Health care reform: high-risk pool aims to spread insurance to patients with costly medical conditions

One notable feature of the Patient Protection and Affordable Care Act of 2010 – better known as health care reform – is the extension of coverage to high-risk individuals with costly medical conditions through the creation of insurance pools.

The program is designed to help individuals whose pre-existing chronic or other conditions have made it difficult for them to afford or find insurance. As we’ve noted before, Blue Cross Blue Shield of Michigan is unique among insurers in that we never deny anyone coverage based on their medical history. Many other insurers, both non-profit and for-profit deem these people too costly to insure.

As part of our ongoing series of what health care reform means to you, here’s a look at how the new high-risk pool program will impact people with pre-existing conditions.

Access to the new high-risk pool program starts by July for people around the country. While regulations and clarification from the federal government are still forthcoming, the only eligibility requirements are for individuals to have a pre-existing condition and to be uninsured for six months without access to any other qualified coverage options, such as employer coverage.

Insurers that offer coverage under the high-risk pool must comply with the following regulations:

• A prohibition on pre-existing condition exclusions
• Adjusted community rating
• People won’t be charged higher rates based on health status or gender
• There is a maximum age band of 4 to 1, meaning the oldest people in the pool cannot be charged rates more than four times what the youngest people are charged, , mean
• They must pay for at least 65 percent of enrollee costs on average
• Annual out-of-pocket cost for enrollees is to be no more than $5,950 for an individual and $11,900 for a family

More on what health care reform means to you:

• What health care reform means for Michigan Blues members who buy individual policies
• How health care reform impacts ‘Cadillac’ plans, small businesses and group plans
• What national health care reform means for Michigan Blues members

Tomorrow: Health care reform for Medicare Part D and members with disabilities