Topic: High Risk Insurance Pools

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Posted on: Sep 23, 2010 03:28PM

Posted on: Sep 23, 2010 03:28PM

ananda8 wrote:

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,"

“Before enlightenment, chop wood, carry water. After enlightenment, chop wood, carry water.”
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Sep 23, 2010 04:05PM lago wrote:

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.

DONE!! • Tattoos 2.7.2012 • Nipples 10.6.2011 • Exchange 6.24.2011 • Chemo 1.18. 2011 • BMX 8.31.2010 Dx 7/13/2010, IDC, 5cm, Stage IIB, Grade 3, 0/14 nodes, ER+/PR+, HER2-
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Sep 23, 2010 04:42PM - edited Sep 23, 2010 08:25PM by lovemygarden

Oh gosh you just unintentionally hit a sore spot with this topic for me! Sealed 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?

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Sep 25, 2010 10:07AM - edited Sep 25, 2010 10:14AM by 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.

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Sep 25, 2010 12:16PM - edited Aug 20, 2013 05:48AM by 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.

Mary ~~ lumpectomy 8/10/2009, Oncotype DX 18, Chemo 10/28/09--2/1/10 AC*4, CMF*4 Dx 5/19/2009, IDC, 1cm, Stage IIA, Grade 2, 2/6 nodes, ER+/PR+, HER2-
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Sep 25, 2010 07:30PM - edited Sep 25, 2010 08:22PM by 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. 

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Sep 26, 2010 01:49AM gale1525 wrote:

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?

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Sep 26, 2010 06:15PM - edited Sep 27, 2010 12:31AM by 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.


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Sep 26, 2010 08:29PM - edited Aug 20, 2013 05:49AM by 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.

“Before enlightenment, chop wood, carry water. After enlightenment, chop wood, carry water.”
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Sep 27, 2010 12:09AM - edited Sep 27, 2010 12:36AM by 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?

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Sep 27, 2010 02:02AM ananda8 wrote:

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.

“Before enlightenment, chop wood, carry water. After enlightenment, chop wood, carry water.”

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