North Carolina Health Insurance Risk Pool (NCHIRP)

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North Carolina maintains a high-risk pool, called the North Carolina Health Insurance Risk Pool (NCHIRP), to provide insurance for residents of North Carolina who are unable to buy private health insurance due to their health conditions, and for people who are HIPAA eligible and TAA eligible.

When can I buy health insurance from the high risk pool?

· If you are HIPAA eligible, you can buy health insurance from NCHIRP.

· You can also buy health insurance from NCHIRP if you have lived in North Carolina for at least 30 days and can demonstrate proof of eligibility. There are several different ways to prove eligibility:


o You have been turned down for coverage by one insurance company because of a health condition;


o You have been quoted a premium for an individual policy that is more than the high risk pool premium;


o You have been offered an individual health insurance policy, but it contains an elimination rider on a condition you have;


o You have been diagnosed with a serious condition, such as cancer, AIDS, or Parkinson’s disease, that would limit your ability to purchase health insurance.


You only need to show that you are eligible in one of these ways in order to be eligible for health insurance from NCHIRP.


· You can also buy health insurance from NCHIRP if you have been certified as eligible for federal premium assistance under the HCTC. (see Financial Assistance)

· NCHIRP does not offer family coverage. Each member of your family who wants to enroll in NCHIRP will have to qualify on his or her own.

What will the high risk pool cover?

· Health insurance from NCHIRP includes hospital and physician care, prescription drugs, limited mental health, and other services. Total coverage is limited to a lifetime maximum of $1,000,000.

· NCHIRP offers 3 plan options. Benefits are the same under all options, but the annual deductible and cost sharing varies. Your deductible choices are $1,000, $2,500 or $5,000.

· NCHIRP plans cover hospital and physician services, preventive care, prescription drugs, and limited mental health and substance abuse treatment.

o Under Plan A, the calendar year deductible is $1,000 per person. This plan pays for 80% of in-network or 50% of out-or-network covered services. You pay the remainder, up to a maximum dollar amount, also called your out-of-pocket limit. There is a calendar year out-of-pocket limit maximum of $2,000 on cost sharing for certain services provided by network providers ($4,000 for non-network providers.)


o Under Plan B, the calendar year deductible is $2,500 per person. This plan pays for 80% of in-network or 50% of out-or-network covered services. You pay the remainder, up to a maximum dollar amount, also called your out-of-pocket limit. There is a calendar year out-of-pocket limit maximum of $4,000 on cost sharing for certain services provided by network providers ($5,000 for non-network providers.)


o Under Plan C, the calendar year deductible is $5,000 per person. This plan pays for 100% of covered services after you satisfy the deductible. There is a calendar year out-of-pocket limit maximum of $5,000, on cost sharing for certain covered benefits.

What about coverage for my pre-existing condition?

· If you are HIPAA eligible, NCHIRP will not impose a pre-existing condition exclusion when you enroll.

· If you are not HIPAA eligible, you may have a 12-months pre-existing condition exclusion period. When you enroll, NCHIRP will look back 12 months to see if you had a condition for which you actually received a diagnosis, medical advice, or treatment. Pregnancy can be considered a pre-existing condition.

· NCHIRP will credit prior continuous coverage toward your pre-existing condition exclusion if you apply within 63 days of losing your prior coverage.

What can I be charged for high risk pool coverage?

· NCHIRP premiums are limited to about 175% of the amount that a healthy person would pay if he or she bought a similar plan sold by a private insurer. Premiums will vary based on your age, gender, smoking status, and deductible you choose.

For example, the monthly premium for a 24-year old non-smoking man ranges from $145 to $283 depending on the deductible he chooses. By contrast, the monthly premium for a 64-year old non-smoking man ranges from $731 to $1,340, depending on the deductible he chooses.

· Contact NCHIRP for the most current information about premium and coverage options.

How long does high risk pool coverage last?

· NCHIRP coverage is renewable as long as you pay your premiums, continue to reside in North Carolina, and meet other eligibility requirements. If your high risk pool policy is terminated or you cancel it, you will have to wait 12 months before you can reply for Pool coverage, unless you are HIPAA eligible or HCTC eligible.


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