Coverage of Uninsurable Pre-existing Conditions: State and Federal High-Risk Pools
Updated: February 23, 2012
Includes latest material on implementing health reform: The Pre-existing Condition Insurance Plan (PCIP)
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To aid uninsurable individuals, 35 states implemented high-risk health insurance pools over three decades. The Federal health reform law of 2010 provides $5 billion among all 50 states, for newly created or add-on expanded programs run by states or by a designated insurer, if states choose those options. 27 states had done so by fall 2010. 23 states have deferred to the federal government to handle the new programs; these arrangements may be subject to change in the next two years.
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Chart: 2012 federal
and state roles
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For millions of Americans with a pre-existing medical condition, health insurance can be an unattainable goal. In the absence of laws requiring insurers to provide individual coverage to people with pre-existing conditions, many of these people joined the ranks of the uninsured. These uninsurable individuals have sought coverage, but have been unable to purchase it because they have been rejected or because they have been offered coverage only at unaffordable, high premium rates. Because of their often complex or costly health conditions, uninsurable individuals are the segment of the larger uninsured population that most needs health insurance coverage.
In response to the problems of uninsurable individuals, 35 states set up high-risk health insurance pools over a 25 year span, from 1976 to2009. Across these 35 states, the national enrollment was 208,317 by December 31, 2009. This compared to 200,047 as of December 2007. This is about 1.8 percent of the individual market enrollment, but is up to 25 percent of the individual market documented to be subject to denials or "adverse underwriting" restrictions due to pre-existing medical conditions.
Federal Health Reform
The Patient Protection and Affordable Care Act, signed March 2010
Insurance Reforms: Key Provisions That Take Effect Immediately
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Section 1101: ESTABLISHES AN INTERIM HIGH-RISK POOL PROGRAM
Provides immediate access to insurance for Americans who are uninsured because of a pre-existing condition.
Establishes a temporary national high-risk pool to provide health coverage to individuals with pre-existing medical conditions.
- U.S. citizens and legal immigrants who have a pre-existing medical condition and who have been uninsured for at least six months will be eligible to enroll in the high-risk pool and receive subsidized premiums.
- Premiums for the pool will be established based on a standard population and may vary by no more than a 4 to 1 ratio due to age.
- The law appropriates $5 billion to finance the program.
- The new pools are to be administered directly by a state or a nonprofit entity under contract. States may not reduce their current high risk pool efforts.
- CMS has estimated that about 375,000 people may be eligible to sign up for the federally-funded high risk pools.
Premiums in the new federal pool are designed to be 10 percent to 50 percent lower than current state rates. Co-payments and deductibles are also expected to be considerably lower. Current beneficiaries in state high-risk pools could get the federal coverage only if they drop out of their state pool and remain uninsured for six months.
The high risk pool provision of the federal law became effective 90 days after enactment, June 21, 2010. Individual policies are offered for sale after July 1, 2010; the federal program remains legally in effect until January 1, 2014.1
Updates from NCSL
Lower Premiums and Simpler Rules for High Risk Insurance - NCSL article, published 6/3/2011
Pre-Existing Condition Insurance Plan (PCIP): State by State PREMIUMS and COSTS, 2011 [ PDF File]
State by State Summary of Federal and State High Risk Pools - TABLE 1
As of December 31, 2011 a total of 48,879 individuals were covered by federally-funded PCIP programs -- state by state figures online, released February 23, 2012.
KEY
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= State Administered PCIP, 2010-11
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= Federally Administered PCIP, 2010-11
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X = No state-based pool
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FEDERALLY FUNDED PCIP PROGRAM
Established by The Affordable Care Act
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STATE-FUNDED
HIGH RISK POOLS [i]
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State
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State Runs
Federal Pool?
(12/31/2011)
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Date Coverage Began
(2010)
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# Enrolled as of
February 1, 2011
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# Enrolled as of
Dec. 31, 2011
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Federal Fund
Allocation
$ millions
(2010-13)
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State-Only
High Risk Pool
Enrollment
(12/31/2010)
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Year State
Began
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Annual Total Expenses
$ millions (2010)
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Alabama
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NO
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8/1/2010
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61 |
340
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$69
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2,139
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1998
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$21.1
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Alaska
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YES
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9/1/2010
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20 |
44
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$13
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524
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1993
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$11.7
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Arizona
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NO
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8/1/2010
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270 |
1,783
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$129
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X
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Arkansas
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YES
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9/1/2010
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147 |
404
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$46
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2,865
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1996
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$26.6
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California
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YES
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10/25/2010
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706 |
5,599
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$761
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6,953
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1991
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$61.1
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Colorado
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YES
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9/1/2010
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434 |
1,054
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$90
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**12,732
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1991
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$120.8
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Connecticut
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YES
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9/1/2010
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22 |
163
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$50
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1,870
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1976
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$33.3
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Delaware
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NO
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8/1/2010
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34 |
153
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$13
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X
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Florida
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NO
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8/1/2010
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613 |
3,736
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$351
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235
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1983
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$2.9
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Georgia
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NO
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8/1/2010
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399 |
1,476
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$177
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X
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Hawaii
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NO
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8/1/2010
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23 |
78
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$16
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X
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Idaho
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NO
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8/1/2010
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42 |
316
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$24
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1,565
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2001
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$11.5
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Illinois
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YES
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9/1/2010
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943 |
1,962
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$196
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18,098
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1989
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$193.7
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Indiana
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NO
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8/1/2010
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131 |
678
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$93
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7,327
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1982
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$125.3
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Iowa
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YES
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9/1/2010
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80 |
238
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$35
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3,154
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1987
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$35.9
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Kansas
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YES
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8/1/2010
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112 |
301
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$36
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1,671
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1993
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$26.8
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Kentucky
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NO
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8/1/2010
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56 |
435
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$63
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4,837
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2001
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$64.2
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Louisiana
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NO
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8/1/2010
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92 |
377
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$71
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1,639
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1992
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$17.1
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Maine
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YES
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8/1/2010
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13 |
30
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$17
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X
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Maryland
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YES
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9/1/2010
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145 |
741
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$85
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19,944
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2003
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$179.9
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Massachusetts *
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NO
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8/1/2010
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0 |
5
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$77
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X
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Michigan
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YES
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10/1/2010
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245 [4/15/11] |
789
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$141
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X
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Minnesota
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NO
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8/1/2010
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29 |
244
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$68
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27,073
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1976
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$273.6
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Mississippi
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NO
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8/1/2010
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58 |
163
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$47
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3,514
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1992 +Exch.
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$31.2
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Missouri
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YES
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8/15/2010
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166 |
1,031
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$81
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4,046
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1991
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$43.2
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Montana
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YES
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8/1/2010
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153 |
280
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$16
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2,953
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1987
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$24.8
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Nebraska
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NO
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8/1/2010
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39 |
174
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$23
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4,570
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1986
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$54.3
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Nevada
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NO
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8/1/2010
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125 |
579
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$61
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X
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New Hampshire
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YES
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7/1/2010
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78 |
306
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$20
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1,573
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2002
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$13.7
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New Jersey
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YES
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8/15/2010
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216 |
794
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$141
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X
|
|
New Mexico
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YES
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8/1/2010
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198 |
805
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$37
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8,429
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1988
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$110.8
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New York
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YES
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10/1/2010
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411 |
2,632
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$297
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X
|
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North Carolina
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YES
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8/1/2010
|
674 |
** 2,889
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$145
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4,846
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2009
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$26.4
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North Dakota
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NO
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8/1/2010
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5 |
32
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$8
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1,462
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1982
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$12.4
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Ohio
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YES
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9/1/2010
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726 |
2,137
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$152
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X
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Oklahoma
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YES
|
9/1/2010
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190 |
576
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$60
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2,175
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1996
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$29.1
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Oregon
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YES
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8/1/2010
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483 |
1,187
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$66
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13,618
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1990
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$174.2
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Pennsylvania
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YES
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10/1/2010
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2,046 |
4,567
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$160
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X
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Rhode Island
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YES
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9/15/2010
|
85 |
136
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$13
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X
|
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South Carolina
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NO
|
8/1/2010
|
242 |
948
|
$74
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2,256
|
1990
|
$31
|
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South Dakota
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YES
|
7/15/2010
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62 |
153
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$11
|
645
|
2003
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$6.6
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Tennessee
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NO
|
8/1/2010
|
171 |
878
|
$97
|
3,973
|
2007
|
$42.7
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Texas
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NO
|
8/1/2010
|
1007 |
4,029
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$493
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26,431
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1998
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$316.7
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Utah
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YES
|
9/1/2010
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117 |
696
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$40
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4,158
|
1991
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$35
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Vermont *
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NO
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9/1/2010
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0 |
0
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$8
|
X |
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Virginia
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NO
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8/1/2010
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204 |
982
|
$113
|
X
|
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Washington
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YES
|
9/1/2010
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139 |
708
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$102
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3,923
|
1988
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$82.2
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West Virginia
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NO
|
9/1/2010
|
15 |
76
|
$27
|
884
|
2005
|
$4.7
|
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Wisconsin
|
YES
|
8/1/2010
|
307 |
1,000
|
$73
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18,965
|
1981
|
$162.8
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Wyoming
|
NO
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8/1/2010
|
49 |
137
|
$8
|
829
|
1991
|
$9.8
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D.C.
|
NO
|
10/1/2010
|
10 |
38
|
$9
|
X
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Nationwide
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Yes = 27
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Total 12,437
Feb. 1, 2011
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Total 48,879
Dec. 31, 2011
Total 56,257
Feb 29, 2012
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$5,000
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221,879
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$2,418.4
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Total # enrolled as of March 31, 2011 was 18,313
Total # enrolled as of November 1, 2010 was 7,986
* Massachusetts and Vermont are guaranteed issue states that have already implemented many of the broader market reforms included in the Affordable Care Act
[i] National Association of State Comprehensive Health Insurance Plans (NASCHIP). “About High Risk Pools” www.naschip.org
Resources for Transition to Federal High Risk Pools
New Plan Options for Federally Administered Pre-Existing Condition Insurance Plan in 2011
On November 5, 2010, the Department of Health and Human Services (HHS) announced new plan choices for people enrolling in the Pre-Existing Condition Insurance Plan (PCIP) for 2011. These options will give current and future enrollees a greater number of coverage choices and allow people to select the plan that best meets their needs. The new options will be offered in a three-tiered structure beginning January 1, 2011, and will be available in States where the program is federally administered through the Office of Personnel Management. These choices build on the current single plan option: experience with the program has provided valuable information that has allowed for the creation of new and improved options. The federally administered program is available in 23 States and the District of Columbia.
PCIP provides Americans living with such conditions as cancer, diabetes, or heart disease to obtain insurance coverage. The program covers a broad range of health benefits and is designed as a bridge for people with pre-existing conditions who cannot obtain health insurance coverage in today’s private insurance market. In 2014, all Americans – regardless of their health status – will have access to affordable coverage either through their employer or through a new competitive marketplace, and insurers will be prohibited from denying coverage to anyone based on the state of their health. For more information about eligibility and benefits please visit www.pcip.gov.
Expanded Plan Options in 2011
In 2010, people enrolled in the federally-administered PCIP program were offered one plan. Beginning in 2011, such enrollees in the federally administered PCIP program will be able to choose between three plan options: the Standard Plan, the Extended Plan and the Health Savings Account eligible plan. In addition, families will be able to enroll their eligible children in PCIP at child-only rates. These options will allow enrollees to select a plan that best meets their needs.
2011 Standard Plan. The existing option in PCIP has been made more flexible. The 2010 Standard Plan had a single, combined medical and pharmacy deductible of $2,500. The 2011 Standard Plan now has two separate deductibles -- a $2,000 medical deductible and $500 drug deductible, while also offering premiums that are almost 20% lower than the 2010 premiums. The reduced pharmacy deductible is particularly beneficial for people who take one or more maintenance medications. The lower premiums result from experience and are expected to be more affordable for the eligible population with pre-existing conditions.
2011 Extended Plan. A new plan option, called the Extended Plan, has a $1,000 medical deductible and $250 drug deductible plan. The premiums for the 2011 Extended Plan will be slightly higher than 2010 premium levels. Just as with the Standard Plan, separating the drug and medical deductibles makes this plan option more valuable for those enrollees who take one or more maintenance medications.
Health Savings Account Option. The Health Savings Account (HSA) Option will carry a $2,500 deductible but with premiums that are 16% less than 2010 premiums. As with the current plan, this option is eligible to receive favorable tax treatment by the federal government when used with a Health Savings Account (HSA).
Child-Only Rate. To ensure that children have more affordable access to coverage, HHS has established premiums targeted for covering children under PCIP, creating a child-only rate for PCIP enrollees between 0-18 years of age.
Extra Funds for States Sought - January 2012
For the first 16 months of operation (Sept, 2010 to December 2011) only 42,000 new individuals enrolled, with resulting expenditures of less than $500 million. However, newly signed-up severely ill patients and different state-specific situations are leading to allocating funds not just according to the original population estimates.
As of January 8, 2012 nine states have asked the federal government for more money to assure their new high-risk pools don’t run out of money before 2014.
- Two of the states — California and New Hampshire have been granted additional federal funds.
- Seven other states have requests pending with CCIIO at HHS, They are Alaska, Colorado, Montana, New Mexico, Oregon, South Dakota and Utah.
Posted: November 5, 2010
- HHS posting: High-Risk Pool Programs Take a Step Forward - Statement by HHS office of the Assistant Secretary for Public Affairs, 4/30/10
- NCSL State-by-State Tally: [UPDATED June 29, 2010] so far 29 states plus D.C. will run programs themselves; 1 state (RI) has designated a 'HIPAA insurance carrier' to run the program, 19 states deferred to a federally-run option and one state (KY) was seeking more information. The list is subject to additions and clarifications. View future updates here.
- HHS Fact Sheet: Temporary High-Risk Pool Program - April 23, 2010
- An official summary, including new 50-state funding allocations of high-risk pool funds [full 50-state table below]
- Department of Health and Human Services (HHS) Secretary Kathleen Sebelius sent letters to governors and independent insurance commissioners on April 2, 2010, seeking to gather information on the number of states that would be interested in participating in the temporary high-risk pool program established by the new health insurance reform law. States have been given the option to participate in the program that will provide coverage to the uninsured with pre-existing conditions. The new health insurance reform law provides $5 billion in federal funds to support this new program. In the letter she outlined the number of options for states concerning their participation in the temporary high-risk pool program which include:
1. Operate a new high-risk pool alongside a current state high-risk pool;
2. Establish a new high-risk pool (in a state that does not currently have a high-risk pool);
3. Build upon other existing coverage programs designed to cover high-risk individuals;
4. Contract with a current HIPAA-designated insurance carrier of last resort or other carrier, to provide subsidized coverage for the eligible population; or
5. Do nothing, in which case HHS would carry out a coverage program in the state.
HHS Press Release--Letter
NCSL Health Reform Webinars
► High Risk Pools -- What Legislators Need to Know (Update). Slides Online - held September 30, 2010
► High Risk Pools -- What Legislators Need to Know. Slides and Audio Online - held May 17, 2010
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On May 10, 2010, HHS released a solicitation for proposals for States to operate qualified high risk pools under section 1101 of the Patient Protection and Affordable Care Act (Public Law 111-148), which authorizes HHS to carry out the program directly or through contracts with States or private, nonprofit entities.
State High Risk Pool Solicitation (PDF 205 KB) | State High Risk Pool Cover Letter (PDF 24KB)
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NEWS & OPINION:
- Colorado high-risk health insurance pool burning through money fast - Denver Post, 7/4/2011. The federally sanctioned high-risk insurance pool for Colorado is signing up fewer patients and burning through its limited cash faster than expected, as the plan attracts the sickest of the sick.
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Michigan Tries New Strategy On High Risk Pools Detroit Free Press - 4/18/11
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Study: Up to 129 Million have preexisting conditions. Wasington Post, 1/18/2011.
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High-Risk Insurance Pools Are Attracting Few - While 375,000 people with pre-existing conditions were expected to enroll in the pools, only 8,011 have done so. - New York Times, 11/4/2010
- High-risk pools prepare ad campaigns - Facing dismal enrollment numbers, state Pre-Existing Condition Insurance Plans are gearing up to spend big on professional marketing campaigns. - Politico, 10/25/10.
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States Look to Current TPAs to Operate New High-Risk Pools Under Reform - AIS - Health Reform Week, 8/13/2010.
- The Cost of Delayed Reform: The temporary federal high-risk pools won't reach most of the medically uninsured. - The American Prospect, September, 2010 [posted 8/6/10]
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State rules clash with health pools - Politico, July 20, 2010 - includes details from ME, MA, NJ, NY and VT.
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Insurance Pools Readied in Some States - New York Times. Sunday, June 27, 2010 - includes NCSL material.
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High-Risk Health Insurance Pools Miss Deadline Under US Health Reform - Insurance News Network, June 24, 2010
- 18 States refuse to run insurance pools for those with preexisting conditions- The Washington Post, May 4, 2010
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GOP governors opting out of health reform pool for high-risk uninsured - The Hill - April 30, 2010
- High-Risk Insurance Pools Divide the States - Wall Street Journal - April 30, 2010
- Deadline Looms for States To Decide on High-Risk Pools - California HealthLine - April 27, 2010.
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"California: Health reform may alter high-risk pools" - San Francisco Chronicle, Apr. 12, 2010. It's a race to a deadline," said Richard Cauchi, health program director for the National Conference .... "In practical terms, many states may not be able to make formal or permanent changes to their current programs this year."
- Maryland: "Reform Carries Hope For Those With High-Risk Medical Conditions - WYPR radio, April 20, 2010
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Texas needs more time to decide on health insurance pools required by new federal law. - Austin Statesman April 22, 2010. Joy Johnson Wilson, the health policy director for the National Conference of State Legislatures, talked about the high-risk pools when she testified today in front of a select House committee tasked overseeing the new federal law in Texas. She said that states would be challenged by the April 30 deadline. “Right now, everybody’s not sure what they want to do because they don’t have enough information.”
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State High-Risk Health Insurance Pools- An "Expert Voices" fact sheet published by NIHCM (National Institute for Health Care Management), April 2009.
- The Minnesota high-risk pool as a potential model for implementing health reform. http://healthaffairs.org/blog/2010/03/19/all-high-risk-pools-are-not-equal-examining-the-minnesota-model/
- "Issues for Structuring Interim High-Risk Pools" - a brief by Kaiser Family Foundation, January 2010
Sources: NAIC "State Insurance Regulator Responsibilities Under Health Reform" March 23, 2010; September 2010; HHS Guidance
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Mississippi Uses Existing High Risk Pool to Establish Health Insurance Exchange
Mississippi was the first state to announce that its high-risk pool program, the Mississippi Comprehensive Health Insurance Risk Pool Association, will establish the state’s health insurance exchange. The independent, not-for-profit association was created in 1991 to operate the state’s high- risk pool– an insurance program that provides coverage for people who want to purchase insurance but cannot obtain it because of health conditions.
Mississippi’s Insurance Commissioner Mike Chaney was interested in moving forward on health exchanges and determined that the association had the statutory authority to establish one, according to Lanny Craft, executive director of the Association. He asked the Association to consider establishing and operating Mississippi’s health insurance exchange, and in May it agreed to do so. Once the association presents a plan, it will need approval from the insurance commissioner and HHS but will not need further legislative action to move forward due to statutory authority it was given in 2009 as the state high risk health pool.
-July 1, 2011 |
Examples of State Legislation - TABLE 2
In 2011, three states,Nebraska, Oregon, and South Dakota enacted new laws coordinating High Risk and PCIP programs. [See NCSL's Health Reform Database for latest actions]
In 2010, six states, California, Colorado, Illinois, Louisiana, Maryland and Oregon enacted laws in anticipation and response to the federal high-risk pool provisions. At least four other states, Georgia, Missouri, Pennsylvania and West Virginia, considered similar bills.
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California AB 1887 by Assm. Villines
Establishes a federally qualified high-risk insurance pool for individuals who are unable to obtain private coverage because of a pre-existing condition. California already has a high-risk insurance pool that covers about 7,000 residents, but it does not meet requirements to qualify for federal subsidies under the new health reform law. Authorizes the existing MRMIB to apply for any federal funding the board determines to be cost effective for purposes of extending major risk medical coverage to more applicants.
(Filed 2/16/10; passed Assembly; passed Senate , 27y-8n ; signed into law by governor as Chapter 32, 6/29/10)
SB 227 by Sen. Alquist
Authorizes the state to set up a federally qualified high-risk insurance pool and contract with private insurance companies to provide coverage.
(Filed 2/2009; amended to reflect federal reform provisions and passed Assembly 6/21/10; passed Senate; signed into law by governor as Chapter 31, 6/29/10)
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Colorado SB10- 20 by Sen. Boyd
Concerns measures to address the financial viability of the CoverColorado Program, including 60-day notice prior to closing enrollment due to lack of funding; authorizes the program to accept federal funds to operate a temporary program created under PPACA, with such funds not used to affect the operations of the existing state-only Cover Colorado program.
(Passed Sen. comm, 7y-0n; passed House 9y-1n; Senate; passed House; signed into law by governor as Chapter No. 239, 5/28/10)
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Illinois S 663 by Sen. Cullerton
Amends the Comprehensive Health Insurance Plan Act (state high risk pool); provides that the Plan shall pay covered expenses up to a lifetime benefit limit of $5 million, an increase from $2 million; provides that certain preexisting condition exclusions shall be waived if a former member reenrolls within 90 days of the new $5 millian expanded cap. Effective date June 24, 2010.
(Passed Senate; passed House; signed into law by governor as Act 96-0938, 6/24/10)
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Iowa (2012 update) Senate Study Bill 3128 by Senator Matt McCoy and Sen. Hatch. The federal program in Iowa is called HIPIOWA-FED. Unlike its Iowa counterpart, many irregularities have been discovered. to correct this program and allow more people into it. It requires the program to abide by Iowa’s opening meetings and records laws, allow third-party payees into the program (mostly HIV patients), and limits the expenses of administration. This program is entirely funded by the Federal ACA act.
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Louisiana SB 153 by Sen. Erdley
Amends the structure for the High-Risk Pool, providing that it "may establish, provide for, administer, and contract to provide coverage for a health plan to offer eligible individuals and families the ability to purchase or enroll in a program established under federal law that provides expanded coverage for state high-risk pools. Initial rates for plan coverage provided to federally defined eligible individuals cannot be less than 125 percent of rates established as applicable for individual standard risks.
(Filed 3/16/10; amended, passed Senate 38y-0n, 4/26/10; passed House 5/10; signed into law by governor as Act 123, 6/8/10)
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Maryland emergency legislation: HB 1564
Authorizes the "Board of Directors for the Maryland Health Insurance Plan to elect for the plan to administer a specified national high-risk pool program for the state; authorizing the board to enter into any agreements necessary for the board to administer the program" including establishing a benefit package and premium rate for individuals enrolled in a national, temporary high-risk pool program requiring the state to meet a certain maintenance of effort requirement.
(Filed 3/22/10; passed House 3/23/10; passed Senate; signed into law by governor as Chapter 173, 4/13/10)
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North Carolina S 1294
Authorizes the North Carolina health insurance risk pool to provide premium subsidies if funds are available, and to require insurers to notify applicants for health insurance coverage about the existence of the pool.
(Filed 4/9/09; signed into law by governor as Session Law 2009-286, 7/10/2009)
|
|
Oregon H 3659 a
Establishes a Temporary High-Risk Pool Program to ensure health insurance coverage for individuals who are uninsured and not receiving publicly funded medical assistance, which will become operative after receiving federal funding; establishes the Temporary High-Risk Pool Program Fund and continuously appropriates money to the State Medical Insurance Pool Board to carry out the program.
(Passed House and Senate; signed into law by governor as Chapter 47, 3/10/2010)
|
TABLE 3: Historical Comparison
HIGH-RISK POOLS: STATE-ONLY ENROLLMENT, 2008
It also includes updated information based on the HHS release of April 30 plus state letters and media reports (and subject to change) regarding state optional participation:
YES = State will run the federally funded program; NO = state defers to federally run program. Note that states have several operational choices, with details to be added as they are released by governors.
♦ = State proposal submitted to HHS (as of 6/9/2010; subject to additions)
|
State
|
State
runs Federal Pool?
(10/30/2010)
|
State
News
links
|
State-only
High-Risk
Pool Enrollment
(Dec. 31)
|
State-ony
Pool open to
HIPAA eligible?
|
State-only pool
Open to federal
HCTC eligible?
|
State Individual
market participants
(2005)*
|
State-only Pool Enrollment
as % of Individual Market
|
|
|
2010
|
2008 |
2008
|
2008
|
|
AL
|
NO
|
news
|
2,653
|
Yes
|
No
|
174,000
|
1.9%
|
|
AK
|
♦ YES
|
|
469
|
Yes
|
Yes
|
30,000
|
1.7%
|
|
AZ
|
NO
|
news
|
No pool
|
-
|
-
|
|
|
|
AR
|
♦ YES
|
news
|
3,061
|
Yes
|
Yes
|
171,000
|
1.7%
|
|
CA
|
YES
|
news
|
7,036
|
No
|
No
|
2,913,000
|
0.3%
|
|
CO
|
♦ YES
|
news
|
8,543
|
Yes
|
Yes
|
367,000
|
1.4%
|
|
CT
|
♦ YES
|
news
|
2,336
|
Yes
|
Yes
|
194,000
|
1.3%
|
|
DE
|
NO
|
|
No pool
|
-
|
-
|
|
|
|
FL
|
NO
|
|
enrollment closed/ 300
|
No
|
No
|
n/a
|
n/a
|
|
GA
|
NO
|
news
|
No pool
|
-
|
-
|
|
|
|
HI
|
NO
|
|
No pool
|
-
|
-
|
|
|
|
ID
|
NO
|
|
1,338
|
Yes
|
Yes
|
n/a
|
n/a
|
|
IL
|
YES
|
|
15,682
|
Yes
|
Yes
|
570,000
|
2.9%
|
|
IN
|
NO
|
|
6,561
|
Yes
|
Yes
|
364,000
|
2.0%
|
|
IA
|
♦ YES
|
|
2,732
|
Yes
|
Yes
|
224,000
|
0.6%
|
|
KS
|
♦ YES
|
|
1,830
|
Yes
|
Yes
|
176,000
|
1.0%
|
|
KY
|
NO; more info |
|
4,458
|
Yes
|
No
|
150,000
|
2.4%
|
|
LA
|
NO
|
|
1,110
|
Yes
|
Yes
|
236,000
|
0.5%
|
|
ME
|
♦ YES
|
news
|
No pool / Guaranteed issue
|
-
|
-
|
|
|
|
MD
|
♦ YES
|
news
|
15,180
|
Yes
|
Yes
|
290,000
|
2.6%
|
|
MA
|
NO; exchange
|
news
|
No pool / Guaranteed issue
|
-
|
-
|
|
|
|
MI
|
YES
|
|
No pool
|
-
|
-
|
|
|
|
MN
|
NO
|
|
27,386
|
Yes
|
Yes
|
388,000
|
8.0%
|
|
MS
|
NO
|
|
3,464
|
Yes
|
No
|
174,000
|
2.5%
|
|
MO
|
7♦ YES
|
news
|
2,999
|
No
|
Yes
|
436,000
|
0.7%
|
|
MT
|
♦ YES
|
news
|
2,995
|
Yes
|
Yes
|
82,000
|
3.9%
|
|
NE
|
NO
|
news
|
5,089
|
Yes
|
Yes
|
138,000
|
4.1%
|
|
NV
|
NO
|
news
|
No pool
|
-
|
-
|
-
|
|
|
NH
|
♦ YES
|
|
1,094
|
Yes
|
Yes
|
72,000
|
0.9%
|
|
NJ
|
♦ YES
|
|
No pool / Guaranteed issue
|
-
|
-
|
-
|
|
|
NM
|
♦ YES
|
news
|
6,020
|
Yes
|
No
|
79,000
|
2.4%
|
|
NY
|
YES
|
news
|
No pool / Guaranteed issue
|
-
|
-
|
-
|
|
|
NC
|
4 ♦ YES
|
news
|
3,400***
|
Yes
|
Yes
|
n/a
|
n/a
|
|
ND
|
NO
|
news
|
1,463
|
Yes
|
Yes
|
56,000
|
3.1%
|
|
OH
|
YES
|
news
|
No pool
|
-
|
-
|
|
|
|
OK
|
♦ YES
|
|
2,098
|
Yes
|
Yes
|
161,000
|
1.7%
|
|
OR
|
♦ YES1
|
|
15,320
|
No
|
Yes
|
244,000
|
6.1%
|
|
PA
|
♦ YES
|
news
|
No pool
|
-
|
-
|
|
|
|
RI
|
YES; designated carrier2
|
news
|
No pool / Guaranteed issue
|
-
|
-
|
|
|
|
SC
|
NO
|
news
|
2,328
|
Yes
|
Yes
|
155,000
|
1.4%
|
|
SD
|
♦ YES
|
|
653
|
Yes
|
No
|
87,000
|
0.8%
|
|
TN
|
NO
|
|
4,516
|
Yes
|
No
|
323,000
|
**
|
|
TX
|
NO
|
news
|
26,908
|
Yes
|
Yes
|
1,155,000
|
2.4%
|
|
UT
|
YES 3
|
news
|
3,715
|
Yes
|
No
|
156,000
|
2.1%
|
|
VT
|
NO
|
news
|
No pool / Guaranteed issue
|
-
|
-
|
|
|
|
VA
|
NO
|
news
|
No pool
|
-
|
-
|
|
|
|
WA
|
YES
|
news
|
3,397
|
No
|
No
|
370,000
|
0.8%
|
|
WV
|
NO 5
|
news/ 2
|
653
|
Yes
|
Yes
|
51,000
|
0.2%
|
|
WI
|
♦ YES
|
|
16,284
|
Yes
|
No
|
328,000
|
5.9%
|
|
WY
|
NO
|
|
687
|
Yes
|
No
|
45,000
|
1.4%
|
|
D.C.
|
♦ YES
|
|
|
-
|
-
|
|
|
|
TOTAL
|
|
|
200,358
|
|
|
|
|
NOTES for Table 3:
1= The Oregon Governor expressed interest and sought answers to six questions, concluding, "If the above issues can be worked out, Oregon would be interested in participating..."
2 = Rhode Island on 6/25/2010 responded, "With the understanding and the condition that the State of Rhode Island will have no legal or contractual responsibility either now or in the future to the Federal Government, Blue Cross and Blue Shield of Rhode Island or persons receiving benefits through the High Risk Pool, the State hereby designates Blue Cross and Blue Shield of Rhode Island (BCBSRI) to be the Administrator of the High Risk Pool funds available to citizens of Rhode Island under PPACA."
In late May they stated, "The state's finances are sufficiently precarious that it cannot entertain the possibility of assuming any financial responsibility for the program in the event of the withdrawal of federal funds or lack of adequate funding.... We look forward to discussing these issues with you further."
3 = The Utah Governor announced June 24 the state would run the new federally-funded option. The decision, said Gov. Herbert, hinged on getting “the most bang for the buck” for the 17,000 Utahns estimated to be eligible for the special insurance program. There are still many unknowns about how people will apply and whether they’ll be served on a first-come, first-serve basis. The health plan that offers the state-only programs noted that , “I don’t expect we’ll have 2,300 people waiting at our door to sign up. There’s a lot that needs to be done before I can quote benefits and rates.” (6/24/10)
4 = NC estimates that up to 8,000 new people could enroll. They plan to have the federally-funded element launched by July 1, 2010. (Watch the NC Video 6/24/10 - Federal subsidies will lower health premiums for some)
5 = The WV legislature in July special session, rejected a bill to authorize state-run fedeerally funded programs [Artice: lPolitics blamed for W.Va. high-risk pool costs, AP 8/23/10]
MO = Since enrollment in the pool opened in July, Missouri has received just 70 applications and approved 47. The state's $81 million share of the federal subsidy is expected to accommodate 1,000 applicants this year. [article 9/4/2010]
* 2008 and 2007 enrollment data from NASCHIP; Census 2005 data.
Florida closed enrollment closed in 1991. Therefore, it is not considered an active coverage mechanism.
** Louisiana's data reflects combined numbers for Risk Pool and HIPAA Pool.
*** North Carolina's high-risk pool was created on Aug. 31, 2007. Enrollment statistic is as of January 2010.
State-only Program Background: Facts andStructures Prior to 2010 Federally-funded High-Risk Pools.
Source: National Conference of State Legislatures, 2009-2011.
Map Notes: Although Florida does have a high-risk pool, it has been closed to new enrollment since 1991, covering 300 individuals in 2008. Therefore, it is not considered an active coverage mechanism. Pennsylvania has no statutory requirement for open enrollment; however, the state's Blue Cross Blue Shield plans offer open enrollment as insurers of last resort.
--------------------------------------------------------------------------------
High-risk pools were primarily state funded (as of spring 2010):
Participants pay a premium rate that is established based on a formula included in state law. A typical high-risk pool rate is 125 percent to 200 percent of "average medically underwritten" individual insurance rates in the state.
- On average, the per-capita annual cost of high risk pool enrollees exceeded $9,000 in 2007.
- Enrollee premiums financed almost 60 percent of these expenses, states used other funds to cover the remainder – amounting to well over $700 million across 35 states.
Participants generally pay a premium rate that is established based on a formula included in state law. The typical hgh risk pool rate in 125 to 200 percent of average medically underwritten individual insurance rates in the state.
- Insurer assessments are used in most states to cover part of the cost of individual high-risk policies.
- Provider assessments, tobacco tax/settlement, general fund or other state funds may also be used.
- In recent years, (CMS) grant assistance has been made available on a year-to-year basis for pool start-up costs or to help cover excess use costs. $49,126,500 was awarded as of July 2008. $74 million was to be made available in July 2009.
Most were established by state statute, creating a nonprofit organization to offer comprehensive health insurance to individuals who are unable to buy regular health insurance because of their health status. The programs typically offer coverage of last resort for 1) uninsurable individuals, 2) federally eligible individuals specified by HIPAA and 3) those eligible for the federal Health Coverage Tax Credit (HCTC). The agencies that run these programs created the "National Association of State Comprehensive Health Insurance Plans" (NASCHIP), which provides detailed information on the operational state programs listed below. Their website contains extensive descriptions of individual programs as well as news of recent developments affecting high-risk pools
Two alternative strategies employed by some states to address coverage of high-risk individuals and those with HIPAA or HCTC eligibility are guaranteed issue and open enrollment. Guaranteed issue prevents private, individual plan insurers from denying coverage to applicants due to high-risk medical histories.
► Guaranteed issue is often paired with some form of community rating, preventing insurers from performing medical underwriting, the practice of varying enrollee premiums based on the risk they present to the pool. Community rating spreads the risk more evenly across the pool, greatly lowering the premiums for high-risk members but increasing premiums for the other members.
► Open enrollment requirements act as a limited form of guaranteed issue where a capped number of spots within affected plans are available during the open enrollment period, filled in order of application.
In a survey of states with high-risk pools in 2007, 30 out of 32 states had a pre-existing condition exclusion. The following chart shows the number of states that have a specific exclusion period for individuals with a pre-existing condition exclusion. As of 2010 these apply only to existing
state-funded programs, and generally not to the new federally-funded benfit plans.
| EXCLUSION PERIOD |
NUMBER OF STATES |
|
EXCLUSION PERIOD |
NUMBER OF STATES |
| no exclusion |
2 |
|
6 months
|
16
|
|
2 months
|
1
|
|
9 months
|
1
|
|
3 months
|
4
|
|
12 months
|
8
|
Most high-risk pool states (24) had a look-back period for pre-existing conditions of six months. Sixteen states offered coverage credit for prior insurance coverage; while 10 other states offered coverage credit under limited circumstances. Sixteen states used the objective person standard in excluding coverage on the basis of a pre-existing condition.
Source: Kaiser State Health Facts: State High-Risk Pool Pre-Existing Condition Exclusion and Look-Back Periods, Data as of Jan. 31, 2009(http://www.statehealthfacts.org/comparetable.jsp?cat=7&ind=604)
The NCSL Health Committee took an in-depth look at this topic in April 2008, inviting two national experts to describe latest activities and future proposals. The description and speakers' resources are linked below:
Covering High-Cost, High-Risk People: Whose Responsibility?
|
NCSL session held April 2008, Washington, DC. |
State interest in both health "reform" and health cost savings creates special challenges for covering patients considered "high risk" and high cost. The sickest 10 percent of our population often cost tens of thousands of dollars annually, accounting for more than 60 percent of U.S. health spending. Yet a cancer survivor may have low annual costs but be uninsurable. How should these people be treated by insurance market underwriting practices? What are the roles of state-sponsored high-risk pools, the health insurance industry, government, providers and the high-cost individuals themselves in providing and paying for care? Two national experts share facts and recent thinking.
- Karen L. Pollitz, Project Director, Health Policy Institute, Georgetown University, Washington, D.C. - [ Slide Presentation]
- Karen Ignagni, President and Chief Executive Officer, America’s Health Insurance Plans (AHIP), Washington, D.C.- [ Slide Presentation]
|
STATE HIGH-RISK POOL PROGRAMS
Table data sources: Karen L. Pollitz, Project Director, Health Policy Institute, Georgetown University, Washington, DC; NASCHIP: "States with Pools"
SOURCES AND RESOURCES
-
National Association of State Comprehensive Health Insurance Plans (NASCHIP) provides detailed information on the operational state programs. 2010, 2009, 2008 www.naschip.org.
-
"Comprehensive Health Insurance for High-Risk Individuals" Douglas Stratton. NASCHIP. September 2008.
-
State High-Risk Pools - An Overview - Issue brief by MN SHADAC, July 2008.
Author: Richard Cauchi, Program Director, NCSL Health Program, Denver, Colorado
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