CMS-10320.Appendix_F_PoolRequirements

Appendix F - High Risk Pool Market Requirements

High Risk Pool Market Requirements

One market of heightened interest to those without insurance currently are high risk pools. Section 1101 of PL 111-148 requires that the Secretary establish a high risk pool to provide temporary coverage for eligible individuals. However, a number of states have existing programs designed to provide health insurance to residents who are considered medically uninsurable and are unable to buy coverage in the individual market.

These health benefits high risk pools operate in 35 states (as of 2009) but vary as to who is eligible, cost sharing requirements, and availability of premium subsidies. While State health benefits high risk pools are the ultimate source of information on these programs, this data has already been compiled by the National Association of State Comprehensive Health Insurance Plans (NASCHIP). In order to minimize the burden on State health benefits high risk pools, the Secretary arranged by agreement with NASCHIP to obtain the following set of elements for each high risk pool program as of May 21, 2010. Voluntary updates from plan administrators are allowed. No additional collection is planned under the period of the emergency request.

1. State: The state associated with the individual program.

2. Customer Service Phone Number – Toll-Free: This element should be provided if a toll free number is available for specific consumer requests for plan information.

3. Website address – link to pool information: The URL at which eligible individuals may obtain information and/or apply to a program.

4. State Residency Requirement: * for non-HIPAA? This requirement records whether the program requires state residency for participation, and the length of time of residency required.

5. Age Limit: If there is a specific age limit for participation.

6. Condition Specific(s): This requirement will record whether participation is premised on specific conditions, and if so what conditions are covered.

7. Rejection Letter: Some high risk pools require an applicant to show letters of rejection from insurers. To inform consumers of conditions, we require to know if that applies to this plan and how many letters are required.

8. Restrictive Rider: Some plans maintain provisions which specifically add or exclude forms of coverage. If this is the case, we require that the information be provided.

9. Excessive Premium: Some states require the return of an entire premium provision in cases where an individual or entity takes an unauthorized payment to deter fraud. This can be an important provision to report to inform consumers of their risk, and to reinforce provisions of state policy.

10. HCTC Eligibles: Some states allow for automatic qualification premised on an individual’s eligibility for the federal Health Care Tax Credit established by the 2002 Trade Act for people who have lost their job to foreign competition and meet other qualifying conditions.

11. HIPAA Eligibles: The Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) established requirements that health insurance plans offer coverage to individuals who had been covered by group plans who meet certain conditions. Many states guarantee access to non group coverage in a high-risk pool instead of in the private health insurance market.

12. Medicare Eligibles: Many state high risk pools do not allow enrollment for Medicare eligible persons. While coverage of this population may be handled differently, medicare eligibles who are looking for affordable insurance must be made aware if they have this option available to them.

13. Other Eligibles: If other groups are automatically eligible to join a high risk pool on the basis of eligibility in some other program, NASCHIP will inform us as to this characteristic of the plan.

14. Low-Income Subsidy: Some state high risk pools include additional premium subsidies for those with incomes below a certain amount. We require this information and the income limit in order to adequately inform consumers as to the affordability of these options to them.

15. Current Accreditation Organization: This information allows for understanding of the financial status of these pools and further consumer research.

16. Current Status: We need to inform consumers as to whether a program is allowing new enrollment, and some idea as to the length of wait before acceptance.

17. Expiration Date: Expiration date of the pool program.