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No health insurance? Here's a new plan

The new state high-risk plans are just a stopgap. But they might provide the insurance coverage you need until health care reform fully kicks in.

By Karen Datko Aug 26, 2010 6:42PM

As required by health care reform, states are rolling out temporary high-risk plans for those who've been denied health insurance because of their medical history. We had thought the spots would go fast with so many millions in need, but a recent news story said only 3,600 people nationwide had applied for the coverage.


If insurance companies have turned you down because of a pre-existing condition, you still have time to get in on this deal -- a stopgap until 2014, when federal law will forbid health insurance companies from denying coverage.


Here's what you need to know:


Eligibility. You can apply if you've been uninsured for at least six months and have a pre-existing condition. (You can read more about the federal requirements here.)


Also, a U.S. government website says:

If you are uninsured and have been told that you may be eligible for other coverage programs like Medicaid and the Children's Health Insurance Program, you should check out those programs first, as they may better meet your needs. If you have job-based coverage, or individual insurance coverage, you aren't eligible to apply.

Check with your state insurance department for the specific requirements where you live. For instance, here in Montana, where the program's monthly premiums range from $190 to $615 for a $2,500 deductible policy, the rules state:

To qualify, an individual must be a citizen or national of the United States, or lawfully present, must be a Montana resident, must have a pre-existing medical condition and must have been uninsured for at least 6 months before applying for the federal program. ...
Applicants will need to provide documentation of citizenship, Montana residency, and proof of a pre-existing condition or two denials or offers of coverage which excludes benefits for a pre-existing condition.

Sounds simple enough. However, if your pre-existing condition isn't on the official list (.pdf file) (it reads like one of those diagnostic sessions on "House" -- Wilson's, Parkinson's, Huntington's Chorea, kidney failure, etc.), you must have two health insurance rejections within the last six months to qualify. That may help explain why so few people have applied so far.

Premiums. The premiums can be no higher than what's normally charged to people of your age where you live. (The premiums are being subsidized by the federal government at a total cost of $5 billion.) And just like private insurance, you'll likely pay a higher premium if you smoke.


That being said, premiums aren't necessarily cheap. For instance, premiums in Washington state's plan range from $161 to $1,500, according to KUOW News. In New Jersey, the range is $212 to $768 per month. In Ohio, it's $98 to $642 for a $2,500 deductible plan. This news story mentions a 59-year-old woman in New Mexico with a history of bladder cancer who pays $251 a month for her $2,000-deductible plan. That's a good deal.


On the plus side, the premiums for these new high-risk pools are generally lower than those for your state's regular high-risk pool, if it has one. (And if you are currently enrolled in that more expensive high-risk pool, you can't switch without giving up your coverage for six months -- a very bad idea if you're sick. Also, the spots in the new pool could be filled by then.)


Other expenses: Total out-of-pocket expenses for participants cannot exceed $5,950 (not including premiums). For example, Crain's Detroit Business offered a further breakdown of patient costs in Michigan, which will likely begin accepting applicants at the end of the month.

  • Co-pays of no more than $20 for office visits; $100 for emergency department care; $10 for generic prescription drugs and $30 to $50 for brand-name drugs.
  • Free prevention services, such as annual physicals and mammograms.
  • Caps at $100,000 for prescription drug costs and 60 visits a year for physical and occupational therapy, for each condition.

Availability. About 30 states have the new high-risk pools in place, and more are becoming available all the time. The plans will continue through 2014 or end sooner if a state's federal subsidy runs out.


Program administrators are surprised that so few positions have been filled so far. We suspect that's because too few people know the programs exist. And for many the premiums will still be unaffordable. (Subsidies will be in place in 2014 to help all Americans afford coverage.)


The need for insurance is certainly there. For example:

  • Colorado has 700,000 uninsured residents, including 30,000 who likely would qualify for the state's new high-risk plan, The Denver Post reports. The state has enough federal money to enroll about 4,000 people.
  • About 1.5 million people in Ohio lack health insurance, including 17,000 who would likely qualify, but that state's program will have room for only 5,500 of them.
  • "Pennsylvania has enough funds to enroll 3,500 people initially; any extras will go on a wait list," says WHYY.

The Congressional Budget Office estimated that 4 million U.S. residents would meet the plans' eligibility requirements. All told, the new high-risk pools might have 200,000 spots.


What if all the spots are filled before you apply? You will be able to buy insurance after the rest of federal health care reform kicks in 2014, when insurance companies will no longer be able to deny coverage to people with pre-existing conditions, and subsidies will be in place to help those who can't afford the cost. The Associated Press reports:

Some advocates for the uninsured have expressed concern that the money will run out before 2014, when the law creates new insurance markets, called exchanges.
"Once the money is gone, the program will end," (Ohio Insurance Department spokeswoman Carly) Glick said. "It's basically a stopgap to get us through to the exchanges."

It's something. It's a help. If you've been denied individual coverage, will this work for you?

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