State Risk Pool

CMS Form Number: CMS-10320
OMB Control Number: 0938-1086
Expiration Date: XX/20XX

Appendix F - High Risk Pool Market Requirements
High Risk Pool Market Requirements
One market of heightened interest to those without health insurance is 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 need 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 Eligible: 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 Eligible: 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 Eligible: Many state high risk pools do not allow enrollment for Medicare eligible persons.
While coverage of this population may be handled differently, Medicare eligible persons who are
looking for affordable insurance must be made aware if they have this option available to them.
M. Other Eligible: 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.
N. 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.
O. Current Accreditation Organization: This information allows for understanding of the financial status of
these pools and further consumer research.
P. 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.

Q. Expiration Date: Expiration date of the pool program.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1086. The time required to
complete this information collection is estimated to be XX hours per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the information collection.
If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly delay application
processing.

R.

1