Health Administration Responsibility Project
State High Risk Health Insurance Pools

courtesy of

Tom McCormack

Twenty nine states operate or sponsor state health insurance risk pools, which offer health insurance (subsidized by state taxes or assessments) similar to that offered by major employer group plans with somewhat higher-than-market-range premiums for those who cannot get insurance at all, at reasonable rates or without prohibitive preexisting condition limitations.

Many state risk pools have legislation, regulations or operating policies that impose durational residency waiting periods (as distinguished from clearly-allowable prior creditable coverage-related waiting periods) as a condition of eligibility. On the few known occasions when they've even been confronted with the legal dubiousness of the durational residency (and other questionable) rules, pool administrators' first, seemingly disingenuous-- but actually legally-unschooled-- response is to claim that the pool is a private entity not subject to standards applied to public programs (because pool and even some state staff erroneously convince themselves that, since states contract to use private insurance firms as claims and sales administrators for the pool, they're somehow private businesses not subject to rules for public programs).

At least 7 states EVEN FURTHER subsidize premiums for those who meet state low-income guidelines. Many state risk pools offer several plans, including fee-for-service, PPO and HMO options, as well as variations for location or amount of desired deductible.

Most, but not all, ban enrollment of Medicare eligibles. Of those that do allow them, some but not all offer premium discounts because Medicare is primary payer. But a few states that cover Medicare eligibles offer them only a standard Medigap plan (with no meaningful drug coverage) rather than full, comprehensive secondary coverage in the risk pool.

Many risk pools have laws or regulations prohibiting the use of public monies to pay patients' premiums (e.g., from the Medicaid, Ryan White, maternal and child health, mental illness, mental retardation or developmental disability programs). One or two only exist for portability purposes under HIPPA, while at least two are continually or often closed to new applicants due to funding shortages.

State insurance agencies have more details.

See Also:

"Comprehensive Health Insurance For High-Risk Individuals, 2002" [218] 739-3241),

National Association of State Comprehensive Insurance Plans)

Texas Health Pool (512) 441-7665

"Insuring the Uninsurable: An Overview of State High Risk Insurance Pools"

State Health Insurance Risk Pools:
Access, Characteristics and Typical Premiums

State Characteristics Typical premium
AL 1, 6, 9 $206
AK 2, 3, 4 445
AR 1, 6, 7  
CA 1, 6, 10 319
CO 5, 6, 8 229
CT 2, 6, 7, 8 
FL 2, 3, 4, 6, 7, 10 
IL 2, 3, 6, 10 307
IN 2 225
IA 2, 3, 6 425
KS 1, 6 371
KY 5, 6, 7 
LA 1, 6, 7 
MN 2, 3, 6 411
MS 5, 6, 7, 11 
MO 5, 6, 7 
MT 2, 3, 4, 6 233
NE 2, 6, 7 
NM 2, 6, 7 237
ND 2, 3, 4, 6 224
OK 1, 6 218
OR 2, 6, 8 313
SC 5, 6 280
TN 2, 6, 8 0-155
TX 5, 6 230
UT 5, 6 238
WA 2, 3, 4, 6, 8 298
WI 2, 3, 6, 8 186
WY 2, 3, 4 , 6 239

Note: All risk pools require previous minimum time of immediately prior creditable coverage in other state risk pools, group or individual health insurance, Medicaid or (sometimes) Medicare to exempt one from pre-existing condition coverage waiting periods of 6-12 months. (Each month of prior coverage earns a month’s credit toward the waiting period requirement, if any.) Premium shown is the latest published (1999, 2000 or 2001) rate for an age 35 male non-smoker in the state’s largest city for the plan with the lowest deductible and least managed care restrictions, but doesn’t include any discounts a state might offer to those it considers poor or to Medicare patients. State insurance commissioners and risk pool staffs have details.

1. Bans Medicare eligibles
2. Allows Medicare eligibles
3. Gives Medicare eligibles discount when the risk pool is the secondary coverage
4. May only offer Medicare eligibles one of the federally defined (options A through J) “Medigap” plans, which lack meaningful drug benefits; clarify with insurance commissioner & risk pool agency
5. Policy on Medicare eligibles unknown (contact state insurance commissioner & risk pool agency)
6. May have statute/rule banning use of public funds to pay premium (e.g., Medicaid, Ryan White, MCH , mental health, mental retardation, developmental disabilities or substance abuse program funds)
7. Call state insurance comr. & risk pool staff for premium by sex, age, city, plan type & deductible
8. Premium reduction for those considered “poor” under state guidelines (CO under $30,000; CT under 200% poverty; NM 200%; OR 170%; TN 400%; WA 300%; WI $24,000)
9. Only for federal HIPPA portability eligibles
10. Enrollment either closed continually (FL, IL) or has waiting list (CA); however, a more expensive, “look-alike” private health plan is sold to those on risk pool waiting list.
11. While banning Medicare eligibles from joining risk pool, MS allows them to keep pool coverage if they first become Medicare-eligible AFTER they enroll in the pool.

Besides the prioritization of elective medical services that will be covered (and NOT covered) by the state program---probably the most publicized, misunderstood feature of the Oregon Medicaid waiver----the state plan's other "famous', supposedly unique provision is that it will cover ANYONE (except Medicare eligibles, who must have income under the even lower $545 monthly SSI level) with income under 100% of poverty ($738 monthly).

Thus, Oregon Medicaid offers coverage to almost anyone under 100%---even if they're NOT an ordinarily Medicaid-coverable type of person, such as aged, blind, disabled, member of a family with children under 19, TB-positive, breast or cervical cancer-positive, pregnant, under 21, a disabled person who's returned to work and then recovered, and several even more obscure eligibility groups. Although this provision---the coverage of VERY poor, childless, non-disabled adults between 21 and 64--- is also spoken of proudly as a unique feature of Oregon's Medicaid program, quite a few other states have similar rules.

The state high risk health insurance pool (not to mention ordinary, private group and individual health plans), of course, is separate from what's generally considered the "Oregon plan"---which, strictly speaking, generally refers only to the state Medicaid program (with its waivered adaptations).

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