Health Care Options for Uninsured Patients in Pennsylvania

 

Family Planning Services

Funds are available for women and men whose income is at or below 225% of the federal poverty level to get counseling and treatment for birth control and sexually transmitted diseases. Teens under age 18 can also receive such care, regardless of family income or insurance, if they feel they cannot discuss these topics with their parents and need confidential care (no consent of parent needed / no bills sent to the home). This program is limited to men, women and teens ages puberty to 49 who have not been permanently sterilized, but includes related services such as pap smears and screening for sexually transmitted diseases in people who have no symptoms. Problems that can mimic sexually transmitted diseases -- like bladder infections -- are also covered.

These services are available only through non-profit agencies. In the past, that had meant at sometimes impersonal and often women-oriented clinics. Now, Urban Solutions and the Family Planning Council are pioneering a new way of receiving family planning services -- at private doctors' offices. Health Associates of South Philadelphia will be the first office in this pilot project.

For adults ages 18 to 49, you will need to meet the following pre-tax, household income limits to use federal family planning funds. (Be sure to arrive at each appointment with information on what every member of your household earns.) Since families with income under the federal poverty limit are eligible for medical assistance coverage, we will help you enroll if you are under the limit for free care. You will need to show why you were turned down for medical assistance to continue to receive free care after your first visit.

People in ...................Weekly Income Limit,...........................Weekly Income Limit,
Household............................free care..........................................sliding fee scale care

1.............................................$187.96......................................................$469.89
2.............................................$253.16......................................................$632.91
3.............................................$318.37......................................................$795.93
4.............................................$383.58................................................... ..$958.96
5.............................................$448.79....................................................$1121.98
6.............................................$514.00............................................. ......$1285.00
7.............................................$579.21....................................................$1448.02
8............................................
.$644.42....................................................$1611.05

Although people whose income is near or above the upper limit of the fee scale will not get a large discount on office visits, they may still save significant money on prescriptions and laboratory testing, since prices are based on the discounted group lab fees negotiated by each family planning center rather than the usual cash-patient price.

 

Urban Solutions' HIV Programs

Through the Ryan White Care Act, Urban Solutions is able to provide primary care services to HIV positive people living in Pennsylvania. Uninsured patients receive testing and counseling as well as help obtaining health care coverage for follow up tests and treatment. Medical care is provided through general internal medical and pediatric offices like Health Associates of South Philadelphia for patients who may be uncomfortable receiving care at an HIV clinic.

 

adultBasic Health Insurance

Great news for Pennsylvanians! Part of the money from the tobacco companies' settlement is being used to provide low-cost insurance for adults. Insurance includes major items like doctor visits, hospitalizations, lab and xray tests, preventive care, maternity services, emergency room care, and skilled care/physical rehabilitation. (Notably lacking are prescription coverage, mental health care, eye and dental.) For qualifying adults, the cost is only $30/month. Co-pays are $5 per primary care doctor visit, $10 per specialist visit, and $25 for an emergency room visit (when it doesn't lead to hospital admission).

Not surprisingly, this program filled up fast, and there is now a waiting list. It is possible to enroll at the regular cost while on the waiting list. This is the cost the coverage would be for an employer group, still a BIG discount from what individual coverage costs. If you have tried paying cash for medical care, you have found that the cash patient pays much higher charges than large insurers, who can demand deep discounts. (In fact, their demand for "discounts" has a lot to do with why the regular prices are set at levels no one can really pay.) Once your turn on the waiting list comes up, you are eligible for the $30/month rate.

In the Philadelphia area, adultBasic is administered by Keystone Health Plan East, and patients can use all of Keystone East's regular network. Pre-existing conditions are not excluded from coverage. To be eligible, a person must not have other insurance and must have household income less than twice the federal poverty level. Certain expenses -- like unreimbursed medical expenses, auto insurance, etc. -- can be excluded from total income. Call 1-800-G0-BASIC for an application which covers adultBasic and CHIP or apply online.

 

Children's Health Insurance Program (CHIP)

Uninsured children ages 18 and under whose families meet income requirements can receive free or low cost insurance through this federal program administered by the Commonwealth of Pennsylvania. Families in the Philadelphia area can choose insurance from Aetna US Healthcare, Independence Blue Shield, or Americhoice (HMA). You can apply online.

Family income limits for free CHIP are as follows:

Persons in Household / Yearly Income Limit for Free CHIP
(200% of federal poverty guidelines)
2 / $26,400
3 / $33,200
4 / $40,000
5 /$46,800
6 / $53,600
7 / $60,400
8 / $67,200

Family income limits for reduced cost CHIP are as follows:

Persons in Household / Yearly Income Limit for Cheaper CHIP
(235% of federal poverty guidelines)
2 / $26,401- 31,020
3 / $33,201- 39,010
4 / $40,001 - 47,000
5 / $46,801 - 54,990
6 / $53,601 - 62,980
7 / $60,401 - 70,970
8 / $67,200 - 78,960

 

Healthy Woman Project

This is a Pennsylvania program to provide screening pap smears, mammograms, and follow-up services to low and moderate income uninsured women 40 - 64 years of age. Women of any age can obtain services if they already have an abnormal pap smear, mammogram or breast exam. (If this screening finds possible cancer or cervical dysplasia, uninsured women can then be enrolled in medical assistance through the BCCPT program -- see below). Insured women are eligible for Healthy Woman 50+ if their insurance doesn't pay for all of these services. Unfortunately, very few offices still offer this because of bureaucratic hassles since the BCCPT program was linked to it.

Income limits for the Healthy Woman Project are as follows:

People in Household .............Yearly Income Limit
...................................(250% of federal poverty guidelines)
.....1 ...................................................$24.500
.....2....................................................$33,000
.....3....................................................$41,500
.....4.......................................,............$50,000
..
.....5.......................................... .........$58,500
.....6............................................ .. ....$67,000
.....7....................................................$75,500
.....8....................................................$84,000

Income is based on current sources, so if your financial situation has recently changed, your current weekly income will be used.

In addition, 75% of the Healthy Woman participants must be 50 years of age or older (so if you are in your 40's, help out by spreading the word to a few uninsured older friends!)

 

Birth Mother Services from Adoption Agencies

If you are pregnant and planning to allow your child to be adopted, agencies/adoptive parents typically will pay any uninsured medical expenses of the pregnancy, often including housing and transportation. Some adoption agencies in Pennsylvania are listed here; a birth mother can also work with an out-of-state agency. There are long waiting lists of people waiting to adopt healthy infants of all races, and many agencies allow the birth mother to choose the parents to receive her child -- and even to maintain contact with her child as it grows up, if she wishes.

 

The Vaccines for Children Program (VFC)

This program provides free vaccines to doctors' offices, which can use them to give vaccines to children age 18 and under who do not have insurance that covers immunizations -- regardless of family income. This was done to prevent families from having to go to public health clinics to avoid the cost of vaccines. Instead, their shots can now be kept up to date by their regular doctors. Most routine vaccines are included in this program.

 

Medical Assistance (Medicaid)

This is a program to provide medical insurance to extremely low income people. It was once tied to eligibility for cash assistance, but with the Welfare to Work program, states are encouraged to make it available to more working people and children who don't qualify as "categorically needy." There are several levels of benefits, all based on the federal poverty levels listed below. Adults and children over 6 years of age may receive benefits if their family income is below the poverty limit (an extra $20/month is allowed above that limit). Pregnant women and their children under one year of age are covered if their family income is under 185% of the limit. Children ages 1 - 6 are covered if their familiy income is under 133% of the limit. (Children may be covered even if their parents are not.) Medicare beneficiaries can get part or all of their part B premium paid on a sliding scale up to 175% of the poverty limit. There may be a requirement that a healthy beneficiary work 20 hours a week, but volunteer work qualifies. If you apply for adultBasic or CHIP, your application will automatically be sent to Pennsylvania's department of medical assistance if it appears you would qualify.

People in Household / Federal Poverty Level

1

$ 9,800.00

2

$ 13,200.00

3

$ 16,600.00

4

$ 20,000.00

5

$ 23,400.00

6

$ 26,800.00

7

$ 30,200.00

8

$ 33,600.00

over 8 / add $ 3,400 per extra person

(Note that income limits are evaluated based on monthly income; you don't have to be out of work a year to qualify!)

 

Breast and Cervical Cancer Prevention and Treatment Program

A law passed by President Clinton provided matching funds for states to provide medicaid coverge for women with breast cancer, cervical cancer, and precancerous conditions of the breast or cervix, regardless of income. (Once a woman qualifies for medical assistance under this program, her coverage is the same as anyone with medicaid and is not limited only to treatment of the breast or cervix.) In Pennsylvania, enrollment is done by sites providing services under the HealthyWoman 50+ program.

 

The Philadelphia Corporation for Aging

Nobody wants to give up their independence when they get old. Often, only a few simple things are needed to prevent a person from having to leave their home and enter a nursing home. Unfortunately, health insurance usually won't cover home care unless it is needed to keep someone out of an acute care hospital. The Pennsylvania Department of Aging's "PDA Waiver Program" provides funds from the state lottery for these types of needs in order to avoid more expensive nursing home care. To be eligible, a patient must be at least 60 years old -- younger if diagnosed with chronic dementia -- and be able to remain in the community at a cost of less than 80% of medicaid nursing home rates. Low income seniors (less than 125% of poverty level) receive help at no cost; moderate income seniors (up to 300% of the maximum SSI payment and assets of less than $2000) can get subsidized services through the "Options" program. The types of services available include things like homemaker services for shopping and laundry, nursing assistants for bathing and other personal care, meals on wheels, adult day care centers, respite care short-term in a nursing home when a caregiver is ill or on vacation, etc. The Philadelphia Corporation for Aging serves patients within Philadelphia; other counties have their own programs.

 

Public Health Clinics

Many counties operate free or sliding scale clinics for uninsured and medical assistance patients. (Philadelphia Department of Health has a network of clinics in various areas of the city.) These often can provide free medication to their patients from their own pharmacies, and may provide lab and radiology services. They will usually provide family planning services, sexually transmitted disease clinics, tuberculosis care and child immunizations/flu shots as well.

 

Behavioral Health Care (Mental Health, Mental Retardation, Drug/Alcohol Addiction Treatment)

Mental health problems have a direct effect on patients' incomes, so care is available directed specifically at those problems. Mental health and substance abuse treatment is available through local public health agencies; in Philadelphia there is a network of base service units (BSU's) that evaluate people who need services and provide care/referrals on a sliding scale. In an emergency (suicidal/homicidal thoughts, for instance) a number of emergency rooms operate crisis centers, which are emergency rooms for mental health problems. In Philadelphia these are Pennsylvania Hospital/Hall Mercer Center, Temple University Hospital, Misericordia Hospital, Friends Hospital and Albert Einstein Hospital. If you aren't sure where to go, call one of these emergency rooms and they will be able to tell you which hospital serves your area of the city.

 

Homeless Services

There are special problems for homeless individuals seeking health care. The Greater Philadelphia Urban Affairs Coalition has compiled a list of resources.

 

Greater Philadelphia Chamber of Commerce

Health insurance costs reflect the size of the company purchasing it; large companies have enough healthy employees to offset the cost of a few sick ones. Small companies may find insurance for their employees is too expensive. By joining a larger group, you can purchase insurance at more reasonable rates. The GPCC offers one such plan, and is a good option for small business owners.

 

Individual Health Coverage

Although usually expensive, some insurers may offer health coverage to individuals with limitations that make it affordable, such as excluding pre-existing conditions (to discourage people from going without coverage until they are sick, as insurance relies on having a large pool of healthy people to cover the costs of the gravely ill ones.) Contact local insurers to see what is available, as such plans come and go often.

One such program is Special Care, which covers a limited amount of services each year. Remember also that if you qualify for adultBasic, signing up for a "credible insurance plan" may make you ineligible for the fairly comprehensive coverage and lower cost of adultBasic when you get to the top of the waiting list. It may be best in the long run to pay the higher full price for adultBasic and wait for the $30 rate to become available instead of signing up for a cheaper but less comprehensive plan like Special Care.

An option that is attractive for young people is Health Savings Accounts. The enrollee pays monthly premiums to an insurer. Part of that coverage is for a "high deductible health plan" -- an insurance that only starts paying after you have paid out of your own pocket for quite a bit. But the other part of the premium goes into a health savings account. Any medical expenses are paid from that account until the enrollee hits the deductible amount, and because they are paid through a debit-card like insurance card, the enrollee only has to pay the discounted rates for medical care that the big insurer would have to pay. But if the medical costs for that year are less than the amount in the account, the money rolls over until the next year. After a few years, if a person remains healthy, there is enough in the account to pay expenses up to the amount of the deductible, so a castastrophic illness would not lead to unmanageable medical expenses right at the time a person may be losing time from work. Some plans exclude important preventive care from the deductible: For instance, even if you haven't met your deductible, your yearly pap smear and mammogram may be covered. The money paid into the health savings account is tax deductible, even if you don't itemize.

The down side is that because few people are signed up yet, and because most young people don't think they ought to have to pay for insurance if they aren't sick yet, insurers don't provide flat fees for insurance. You will have to pay more for the high deductible health coverage part of the plan if you are older or have pre-existing conditions.

 

Medicare

Medicare is the medical insurance provided with social security. However, it is a separate program with slightly different eligibility. It is available to retirees over 65 (even though social security is available at age 62), their spouses, railroad retirees, disabled workers who have been on social security for two years, people with kidney failure, and disabled children of eligible workers. To be eligible, you must have paid FICA taxes out of your paychecks for at least 40 quarters (ten years total). If you worked for a goverment agency that did not participate in FICA part of that time, you could end up with too little time to qualify for either Medicare or a government retiree benefit, however. And those who were paid under the table lose out big time.

Medicare part A covers hospitals and tests. It pays 100% after a yearly deductible for hospital care. Part B covers doctors, and is a separate premium (usually deducted from the social security check or paid by the state for people who are low income.) It covers 80% of bills after a yearly deductible. People with Medicare may get higher levels of coverage by signing up with a Medicare+Choice HMO ("Part C"), but they must give up their Medicare A and B coverage to get it.

The new Part D covers prescription. All Part D is provided by private companies -- there is no option to just stay with the government as the insurer, as there is with Parts A and B. There may or may not require an extra premium for Part D, depending on whether it is combined with HMO coverage from the same company and based on how much coverage is provided. In order to keep the cost of the Part D program from being absolutely ridiculous, but in order to get as many people as possible getting some benefit (and feeling grateful at election time), the program has a "doughnut hole" in the coverage: You get coverage for the first couple thousand dollars of medications, but then your plan doesn't have to cover anything until you have paid the next several thousand dollars out of your own pocket. Some plans do provide coverage for at least generic medications in the doughnut hole; shop around. People with Medical Assistance get coverage from the state for these uncovered expenses, but they have exclusions such as cough and cold prescriptions that were usually covered when their Medicaid supplemental coverage was through an HMO.

 

Special Pharmaceutical Benefits Program

This Pennsylvania state program is designed to ensure that patients with HIV or schizophrenia have access to the new treatments available. These medications are highly expensive, and often out of reach even to insured patients or those of moderate income. SPBP covers most drugs used for HIV (including antibiotics), as well as Clozaril for schizophrenia. The income limit is $30,000 per year for a single person, with an additional $2,480 per extra person per year if there are additional household members. The phone number is 1-800-922-9384.

 

Pharmaceutical Company Indigent Patient Programs

Most drug manufacturers will provide a supply of their brand name drugs for low income patients who are not covered by any prescription plans. In order to receive these, a patient's physician must usually contact the manufacturer. Income limits and documentation requirements vary -- some just want a note from your doctor that you can't afford the medication; some will send you a form that looks like a college financial aid form and have strict income limits. Each manufacturer's program is separate, so if you are on several medications, your doctor must contact each company separately. The Pharmaceutical Research and Manufacturers of America have a directory of programs by their members. RxAssist, a program of the Robert Woods Johnson Foundation, has application forms that can be printed and brought to your doctor. Other sites include NeedyMeds and RxHope.com.

 

Smart Shopping

If you are paying cash, you will often be charged a higher rate than insured patients! This is because insurers control so many patients that doctors, hospitals and pharmacists are forced to offer them discounts to keep their patients. Those discounts may be made up by you! Don't be afraid to compare prices and ask what discounts are available to people who pay at the time of service. Hospitals may offer significant discounts if you pay up front or use a credit card. Pharmacies may shift costs from expensive brand drugs to the inexpensive generics, believing you won't worry whether a drug costs $10 or $15, but will scream if it goes from $110 to $115. One-time drugs, like antibiotics, are often overpriced, and "discount" pharmacies must make up their cost on other drugs or products in the store.

 

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