with cancer may be immediately eligible for limited Medicaid.


I’m not eligible for employment-related coverage or government programs, and I can’t afford private 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 community clinics (which set fees based on income). For a selected list of clinics see the end of this guide, or visit The Bureau of Primary Health Care, which can direct you to a sliding-scale clinic closest to your home.

Healthy San Francisco is a new program that makes basic and ongoing medical care accessible and affordable to all uninsured San Francisco residents regardless of immigration status, employment status, or pre-existing medical condition. Please note that this program is not health insurance, as enrollees can only receive care in the program’s network of clinics and hospitals.

The San Francisco Community Clinic Consortium's nine partner clinics serve over 65,000 low-income, uninsured, and medically undeserved people per year. The clinics are located strategically throughout San Francisco. Services are available for free, or on a sliding scale based on income.

The San Francisco Community Health Network, a division of the Department of Public Health, offers an array of services including primary care, specialty care and acute care. To see a complete list of clinic locations and hours, visit their website.

The Alameda Health Consortium serves as the coordinating body for 8 community health centers in Alameda County that provide comprehensive care to low-income and uninsured individuals.


I can’t afford my medications. Can I get them for less, or free?

The Partnership for Prescription Assistance offers 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 offer over 300 generic medications for $4 for a 30-day supply. Costco also offers members discounts via their prescription program.


I have mental health needs and I don’t have insurance. What should I do?

If you are in crisis, call the San Francisco Suicide Prevention hotline at 415-781-0500 or the Crisis Support Services of Alameda County at 800-309-2131. Both hotlines are available 24 hours per day, 7 days per week. They can talk with you and refer you to services in your area. The AIDS/HIV Nightline at 800-273-AIDS provides emotional support, information and referrals for HIV+ individuals when other agencies are closed.
The Mental Health Association of San Francisco lists local organizations that provide a variety of mental health services at reduced rates.
Alameda County Behavioral Health Care Services offers a comprehensive database of mental health resources in the Oakland area. For a selected list of clinics in the Bay area, refer to the end of this guide.


How can I lower the cost of dental services?

The University of California at San Francisco School of Dentistry  and the University of the Pacific School of Dentistry offer services in every area of dentistry and oral health. The work is done by students, residents and faculty, and the cost is about half of what it would be at a private practice.
Alameda County Medical Center offers a Drop-In Dental Clinic at Highland Hospital in Oakland. Patients without insurance are billed at a discounted rate.

Dental insurance plan summaries, comparisons and applications are available at www.dentalinsurance.com.

Dental discount plans offer discounts on services at participating dentists for an annual membership fee. Discount plans are not insurance. Patients’ experiences with these plans are mixed; they seem to work best when a dentist you already know and trust is participating. Use caution here. Links to these plans can be found at www.dentalplans.com.


San Francisco Selected Hospitals

California Pacific Medical Center, 3700 California St. (415-600-6000)
San Francisco General Hospital, 1001 Potero Ave. (415-206-8000)
UCSF Medical Center, 1600 Divisadero St. (415-567-6600)


San Francisco Selected Community Health Care Clinics

Castro-Mission Health Center, 3850 17th St. (415-487-7500)
General Medical Clinic at San Francisco General Hospital, 1001 Potero Ave.
(415-206-8492)
Haight Ashbury Free Medical Clinic, 2 locations:
558 Clayton St. (415-746-1967)
and 1735 Mission St. (415-746-1940)
San Francisco Free Clinic, 4900 California St. (415-750-9894)
Women’s Community Clinic, 2166 Hayes #104 (415-379-7800)


San Francisco Selected Mental Health Care Clinics

Westside Community Behavioral Health, 888 Turk St. (415-353-5050)
Haight Ashbury Psychological Services, 2166 Hayes St. (415-221-4211)
San Francisco Counseling Center, 1801 Bush St. (415-440-0500)


San Francisco Selected 24-Hour Pharmacies

Walgreens, 498 Castro St. (415-861-3136)
Walgreens, 3201 Divisadero St. (415-931-6417)
Walgreens, 5411 Geary Blvd. (415-752-8370)
Walgreens, 459 Powell St. (415-984-0793)


Oakland Selected Hospitals

Highland Hospital, 1411 East 31st St. (510-437-4800)


Oakland Selected Community Health Care Clinics

Eastmont Wellness Center, 6955 Foothill Blvd, Suite 200 (510-577-5668)
Highland Hospital Primary Care Clinic, 1411 East 31st St. (510-437-8500)
West Oakland Health Center, 700 Adeline St. (510-835-9610)
East Oakland Health Center, 7450 International Blvd. (510-430-9401)


Oakland Selected Mental Health Care Clinics

West Oakland Mental Health, 2730 Adeline St. (510-465-1800)
Ann Martin Center, 3664 Grand Ave. (510-655-7880)


Oakland Selected 24-Hour Pharmacies

Walgreens, 5055 Telegraph Ave. (510-595-3605)





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 The flat amount you pay for services, such as office visits, prescriptions, and exams.

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

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.

PPO Preferred Provider Organization) An insurance plan that allows members to use services in or outside of the insurer’s network of providers. Going to network providers is usually cheaper; services outside of the network generally require payment of a deductible and co-insurance.

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

Premium Money paid on a monthly or quarterly basis to an insurer for insurance coverage.

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.