High Risk Pools ("Pre-existing Condition Insurance Plan") update

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The Patient Protection and Affordable Care Act called for the formation of a new high risk pool in each state within 90 days after its enactment. States were required to notify HHS by the end of April if the state would establish its own high risk pool or defer formation of the high risk pool to the federal government.

Earlier this month, HHS announced the creation of these "Pre-existing Condition Insurance Plans" (PCIP) that will offer coverage to uninsured Americans who have been unable to obtain health coverage because of a pre-existing health condition. The PCIP is a temporary program to help provide access to coverage until 2014, when coverage will be available regardless of pre-existing conditions.

Those states that decided to establish their own high risk pool must either contract with administrators or private health plans to operate and/or provide coverage in the pool.

HHS is running the high risk pools in the following states where our affiliated health plans do business: Indiana, Georgia, Virginia, Kentucky and Nevada; the other states where affiliated health plans do business are developing high risk pools run by the state rather than HHS.

Ultimately, high risk pools include those who have been unable to obtain health coverage because:
1. A pre-existing health condition
2. Private insurance being "unaffordable"

High risk pools that are run by HHS will require a denial letter for health insurance which requires underwriting.

• The denial letter must be dated within 6-months of the application to a PCIP and be from an insurance company or health plan showing that an individual has been denied completely due to a pre-existing condition, or the individual was offered coverage but was denied certain benefits (for example, by a rider to an insurance policy) because of a pre-existing condition. 

We support the development of the high risk pools as a method to increase access to health care coverage. We are focused on providing up-to-date and accurate information to our members, customers and brokers and are committed to continuing to work with federal agencies and the Administration as the implementation timeline moves forward.