High Risk Pools (benefits, enrollment, cost) Author:    Posted under: Health InsuranceHealth Insurance Types


Most people, if they are lucky enough, get to enjoy their health insurance through their respective employer or through the employer of a family member through a group health insurance. Today, roughly 60 percent of the country is insured by their employers, and roughly 30 percent gets their insurance through state and national programs such as Medicare. As tiny a percentage of the total population purchases their health care through private insurance companies; an even smaller percentage is consequently denied health care due to pre- existing medical conditions. This would make that individual uninsurable to most, if not all the group health insurance market. This is where High-risk health insurance pool steps in to provide these individuals access to coverage.

High Risk Pools are private – funded health insurance plans organized by certain states to serve these so called high-risk individuals who do not have access to group insurance. Most high risk pools are self-funded thus they are self-governing entities that have their own boards and administrators. Though sometimes, high risk pools also function as part of the state’s department of insurance.

Also, Congressional Republicans proposed the creation of a high risk pool program, included in the historic new health reform law to help provide affordable health insurance coverage to people with pre-existing conditions who clearly fall under uninsurable individuals.

You can apply for high-risk pool coverage directly with the state or through an insurance agent. Generally, this uninsurable individual will have choice of health plan options and will receive enrollment cards and other information much like any other health plan will give you.

In order to obtain insurance through a high risk pool program, an individual must first meet the criteria depending on which state he or she is from. But most fall under these:

  • The individual must be a citizen of the United States or legally present in the United States
  • Have a pre-existing condition, as determined in a manner consistent with guidance issued by the Secretary, and
  • Not have been covered under a credible coverage (as defined in Section 2701(c)(1) of the Public Health Service Act) for the previous 6 months before applying for coverage.

High Risk Pool is generally a comprehensive medical plan with a variety of deductible options. Your options are quite alike to traditional individual health insurance offerings. The common risk-pool option is a PPO plan, but many states nowadays also offer indemnity coverage. Some even have HMO and/or HSA options obtainable to their patients. Coverage for prescription drugs, maternity, and mental health and substance abuse are also offered by most pools. These, along with many other services like disease management programs are also offered for patients of high risk pool programs.

Although high risk pools are designed to have premiums affordable for the participants, the main fact that they are uninsurable to most traditional insurance companies mean that their premiums are still quite expensive compared to the regular premiums. This is still fair considering that traditional insurance companies considered the pool member uninsurable. Generally, rates are most likely determined by your age and even sometimes by where you live.

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