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Risk pools - affordable health insurance
for medically-uninsurable individuals
(October 7, 2003) High-risk health insurance plans "risk pools" -- have become an important safety net for individuals who are denied health insurance because of a medical condition. More than 250,000 enrollees in the 30 states which operate risk pools have been provided with comprehensive insurance protection since the first pools were started in 1976. Risk pools provide a vehicle for individuals who, because of their physical condition, are unable to purchase heath insurance at any price.
A risk pool is a state-created, nonprofit association that -- in most states -- does not require tax dollars for its operational purposes. The risk pools are a temporary stopping point for individuals who are denied health insurance for medical reasons. Risk pools often help individuals fill a gap in insurance coverage.
Who is eligible to participate in a state's risk pool?
Who is not eligible to participate?
Where do risk pools operate?
For more information
Who is eligible to participate in a risk pool?
State residency
All individuals applying for plan coverage must be residents of that state. State legislation outlines a range of residency requirements for eligibility.
Proof of at least ONE of the following:
Proof of rejection. Individuals must prove they have been rejected for similar health insurance coverage by at least one insurer.
Presently insured with a higher premium. State residents are eligible for plan coverage even though they are currently insured, if their present insurance has a higher premium than offered under their plan.
Presently insured with a rider or rated policy. An individual is eligible for plan coverage even though they are currently insured, if their present insurance has a rider attached or is rated.
Reciprocity agreements
Several (but not all) states include a reciprocity agreement for acceptance into the plan, which means that if an individual has been enrolled under a similar state plan, has met the pre-existing waiting period and has not used up the lifetime maximum, he or she is eligible to apply in another state after meeting the residency requirement.
Who is not eligible to participate?
Non-residency
An individual is no longer eligible for plan coverage if he or she is no longer a resident of the state (although some states have reciprocity agreements).
Eligible for Medicare or Medicaid
Many of the state plans do not allow an individual to apply for plan coverage if the individual is eligible for, or receiving, Medicare or Medicaid. However, several states have adopted a high-risk plan for Medicare eligible individuals.
Termination of Coverage
An individual is not eligible for plan coverage if he or she has terminated coverage in the plan unless at least 132 months have elapsed since such coverage.
Extended Lifetime Benefit
An individual is not eligible for plan coverage if he or she has reached the maximum benefit level authorized by the plan.
Inmates
An individual is not eligible for plan coverage if he or she is an inmate of a public institution.
Specific Exclusions
At least one state has excluded coverage for certain diseases or medical conditions.
Enrollment Cap
Several states have placed an "enrollment cap" on their plans. Under this mandate, the plan will accept only a certain number of individuals into the plan at any one time. Others applying
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