Montana has a high risk pool program, called Montana Comprehensive Health Association (MCHA) that offers insurance for people with health conditions who are unable to buy private health insurance coverage and for people who are HIPAA eligible. MCHA is also considered a qualified health plan for individuals eligible for the health coverage tax credit (HCTC). (see Financial Assistance)
When am I eligible for MCHA?
· If you are HIPAA eligible, you can buy health insurance from MCHA.
To be HIPAA eligible, you must meet certain criteria
No matter where you live in the U.S., if you are HIPAA eligible you are guaranteed the right to buy individual health insurance of some kind with no pre-existing condition exclusion periods. In Montana, you are guaranteed the right to buy coverage only from MCHA. To be HIPAA eligible, you must meet all of the following:
· 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 for which you were eligible.
· You must not be eligible for Medicare, Medicaid, or a group health plan.
· You must not have health insurance. (Note, however, if you know your group coverage is about to end, you can apply for coverage for which you will be HIPAA eligible.)
· You must apply for health insurance for which you are HIPAA eligible within 63 days of losing your prior coverage.
Your HIPAA eligible status ends as soon as you enroll in MCHA or an individual health insurance policy, 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.
· If you are eligible for the Health Coverage Tax Credit (HCTC), you can buy insurance from MCHA. (see Financial Assistance)
· If you are not HIPAA or HCTC eligible, you can buy coverage from MCHA if you are a Montana resident for at least 30 days and can demonstrate proof of uninsurability. You are considered uninsurable in Montana if:
o You have been diagnosed with one of a list of serious health conditions (such as cancer or diabetes);
o In the 6 months prior to applying, you have been turned down for coverage by 2 insurance companies or offered a plan with an elimination rider that excludes coverage for your pre-existing condition; or
o The individual insurance you have or were offered costs more than 150% of the average premium rate used to calculate the Traditional Plan rate offered through MCHA.
· In general, you cannot have MCHA coverage if you are eligible for any other health insurance except Medicare. However, if you are in MCHA and become eligible for another health plan that has a pre-existing condition exclusion period, you can keep your MCHA coverage through the end of that exclusion period.
What does MCHA cover?
· MCHA offers six portability plans, six traditional plans, and one premium assistance plan. Portability plan options are only available if you are HIPAA eligible. The six portability plans offer options from a $1,000 annual deductible with a $3,000 out-of-pocket maximum to a $10,000 annual deductible with a $14,500 out-of-pocket maximum option. Portability plans require a 30% copayment on covered services from in-network providers, and a 50% copayment for covered services from out-of-network providers. Benefits include hospital and doctor services, lab and x-ray tests, home health care, maternity care, treatment for mental illness and chemical dependency, prescription drugs, and other benefits. Covered services have a lifetime limit of $2 million.
If you are not HIPAA eligible, traditional MCHA coverage is your only available option. Traditional plan coverage is similar to portability plans. However, there is no coverage for mental health or chemical dependency. The six traditional plans offer options from a $1,000 annual deductible with a $5,000 out-of-pocket maximum option to a $10,000 annual deductible with a $13,500 out-of-pocket maximum option. Traditional plans require you to pay 20% for covered services from in-network providers and 40% for covered services from out-of-network providers until you reach the out-of-pocket maximum. Then the plan will pay 100% for covered services for the remainder of the year.
The MCHA premium assistance plan is for individuals who qualify for traditional plan coverage and who meet certain income guidelines. Enrollment is on a first-come, first served basis and is limited to the available funding.
Plan options are subject to change. Please contact MCHA for more information.
· If you have Medicare, MCHA also offers a special carve out policy with its own premium. Call MCHA for more information about Medicare carve out coverage.
What about coverage for my pre-existing condition?
· If you are HIPAA eligible or eligible for the Health Coverage Tax Credit (HCTC), you will not have a pre-existing condition exclusion when you enroll in MCHA. Elimination riders are not permitted on MCHA plans.
· If you are not HIPAA eligible, MCHA will exclude coverage for your pre-existing condition for 12 months (4 months in the case of the premium assistance plan). MCHA will look back 3 years before you enroll to see if you had a condition for which you actually received a diagnosis or medical advice or treatment. Unlike group health plans, MCHA can impose a pre-existing condition exclusion period on pregnancy. MCHA will give you credit for prior continuous coverage if it included similar or greater benefits, and if you apply within 30 days of losing your prior coverage.
How much can I be charged for MCHA coverage?
· MCHA premiums vary based on the plan you choose and your age. For example, monthly premiums for traditional coverage range from $150-$427 for a 24-year old male and $468-$1,335 for a 64-year old male. Monthly premiums for portability coverage range from $152-$435 for a 24-year old male and $476-$1,361 for a 64-year old male. Call MCHA for a brochure listing of all coverage options and premiums.
· A premium subsidy is available to high-risk low-income uninsurable Montana residents. The subsidies are 45% of premium after the pre-existing exclusion period is satisfied. The pre-existing exclusion period is shortened to 4-months for individuals who qualify for premium subsidies.
How long does coverage last?
· MCHA policies are renewable as long as you pay your premiums, continue to reside in Montana, and meet other eligibility requirements.
