Implementation: Advocates' To Do List
Temporary Coverage for Uninsured People with
Pre-Existing Conditions
(Section 1101 of the Patient Protection and Affordable Care Act)
Effective within 90 days of enactment, federal funding is available to cover individuals who have pre-existing conditions and who have been uninsured during the six months before they apply for coverage through this new, temporary program. This new “temporary high-risk pool” will continue until 2014, when health reform will prohibit insurers from denying people coverage or charging them higher rates based on pre-existing conditions. The new program can be directly operated by the Secretary of Health and Human Services (HHS), or the Secretary can contract with states or nonprofits (such as existing high-risk pools) to administer coverage to eligible people. Coverage provided with this funding must be at standard premium rates (the rates charged to healthy people) and must meet certain requirements, outlined here. The health reform law allocates $5 billion for this program until 2014.
To do:
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Talk with your insurance regulators and the administrators of any existing plans that your state has to cover people with pre-existing conditions (such as high-risk pools or open enrollment products). Is your state planning to use temporary funding to build on an existing program, start a new program (perhaps through a contract with a HIPAA-carrier), or will your state rely on the federal government to operate the new pool? Which do you think would be most beneficial to consumers?
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If your state plans to operate a temporary high-risk pool, what level of benefits will it offer? The plan must have an actuarial value of at least 65 percent. Can you be on an ongoing advisory committee to make decisions about the application process, outreach, benefits, and other operations?
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How does your state currently serve people with pre-existing conditions who have NOT been uninsured for six months, such as HIPAA-eligibles? Work to lower premiums for that population, and ensure that their coverage is equitable with what the new risk pool provides.
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Whether your state, a nonprofit, or a federal entity operates the temporary coverage available for high-risk individuals in your state, make sure that your insurance department provides accessible resources for consumers to understand the temporary coverage that is available and how they can apply for it.
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Talk to both your congressional Representatives and your state legislators about any unmet funding needs for the temporary high-risk pool and for existing mechanisms to serve people with pre-existing conditions who do not qualify for the new program.
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