When can I buy health insurance from the high risk pool?
- If you are HIPAA eligible, you can buy health insurance from High Risk Pool.
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 period. In Oklahoma, you are only guaranteed the right to buy coverage from the High Risk Pool. 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 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. (Note, however, if you know your group coverage is about to end, you can apply for coverage for which you will be federally eligible.)
- 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 federally eligible again by maintaining continuous coverage and rejoining a group health plan.
- You can also buy health insurance from the High Risk Pool if you have lived in Oklahoma for at least 12 months and can demonstrate proof of eligibility. There are several different ways to show eligibility:
- o You have been turned down for coverage by two insurance companies because of a health condition;
- o You have been quoted a premium rate for an individual policy that is substantially more than the High Risk Pool rate;
- o You have been offered individual health insurance, but it contains an elimination rider on a condition you have;
- o You have been diagnosed with serious condition, such as cancer, AIDS, or diabetes, that would limit your ability to purchase health insurance; or,
- o You had been covered under a High Risk Pool policy because someone else in your family was eligible for Pool coverage, but now you no longer qualify for family coverage because of your divorce from that person or that person’s death.
You only need to show that you are eligible in one of these ways in order to health insurance from the High Risk Pool.
- You can also buy health insurance from the High Risk Pool if you have been certified as eligible for federal premium assistance under the HCTC. HCTC eligible individuals are not required to exhaust COBRA continuation coverage and cannot have other health insurance coverage.
- The High Risk Pool will sell you a family policy, even if only one person in your family qualifies for coverage.
- If you qualify for the High Risk Pool because you involuntarily lost your prior coverage and you apply within 63 days, the High Risk Pool will backdate your start of coverage to the day when you lost your old coverage. You must, however, pay the premiums for that time period.
What will the high risk pool cover?
- Health insurance from the High Risk Pool includes hospital and physician care, prescription drugs, maternity care, and other services. There are separate limits on coverage for alcohol and drug abuse treatment. Total coverage is subject to a lifetime maximum of $500,000.
- The High Risk Pool offers 6 plan options. Benefits are the same under all options, but the annual deductible varies. Your deductible choices are $500, $1,000, $1,500, $2,000, $5,000, and $7,500.
- All High Risk Pool coverage is through a managed care plan. After you have satisfied your annual deductible, the High Risk Pool will pay 80% of covered charges when you get care from a doctor or other provider in the High Risk Pool’s network. If you get care from an out-of-network provider, the High Risk Pool will only pay 60% of covered charges. The maximum annual out-of-pocket expense is $2,000 in-network, and $4,000 out-of-network.
What about coverage for my pre-existing condition?
- If you are HIPAA eligible, you will not receive a pre-existing condition exclusion when you enroll in the High Risk Pool.
- If you are not HIPAA eligible, you may have a 12-month pre-existing condition exclusion period when you first enroll in the High Risk Pool. When you enroll, the High Risk Pool will look back 6 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.
- The High Risk Pool will waive the pre-existing condition period if you had continuous coverage under another health plan. The High Risk Pool counts policies that provide hospital, medical or surgical expense benefits as creditable coverage. Your break in coverage must be less than 63 days in order for your pre-existing condition to be waived.
What can I be charged for High Risk Pool coverage?
- High Risk Pool premiums are limited to about 150% 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, family size, and the deductible you choose.
For example, the monthly premium for a 24-year old single man ranges from $104 to $326, depending on the deductible he chooses. By contrast, the monthly premium for a 64-year old single man ranges from $490 to $1,424, depending on the deductible he chooses.
- If you are eligible for the Health Coverage Tax Credit (HCTC) and enrolled in the High Risk Pool, the federal government will pay 65% of your premium each month.
How long does High Risk Pool coverage last?
- High Risk Pool policies are renewable as long as you pay your premiums, continue to reside in Oklahoma, 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 reapply for Pool coverage, unless you are HIPAA eligible or HCTC eligible.