From the consumer’s point of view, this is how the new program works according to federal and state officials:
Who qualifies for the federal high-risk pool program?
The new law specifies that you must have been without health insurance for at least six months before you apply, have at least one qualifying preexisting medical condition, and be a U.S. citizen or a legal resident.
How do I apply?
You must apply to the federal program provided in the state in which you live. The new HHS website provides contact information—phone numbers and websites—for each state. Click on the link labeled “Pre-Existing Condition Insurance Plan.” If you don’t have computer access, call your state’s department of insurance for information.
How do I prove that I qualify?
It depends on your state’s regulations:
Proving non-coverage: You will need to attest, on the application form, that in the previous six months you have not had “creditable health coverage” from employer group insurance, COBRA, individually purchased insurance (including insurance acquired through state programs) or public coverage such as Medicare, Medicaid and veterans’ benefits. You will also need to provide evidence that you’ve been turned down by an insurance company. If you live in one of the few states that already require insurers to accept people with preexisting conditions, you need to show that their rates are significantly higher than the federal plan’s premiums.
Proving preexisting conditions: You will need a doctor’s letter confirming that you have at least one health condition that makes you eligible for the program. Each state has developed its own list of qualifying medical conditions, which has been approved by federal health officials.
Proving legal residency: If you are not a U.S. citizen, you will need to provide evidence that you are a legal resident (green card holder). Your state may also require you to have lived in the state for a certain length of time, whether you’re a citizen or legal resident.
Can I apply for the federal program if I’m already enrolled in my state’s existing high-risk pool?
No, because this means you’ve been insured within the last six months.
If my application is accepted, how soon will I receive coverage?
If you apply by a certain date (typically the 15th) in any given month, and you are accepted, your coverage will normally begin on the first day of the following month. As the program is only now being rolled out, your state may start accepting applications in July or in August.
What kind of benefits will I receive under the federal program?
Benefit packages vary according to the state you live in because each state is free to develop them, subject to approval by federal health officials. You will receive information about benefits offered in the federal plan available in your own state when you apply.
What will the federal plan cost me?
Again, it depends on the state you live in. Each state decides premiums, deductibles and copays, subject to federal approval.
I’m over 50. Will I have to pay higher premiums because of my age?
The law allows premium rates to be pegged to age, but they cannot be more than four times higher for the oldest people in the pool (those age 60 and older) than for young people under 30. This maximum 4-to-1 ratio is higher than the limits required under existing insurance rules in some states and lower than those in others. Some states may set the limit for the federal plan at a ratio lower than 4-to-1.