Is coverage out of reach? Weigh all the options

No one doubts that there are ample holes, but America’s, and California’s, healthcare safety net might be a little more tightly knit than many expect.

To make the most of the current system, experts say, consumers must first know their options, which differ depending on income.

Children have more options than adults. Medi-Cal, the state insurance program for poor people, covers all health costs for low-income children through age 18. The program Healthy Families provides medical care as well as dental and vision care for some children whose parents earn too much to qualify for Medi-Cal. A family of four, for example, earning $48,384 or less, can qualify for low-cost insurance for the children.

About two-thirds of the uninsured children in California could, if only they’d apply, qualify for Medi-Cal or Healthy Families, according to the UCLA Center for Health Policy Research.

Children in families who are ineligible for these programs can be insured through private programs, such as the Healthy Kids plan, CaliforniaKids and Kaiser Cares for Kids -- all of which have programs with various qualifying requirements to cover children. Monthly premiums start as low as $5 per child, and parents do not have to be insured through the plans.

Middle-income pregnant women can qualify for coverage during and through childbirth via a state program called Access for Infants and Mothers. A single woman, for example, who earns as much as $38,496 can get obstetric coverage for a total, not a monthly premium, of $577.

For many adults, finding coverage is harder, and often expensive, but not always hopeless. A patchwork of state and federal laws, for example, help people with preexisting conditions or people who are suddenly without employer-sponsored coverage.

When an adult loses a job, a federal law called COBRA allows some former employees to continue coverage under their employer’s plan for 18 months. Such coverage can be expensive, because the former employee pays 102% of the premium without any employer contribution. COBRA can be extended for an additional 18 months under some circumstances, but the cost will go up -- to 150% of the premium. A state program called Health Insurance Premium Payment will cover the COBRA premiums for people who qualify for Medi-Cal and have expensive medical conditions -- because it’s less expensive for the state to cover the COBRA premiums than to take on the costs of the medical condition.

Even people who currently have insurance can take steps to protect themselves down the road. Insurance status can change unexpectedly or deliberately -- sometimes because of job upheaval, other times because the entrepreneurial spirit beckons, and people risk chucking the benefits of a 9-to-5 grind to start a self-employed venture.

The most important way to ensure future insurability is to stay covered now -- even if you’re young, healthy and feeling invincible. Simply having health coverage is itself a kind of insurance. Insured people have access to doctors, preventive care and early detection tests, increasing the odds that they’ll stay healthy -- and insurable.

New health savings accounts, provided by some companies, could be a way to begin to build your own defense against future loss of coverage. An employee can contribute $2,000 a year in pre-tax dollars, and the accounts roll over year after year. They are coupled with high-deductible insurance policies for catastrophic coverage. (Some companies offer health spending accounts, but the money contributed must be used up each year for medical expenses, or is forfeited.)

“Let’s say a healthy person contributes for eight years without making any significant claims,” says Phil Lebherz, executive director of the Foundation for Health Coverage Education, an insurance-industry funded group that helps people find suitable public or private insurance coverage. “They’d have $16,000, plus the earnings on the account.”

And if that person then lost employee coverage, the money in the account could be used to pay premiums on an individual policy. Though the scenario is possible, it assumes a long run of good health.

In the individual insurance market in California, the younger you are, the less you’ll pay. But people with preexisting conditions, who are often denied coverage by insurance companies, might qualify for a state program called the Major Risk Medical Insurance Program.

For more help in sorting through coverage options or finding care when you need it:

* Foundation for Health Coverage Education: www.coverageforall.org or (800) 322-5934 for information on finding public or private insurance coverage. Online you’ll find a grid called “California Health Care Options Matrix,” which lists the range of public and private programs and qualifying requirements. Or you can talk with a counselor about what is available for you.

* Major Risk Medical Insurance Program: www.mrmib.ca.gov or (800) 289-6574 if you’ve been denied coverage because of a medical condition. It’s a state program with coverage limited to $75,000 a year, but after three years subscribers are guaranteed coverage in a private plan with higher coverage limits.

* Free or sliding-scale clinics: In L.A. County, Community Clinic Assn. of Los Angeles County: www.ccalac.org. Elsewhere in Southern California, go to www.harp.org/clinics.htm.

* Healthy Families Program: www.healthyfamilies.ca.gov or (800) 880-5305 for children in middle-income families.

* Access for Infants and Mothers: www.aim.ca.gov or (800) 433-2611 for maternity coverage if you earn too much to qualify for Medi-Cal.

* Health Insurance Premium Payment: www.dhs.ca.gov/mcs or (866) 298-8443 if you qualify for Medi-Cal as well as COBRA and have an expensive medical condition.