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New Coverage for the Uninsured

High-risk pools help insure people with preexisting medical conditions

People who have been refused health insurance because of preexisting medical conditions now have a chance to buy coverage through the first major program to be rolled out under the new health care law.

The Pre-Existing Condition Insurance Plan (aka the “high-risk pool” program) may help many uninsured Americans of all ages get health care, though there’s concern that federal funding for it—$5 billion overall—will not be enough to meet demand, and that many won’t be able to afford the premiums.

Intended as a stopgap measure, the program lasts until 2014 when insurers can no longer deny anyone coverage because of health issues.

Although this is a federal program, there is no single uniform plan. Twenty-nine states and the District of Columbia (which already have similar high-risk programs) have chosen to run their own plans, with widely varying costs and benefits. The remaining 21 state programs are run directly by the federal government; these have the same benefit package but different premiums. For consumers, this is how the program works:

Who qualifies? You must have been without health insurance for at least six months before you apply; have a qualifying preexisting medical condition; and be a U.S. citizen or legal resident.

How do I apply? You must apply to the federal plan provided in your state. Go to for information and to apply online. Or call your state department of insurance.

How do I prove that I qualify? You must show evidence that an insurance company has denied you health coverage because of a preexisting condition or excluded coverage for that condition; or, in some states, has quoted you a premium much higher than the federal plan requires. You also need a letter from your doctor confirming that you have a medical condition that makes you eligible.

Does my income make any difference? No. Income isn’t taken into account.

Can I apply if I’m already enrolled in my state’s own high-risk program? No, because this means you’ve been insured within the last six months.

How soon can I receive coverage? If you apply by the 15th of any month and are accepted, full coverage—even for your preexisting medical conditions—starts the first day of the following month.

What benefits will I receive? Benefit packages vary according to the state you live in. But they must all cover a wide range of services, including primary and hospital care, specialists and prescription drugs.

What will it cost me? In the federally run programs, you pay a $2,500 annual deductible (except for preventive services), a $25 copayment for doctor visits, and 20 percent of the cost of other covered benefits. Some state-run programs are a lot more generous. Each state decides premiums, which may vary according to age and tobacco use.

I’m over 50. Will I pay higher premiums? Probably. Premiums in most states vary by age.

Will my out-of-pocket expenses be capped? Yes, at an annual amount specified by law—currently $5,950 for each person, but some states have lower limits. The caps apply to deductibles and copays, but not premiums.

Can I get coverage for my family? There are no special rates for family coverage. Every member of your family who meets the conditions can apply as an individual.

What if I’m not eligible? Check out your state’s own high-risk program, if it has one. In some states you may qualify even if you’ve had insurance within the past six months. To see if your state has its own program, go to or call your state’s department of insurance.

What if I can’t afford the premiums? For this coverage there are no subsidies, no matter how low your income. But some states’ high-risk plans offer special rates for low-income people. Call your state’s medical assistance office to see if you or family members qualify for Medicaid or the Children’s Health Insurance Program.

What if I enroll but federal funding dries up? If that happens, your coverage will not necessarily end. Your program would likely freeze enrollment and wait-list new applicants.

Patricia Barry is a senior editor at the AARP Bulletin.

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