All individual health insurers must participate in a program called the Idaho Individual High Risk Reinsurance Pool, to provide insurance for Idaho residents. There are rules about when you are eligible to buy individual health insurance under this program. There are limits on what you can be charged. Rates are based on choice of plan, age, individual tobacco use, and family size. There are also limits on pre-existing condition exclusion periods that can be imposed.
When can I get coverage from HRP?
- There are four ways that you may be eligible to buy a HRP plan.
First, if you applied for individual health insurance and were turned down due to your health status, that insurer must offer you the option to buy a HRP plan.
Second, if an individual health insurer offered to sell you a policy at a surcharged premium, that insurer must offer you the option to buy a HRP plan.
Third, if you are HIPAA eligible, you are eligible to buy a HRP policy from any approved insurer in Idaho.
HIPAA eligible individuals
In Idaho, where state laws are more protective, all residents are guaranteed the right to buy certain individual health policies under certain conditions. If you are not HIPAA eligible, however, you may face a pre-existing condition exclusion period. If you plan to move to another state, however, you may be guaranteed the right to buy an individual health insurance policy only if you are HIPAA eligible.
If you move out of Idaho, this information may be important to you.
To be HIPAA eligible, you must meet certain criteria:
- You must have had 18 months of continuous creditable coverage, at least the last day of which was under a group health plan.
- You also must have used up any COBRA or state continuation coverage for which you were eligible.
- You must not be eligible for Medicare, Medicaid or a group health plan.
- You must not have health insurance.
- You must apply for health insurance for which you are HIPAA eligible within 63 days of losing your prior coverage.
HIPAA eligibility ends when you enroll in an individual plan, because the last day of your continuous health coverage must have been in a group plan. You can become HIPAA eligible again by maintaining continuous coverage and rejoining a group health plan.
Finally, if you eligible for the Federal Health Coverage Tax Credit (HCTC) through the Trade Act of 2002, you are eligible to buy a HRP policy from any approved insurer in Idaho.
A list of insurers approved to sell HRP plans can be found on the Idaho department of Insurance website at http://www.doi.idaho.gov/health/individual_list.aspx.
What will HRP cover?
- There are five HRP plans. Companies must offer you the basic, standard, two catastrophic plans and a HSA compatible plan. All plans cover similar health benefits but cost sharing varies. All insurers sell the same HRP plans at the same rates.
- HRP plans cover hospital and physician services, preventive care, maternity care (except the HSA compatible plan), prescription drugs, and limited mental health and substance abuse treatment.
- o Under the Basic Plan, the calendar year deductible is $500 per person. Basic plans pay for 50% of covered services. You pay the other 50% up to a maximum dollar amount, also called your out-of-pocket limit. There is a calendar year out-of-pocket limit maximum of $20,000 on certain covered benefits. Also, there is a lifetime benefit maximum of $500,000.
- o Under the Standard Plan, the calendar year deductible is $1,000 per person. Standard plans pay for 70% of covered services. You pay the other 30% up to an out-of-pocket limit. There is a calendar-year out-of-pocket limit maximum of $10,000 on certain covered benefits. Also, there is a lifetime benefit maximum of $1,000,000.
- o Under the Catastrophic A Plan, the calendar year deductible is $2,000 per person. The plan pays 70% of covered services. There is a calendar-year out-of-pocket limit maximum of $10,000 on certain covered benefits. Also, there is a lifetime benefit maximum of $1,000,000.
- o Under the Catastrophic B Plan, the calendar year deductible is $5,000 per person. The plan pays 80% of covered services. There is a calendar-year out-of-pocket limit maximum of $10,000 on certain covered benefits. Also, there is a lifetime benefit maximum of $1,000,000.
- o Under the HSA Compatible Plan, the calendar year deductible is $3,000 per person and $6,000 per family. The plan pays 60% of covered services. There is a calendar year out-of-pocket limit maximum of $5,000 per individual and $10,000 per family. Also, there is a lifetime benefit maximum of $1,000,000. Maternity care is excluded under this plan.
What about coverage for my pre-existing condition?
- In general, HRP plans will exclude coverage for your pre-existing condition for 12 months. The insurer will look back 6 months before your effective date of coverage to see if you have a condition for which you actually received advice, diagnosis, or treatment or have a condition that would cause an ordinarily prudent person to seek medical advice, diagnosis, care or treatment during the 6-month period before the effective date of coverage. You will get credit for prior coverage if you apply for coverage within 63 days of termination.
- If you are HIPAA eligible, no pre-existing condition period will be imposed.
- If you are HCTC eligible, you may be able to avoid the application of a pre-existing condition exclusion period if you have been continuously insured without a break of 63 days prior to buying the HRP plan.
What can I be charged for HRP coverage?
- You cannot be charged more for a HRP plan because of your health status. Premiums will vary based on age, gender, family size, and your tobacco use. This is called modified community rating.
- Premiums for the HRP plans are posted on the Idaho Insurance Department webpage. All insurers must charge the same rate for the HRP plans.
- New rates are set every three months, but the rate in effect when you buy a HRP plan will apply for one year. Contact the Idaho Department of Insurance for more information about premiums or visit their web page on premiums rates for HRP plans at http://www.doi.idaho.gov/health/healthinfo.aspx.
How long does HRP coverage last?
- You can remain enrolled as long as you pay your premium and continue to meet eligibility requirements.