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 health insurance 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 2011) 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), and was provided to the government as of May 21, 2010. Voluntary
updates from plan administrators are allowed. The format of the data is included
below.
A. State: The state associated with the individual program.
B. 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.
C. Website address – link to pool information: The URL at which eligible individuals may
obtain information and/or apply to a program.
D. 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.
E. Age Limit: If there is a specific age limit for participation.
F. Condition Specific(s): This requirement will record whether participation is premised
on specific conditions, and if so what conditions are covered.
G. 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.
H. 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.
I. 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.
J. 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.
K. 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.
L. Medicare Eligibles: Many state high risk pools do not allow enrollment for Medicare
eligible persons. While coverage of this population may be handled differently,

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medicare eligibles who are looking for affordable insurance must be made aware if
they have this option available to them.
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.
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.
Current Accreditation Organization: This information allows for understanding of the
financial status of these pools and further consumer research.
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.
Expiration Date: Expiration date of the pool program.