High Risk Insurance Pools

ananda8

The following is information about the new Health Care programs.  Please do not make political comments.  This quote if from the New York Times.  The link provides more information.

Under the new health care law, the government has earmarked $5 billion for states to set up high-risk pools, as the programs are called, for people who have been uninsured for six months or longer. The pools are to provide a bridge for people most in need of coverage until the insurance exchanges begin operating in 2014. The pools will have no restrictions based on pre-existing conditions; coverage starts immediately and comes with no annual or lifetime limits. Deductibles and co-payments will be kept low.

To learn more, read the full story, "Insurance Pools for High Risk Patients Start Soon,"

lago

But what about those who are about to lose thier insurance… must they be uninsured for 6 months before being able to be part of a high risk pool. 6 month right in the middle of treatment is scary.

lovemygarden

Oh gosh you just unintentionally hit a sore spot with this topic for me! New York's High Risk/PCIP plan goes into effect next week (it's administered by GHI/Emblem) and guess what? NOT ONE of my doctors, etc, who are ALL listed on their plan/pool's website as being providers for this thing, have ever HEARD of it! And I have called 6 different ones so far, plus the hospital that I would use (which is also on the so-called Provider List). Not only have none of them never heard of it, but until/unless they can find out how much they will be paid by GHI for services thereunder, they are denying that they are or will ever be participating providers. I have a hunch that as more and more providers learn about them, they will be dropping out of these high-risk plans like flies, and one feature of the high-risk plan is that a member cannot go out-of-network. So the high-risk pool networks, I fear, will quickly shrink if the providers are not going to be paid what they want to be paid.

From all I have found out over the past 2 weeks, GHI just automatically added all Emblem/GHI providers in NY on the website as "in network" for the new plan, apparantly without even notifying the providers that it was going to happen!

This does not give me a good feeling about how these plans are going to work out. 

 Also, if the other states' plans are like NY, it is "first come/first served" as far as getting onto the plan. It is not a slam-dunk automatic thing; they have to decide whether you qualify as "high risk" or "pre-existing" based on your individual medical case. And at whatever point the plan decides they are "full", they will close it to new applicants.

In the meantime the plans will not give a prospective member any useful information at all (such as answering simple but important questions such as "What is the copay for a Tier 4 drug such as Herceptin?" and "Am I considered high-risk if I have already had my tumors removed and am now getting adjuvant chemo? or am I high-risk only if I have not had my cancer surgery yet?")

I used to work in the insurance business and I know that these pools will find every loophole they possibly can in order to exclude people ("you're not high risk") because there is nothing in the new law that says they have to take every person who APPLIES; they only need take those who meet their qualifications as to medical conditions. The pools also have control over how many people they decide to accept and can arbitrarily close the pool to new applicants at any time and put everyone else who applies on a waiting list. At least that is how the NY pool operates and I can't imagine that other states are going to be any more generous.

Call me a cynic but I am sure these highrisk pools will end up being a perfect example of "If it seems too good to be true... it probably is."

 p.s. to answer Iago: Yes a person who loses their insurance has to be without it for at least 6 months to qualify as "uninsured"; at least in NY they do. I assume that's the same all over?

lovemygarden

By the way, the OP's linked article mentions premium amounts will be more affordable but does not give specific examples. FYI, for purposes of comparison, the NY plan's rates depend on whether you live in an upstate or a downstate county. Residents of upstate counties will pay $362 per month; downstate (closer to NYC) residents will pay $421 per month.

By contrast, NY's separate low-income plan (HealthyNY) premium rates vary depending on which specific county you live in. For instance a single person living in Nassau County would pay $368/month for a plan that includes prescription drug coverage (the lowest cost plan, without Rx coverage, is $250/mo). And the income maximums + past insurance (must have been without insurance for at least 12 months), + employment (must be working or have worked within the past 12 months) qualifications exclude many people from the HealthyNY plan. And there is the usual 12-month waiting period for coverage of all pre-existing conditions, so it is just like the 'normal' policies in that respect -- no immediate help for those already diagnosed.

Although $421/month for the high-risk/PCIP may seem expensive to some people, it is definitely cheaper than the lowest rates for a standard individual health insurance policy (which in NY all include a 12-month waiting period for all pre-existing conditions) directly purchased. Those rates are at least 3x higher; the lowest individual policy rate that I found earlier this year was $1500/month for a single person. There are very few companies that offer medical insurance to individuals in NY anymore; I think it is pretty much limited now to BCBS, Aetna, and GHI/Emblem and that's it. All the others are now offering group policies only (at least in the downstate are where I live).

Also FYI, all these new high-risk pools are for individual-person coverage only. They are not available for couples or families. So for instance if a husband has diabetes and the wife has cancer and they live in a downstate county, they would pay $842/month ($421 each) at the current premium rates.

MaryNY

lovemygarden: For NY's low-income plan (Healthy NY) is not just availabe for those who've been without insurance for 12 months. 

"You have not had health insurance for twelve months prior to your Healthy NY application or have lost that coverage due to a specific event. Some qualifying reasons include loss of health insurance overage due to job loss, divorce or separation, death of a spouse, and change in residence."

Also with HealthyNY, the 12-month wait for pre-existing conditions seems to be a bit ambiguous. They say:

"Your Healthy NY policy will exclude coverage for that condition for up to 12 months. However, this period may be reduced or eliminated if you are transferring from other health insurance coverage which terminated no more than 63 days prior to the date that you submit your Healthy NY application."

I signed up for HealthyNY on August 1. I was transitioning from COBRA which was running out. I was told there would be no 12-month wait period for me. So far I've been covered for a mammogram, ultrasound and biopsy without any problems. 

In my case the HealthyNY plan made more sense than the PCIP, which wasn't yet available at the time anyway. But HealthyNY seems like a better option if you qualify for it without having a break in insurance coverage.

lovemygarden

Hi Mary, yes there are definitely those exceptions to Healthy NY's 12-month-no-insurance guideline; I shouldn't have generalized that part as much as I did!

 The 12-month pre-existing waiting period is indeed modified if the person had any kind of coverage (COBRA, group plan, individual policy, Medicaid, etc) still in force no further back than 63 days prior to the application. Again I wasn't specific enough by just saying "the usual 12-month waiting period"; by "usual" I meant "according to current law" which describes the whole 63-day thing. That element is actually Federal law (HIPAA of 1996, Title I) and I believe that wording ("may", etc) applies across the board to all policies sold (other than the new PCIP pools) in or by any state, not just to HealthyNY. (There are also some fine-print exceptions and such in Title I regarding dental and vision coverage, neither of which are relevant to cancer.)

The HealthyNY plans are less expensive (though not by a huge amount when comparing the 'best' HNY plan to the PCIP one) than the PCIP, and they do have the advantage that HNY also offers multi-person coverage whereas the PCIP plans do not. 

gale1525

The people that live in NY are somewhat better off than Ca. In Ca you have to have no insurance for 6 months regardless if you have had insurance or not (COBRA etc.), it doesn't matter. so if you get in an accident or something I guess you will have to pay out of pocket, or if you are in the middle of treatment. The children's pre-existing condition is already in effect, so what some of the insurance companies doing now are not writing individual policies, so they don't get stuck with alot of sick kids. So is this going to happen in 2014 they won't write policy's for individual's? How is this helping?

lovemygarden

lluistro, the new "high risk" plan in NY works the same as California's does: You cannot have had any insurance at all for at least 6 months prior. It's called the NY Bridge Plan and goes into effect on Oct 1st. You also MUST HAVE a pre-existing condition in order to get onto it, and that pre-existing condition is covered immediately.There are no rules about income or employment.

The plan Mary is talking about is a different plan, called HealthyNY. HealthyNY is for lower-income applicants (for instance a single person must have no more than $2257/month gross [before-taxes/deductions] household income). Healthy NY is subject to the HIPAA rules and thus they impose a waiting period of 12 months for all pre-existing conditions unless the person has been covered by another health insurance within a period of 63 days before he/she applies. If the person had coverage (from another job, Cobra, Medicaid, whatever) in effect at any time within those 63 days, the HealthyNY plan has to either reduce or eliminate the waiting period that would otherwise apply to pre-existing. Whether it's reduced, or eliminated entirely, depends on how long the applicant had the prior insurance. HIPAA only says that "credit must be given" in those situations. But if someone was on COBRA, for instance, and their COBRA expired 65 days before they applied for HealthyNY, that person won't have any coverage for a pre-existing condition for an entire year (because the COBRA terminated more than 63 days before they applied for HNY).

I think you are probably right about insurance companies eventually eliminating the issuance of individual health insurance policies. We in NY have seen it happening for years; even 8 years ago there were a half dozen companies writing individual policies and now there are only 3. Assuming the recently passed healthcare act is still in its current form in 2014, their rationale may be that "People without other options can just join a pool or an exchange". Whether these pools or exchanges wil be any less expensive, or will be required to cover all pre-existing conditions immediately, is anyone's guess because nobody has a crystal ball when it comes to economic conditions.

However, going by my experience so far with the new PCIP plan in NY, I suspect that unless providers are forced by law to accept patients with any of these new plans, they will simply choose not to do so. Currently there is no law that says doctors MUST take this plan or that plan. Providers have freedom of choice as to how they want to be paid. They can already refuse to accept Medicare or Medicaid, and in fact more and more are doing just that (this has been widely reported in the media) so I'm sure they'll be allowed to refuse to take any of the proposed "bridge" or future "exchange" plans also.

 

ananda8

We are getting very close to making this thread about politics rather than actual information.  If politics enters this thread I will ask to have it closed down.  If a poster cannot or will not provide factual and helpful information then don't post.

Speculation on what may happen in the future has no place on this thread.

lovemygarden

Which elements of any of the foregoing posts do you feel are not factual and helpful? Description and clarification of how specific plans work is certainly factual and helpful IMHO.

I have removed the brief general reference, in my previous post, to a specific political event that will occur in a specific future year. However I do continue to stand by my personal opinions that based on what has recently and is currently happening in the health insurance marketplace, (a) companies will probably continue to phase out the issuance of individual policies (which they have been doing for a number of years based on profitability concerns and also in response to state insurance mandates that they may find onerous), and (b) that providers will continue to exercise their right to not accept any insurance plan that does not reimburse them at a level they deem acceptable -- regardless of the source of the plan (private, state, or federal).

My opinions here are about what's currently going on in the health insurance industry re: available coverage, especially for pre-existing conditions, and have nothing to do with any political agenda; in fact the remark that I deleted was a neutral one that did not contain any praise nor any criticism of any political element or person. AFAIK posters are allowed to express opinions on this forum, are they not?

ananda8

I don't want this thread to deteriorate into the mess that has occurred on several other threads that had to be closed down because of the violence of the language.  You can express any opinion you wish on this thread as long as it is not in any way political.  If you wish to discuss the politics of health care in America, you can always start your own thread.  It is quite easy to do.

cary1

I don't get it. First, the link to the article is important. The notion that you would take it down is, with all due respect, disturbing. Second, everything is political.

Thanks for posting the article. 

ananda8

cary1,

I don't think you have seen the threads I am talking about.  The moderators took them down.  They started out calmly about health care and deteriorated into some of the most horrible comments that I have seen on any forum.  I don't want this thread to be a flash point for more anger and stress.  It just isn't appropriate to a cancer forum.  It is strange that the other thread I posted is very calm.  http://community.breastcancer.org/forum/113/topic/758415?page=1#idx_1

Traci-----TripNeg

You may think I'm crazy, but I am seriously considering dropping my health insurance. Maybe you guys can give me some words of wisdom, since you seem to be really in tune with what's going on.

My insurance right now, for me only, is $898.46 per month. (It just went up, again.)

I am not on any kind of treatment now. I'm triple negative. I am due for another scan in about six months. My last scan was clear, and I had a bi-mast and hysterectomy right after dx.

If I drop my insurance, then can I get insurance right before my scan?

gale1525

If you drop your insurance, unless you can go through an employer who has guaranteed issue insurance, you won't be able to get that until open enrollment. The government pre-existing says that you have to be uninsured for six months, or more depending on your state. I don't know of any individual health care plans that you can get with a major pre-existing condition. I would not drop your insurance unless you need the money to eat or keep a roof over your head. I know how expensive it is mine is a lot more. But I wouldn't want to leave my family with major medical bills that would take till  I'am 100 to pay off.

gale1525

Also what if had had accident or something? The emergency room alone could be thousands of $$$.

Medigal

notself:  This same info was discussed on another thread and I don't understand how you or even the moderator can expect us to discuss this healthcare plan without it getting political.  I agree we should act like mature adults and discuss it without profanity but to say it "can't get political" is like saying we can make an apple pie but can't have apples in it! 

I researched this for my state KY and made some calls. I was very concerned about the 6 month waiting period and thought I misunderstood it. What I was advised was that even if one lost their job they had to prove they went without any insurance for 6 months before they could apply and get on one of the High Risk Plans for their state!  I tried to explain to them that people who are "High Risk" may need expensive meds or even end up in a hospital during that time and how were they supposed to pay for their medical costs.  They did not know the answer to this "profound" question.  You don't want this to become political but it was POLITICIANS who came up with this plan without even taking into consideration what dreadful consequenses this "6 month waiting period" would have on medical patients.  

You want to consider another thing nobody bothered to think about.  When someone loses their job and is so desperate they can find a way to pay for their company's COBRA they are still not protected.  As soon as COBRA runs out they must STILL wait the 6 months without medical coverage before they can get on one of their state's High Risk Plans!  

It blows my mine that no one in Washington took into account what would happen to people while they waited out the 6 months.  I will end my post before I forget and use language which is really  what I am thinking about how our politicians come up with these ideas.  Our only hope is that a new party will take over and fix this latest mess with our healthcare system. 

Traci-----TripNeg

Iluistro, you pay more than I do? OMG!!!!! It's insane. You make a good point.

Hi Madalyn!! I haven't 'seen' you in forever! Yes, I'm considering it because it's just so much money. I don't make very much anymore and I freaking hate living paycheck to paycheck. I know I shouldn't be whining about that because so many people have so much less than I do, it's just hard. If it wasn't for my freaking insurance, I could go to every single Cowboys game!!! lol. But, seriously.

Thanks for the advice girls. I just took on a part-time direct sales gig that's starting to prove lucrative. Hopefully, I won't even have to think about it in a few months.

Hugs to all!

Traci

Anonymous

Traci, didn't you move from one state to another (Texas) and couldn't take your insurance with you?  That's one thing I think that needs to be addressed...being able to take our insurance with us when we move.  I don't think that's in this bill, but I could be wrong.  I forget...I'm getting old...LOL

wenweb

Hi,

I have a question.  I live in a state that requires everyone to have health insurance.  How would this new high risk pool work in that situation?  Does anyone know?  

lovemygarden

wenweb, Massachusetts is one of the states that chose not to run its own high-risk pool but has asked the Federal government (Dept of Health & Human Services) to run it instead. Mass is like NY as far as pre-existing conditions go (there can be a waiting period of up to 12 months if there wasn't continuous coverage). So a person who has health insurance in Mass but their pre-existing condition isn't covered yet, can apply for the PCIP/highrisk pool that HHS offers to Mass residents.

wenweb

Thanks, lovemygarden

lovemygarden

Forgot to add that as I understand the Mass law, the way it works is that each person has to have health insurance OR pay a fine for not having it. The fine is based on the person's income but AFAIK the maximum is $90something/month. I don't know how much the typical cost is for a policy in Mass but I'm sure there are plenty of cases where the $60 or $80 or $90/month fine is the lesser of two evils, so they go without insurance for X amount of time and then the pre-existing waiting period would kick in if that person is subsequently diagnosed with bc for example.