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High Risk Health Insurance Pools/Pre-Existing Condition Insurance Plan (PCIP)


Historically, there were two types of plans for people with pre-existing health conditions: Pre-Existing Condition Insurance Plans (PCIP) and high risk health insurance pools. Both are described below. The following information is for historic information onlyh since these plans are no longer relevant to people with a health condition because of the Affordable Care Act (also known as "Obamacare.")  For information about  individual policies available in your  state, see: offsite link

Pre-Existing Condition Insurance Plan (PCIP): 

The Pre-Existing Condition Insurance Plan (PCIP) is a new program offered in every state under the federal Affordable Care Act. A PCIP can be administered by either a state or the Federal government. The PCIP may be able to help you if you've been locked out of the insurance market while the nation transitions to 2014. In 2014, you will have access to affordable health insurance choices through a new organization in your state called an Exchange—a time when you can no longer be discriminated against based on a pre-existing condition.

The Pre-Existing Condition Insurance Plan covers a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs.  All covered benefits are available for you, even if it’s to treat a pre-existing condition.

To qualify for coverage:

  • You must be a citizen or national of the United States or residing in the United States legally.
  • You must have been uninsured for at least the last six months before you apply.
  • You must have a pre-existing condition or have been denied coverage because of your health condition.

For more information about the plan in your state, including how to apply, go to offsite link. Enter the name of your state and work through the requested information.

State High Risk Health Insurance Pools

Thirty four states operate or sponsor state health insurance risk pools, which offer health insurance similar to that offered by major employer group plans at higher-than-market-range premiums.

High-risk pools are for:

  • People who cannot get health insurance at all.
  • People who cannot get health insurance at reasonable rates.
  • People who cannot get health insurance without prohibitive preexisting condition limitations.

At least 11 or 12 states further subsidize discounted premiums for people who meet state low-income eligibility levels.

Many state risk pools offer several plans, including Fee-for-service (Indemnity), PPO and HMO options, as well as variations for location or amount of desired deductible.

One or two pools exist only for portability purposes under HIPPA, while at least two are continually or often closed to new patients due to funding shortages. State insurance agencies and risk pools have more details.

Many, but not all, pools ban enrollment of people who are eligible for Medicare. Of the that do allow admission to people who are Medicare eligible, some (but, again, not all) offer premium discounts because Medicare is primary payer. Yet a few states that do cover Medicare eligibles offer them only a standard Medigap plan. Drug coverage in those pools with Medicare supplements often does not supplement Part D for non-Extra Help patients.

Some risk pools have laws or rules prohibiting the use of funds other than the patient's own to pay premiums---while some do allow payment by corporate Patient Assistance Programs, ADAP/Ryan White programs, or sources other than public agencies or employers. But even so, many effectively still inhibit third party premium payments by requiring payment only via automatic debits from a patient's own bank accounts.

To Find Information About The High-Risk Pool In Your State: See: offsite link

NOTE: For contact information for your state insurance agency, see: offsite link.

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