High-Risk Pools For Uninsurable Individuals
Issue Brief
S Cohen and W Yu, “The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the US Population, 2008-2009. AHRQ Statistical Brief #354, January 2012.
“High-Risk Pools,” State Coverage Initiatives, Robert Wood Johnson Foundation, 2001, available at http://www.statecoverage.org/node/40/cs_states.html
In the Maryland pool, for example, the list of eligible conditions included behavioral health conditions (bipolar disorder, chemical dependency, dementia, psychotic disorders); blood disorders (aplastic anemia, hemochromatosis, hemophilia, sickle cell disease); cardiovascular conditions (angina pectoris, cardiomyopathy, congestive heart failure, coronary artery disease, coronary insufficiency, coronary occlusion); endocrine disorders (Addison’s disease, cystic fibrosis, diabetes, porphyria, Wilson’s disease); gastrointestinal disorders (ascites, Banti’s disease, cirrhosis of the liver, Chron’s disease, esophageal varices, hepatitis B and C, ulcerative colitis); infectious diseases (HIV/AIDS); musculoskeletal/connective disorders (ankylosing spondylitis, lupus, rheumatoid arthritis, scleroderma); pulmonary disorders (chronic obstructive pulmonary disease, emphysema); neoplasm (cancer treated or diagnosed within 5 years, Hodgkin’s disease, leukemia, multiple myeloma, non-Hodgkin’s lymphoma, Wilm’s tumor); neurologic conditions (Alzheimer’s disease, ALS, Friedreich’s Ataxia, Guillain-Barre syndrome, Huntington’s disease, hydrocephalus, multiple sclerosis, muscular dystrophy, myasthenia gravis, myotonia, palsy, paraplegia, Parkinson’s disease, quadriplegia, stroke, Tay-Sachs disease); also major organ transplant and pregnancy.
“High-Risk Pools,” State Coverage Initiatives, Robert Wood Johnson Foundation, 2001, available at http://www.statecoverage.org/node/40/cs_states.html
Communicating for Agriculture, Comprehensive Health Insurance for High-Risk Individuals, 1996.
All but eight traditional state high-risk pools have since suspended new enrollment.
K Schwartz, G Claxton, K Martin, and C Schmidt, “Spending to Survive: Cancer Patients Confront Holes in the Health Insurance System,” Kaiser Family Foundation, 2009. Available at https://www.kff.org/wp-content/uploads/2013/01/7851.pdf
NASCHIP, Comprehensive Health Insurance for High-Risk Individuals: A State-by-State Analysis, 2009/2010.
NASCHIP, Comprehensive Health Insurance for High-Risk Individuals: A State-by-State Analysis, 2011/2012.
Annual maximums applied under state high-risk pools included: AL: $10,000 for pharmacy benefit; AR: $4,000 for mental health/substance abuse benefit; CA: $75,000 for all benefits; CO: $3,000 for DME benefit; ID: $2,000 for rehab benefit, $5,000 for hospice benefit; $10,000 for DME benefit; IN: $50,000 for mental health/substance abuse, Plan 3 only; KS: $100,000 for all benefits; LA: $125,000 for all benefits; MS: $100,000 for pharmacy benefit; MT: $5,000 applies to DME, $4,000 applies to rehab benefit; NH: $10,000 applies to pharmacy, $5,000 applies to DME, $3,000 applies to mental health/substance abuse, various day limits apply to skilled nursing, rehab, home health; NC: $100,000 applies to injectable drugs; various day limits apply to skilled nursing, rehab; ND: $6,000 applies to DME benefit; OK: $4,000 applies to mental health and chemical dependency combined; SD: $2,000 applies to substance abuse, $900 applies to mental health treatments for non-biologically based conditions, $8,000 applies to DME benefit; TN: $200,000 for all benefits plus $100,000 for organ transplant; TX: $2,000 applies to rehab, $5,000 applies to home health, $10,000 applies to hospice, various day limits apply to skilled nursing care and mental health care; UT: $300,000 for all benefits; WV: $200,000 for all benefits. Source: NASCHIP, Comprehensive Health Insurance for High-Risk Individuals: A State-by-State Analysis, 2009/2010.
To compute net losses for a given state, follow links to NASCHIP charts for Total Revenue by Pool, 2011 and Total Expenses by Pool, 2011; subtract the premium revenue for a state pool (first column in the Total Revenue by Pool, 2011 chart) from the total expenses for a state pool (last column in the Total Expenses by Pool, 2011 chart.)
NASCHIP, Comprehensive Health Insurance for High-Risk Individuals: A State-by-State Analysis, 2011/2012.
J Hall and J Moore, The Affordable Care Act’s Pre-Existing Condition Insurance Plan: Enrollment, Costs, and Lessons for Reform, September 2012, available at http://www.commonwealthfund.org/publications/issue-briefs/2012/sep/preexisting-condition-insurance-plan
PCIP Annual Report, 2012 available at https://www.cms.gov/CCIIO/Resources/Files/Downloads/pcip-report.pdf, and PCIP Annual Report, 2013 available at https://www.cms.gov/CCIIO/Resources/Files/Downloads/pcip_annual_report_01312013.pdf.
For example, in Colorado, enrollees in the state PCIP experienced 562 hospital admissions per 1,000 and used 5,174 inpatient days per 1,000, while enrollees in Colorado’s traditional high-risk pool experienced 137 hospital admissions per 1,000 and used 735 inpatient days per 1,000. See PCIP Annual Report, 2012.
PCIP Annual Report, 2013.
PCIP Annual Report, 2012 and 2013.
PCIP Annual Report, 2013. The report notes that various cost containment measures had been adopted prior to enrollment suspension, including switching to a more competitively priced provider networks, negotiating special discounts with hospitals treating a disproportionate share of PCIP enrollees, and requiring use of cost effective preferred pharmacies for specialty drugs. See also PCIP Data Report, March 2013, available at https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/pcip-expenditures-3-31-2013.pdf