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High Risk Pool Beginning to Take Shape

High Risk Pool Beginning to Take Shape

One important reform included in the Patient Protection and Affordable Care Act (PPACA) called for the creation of “high-risk health insurance pools” in each state.  High risk pools will provide eligible patients an affordable insurance option if they faced high costs or have been denied health insurance in the past because of their illness.  Thankfully, legislators realized the immediate need of so many Americans and required these pools to be up and running this year rather than making thousands of sick individuals wait until the insurance regulation changes in 2014 take shape.

As we outlined in a previous post, Pennsylvania is one of the states that has decided to run this program on its own instead of stepping aside and allowing the federal government to do so.  The state submitted an application last month outlining the details of the high risk pool which has since been approved, giving us an idea of what the final version will look like for the anticipated 5,600 consumers in our state that could be enrolled by 2014.

The following are some of the highlights of the pool and should serve as an update to the posting that was made before the proposal was approved.  Hopefully this helps to give you an idea of who is eligible, how long it will be until everything is up and running, and what the costs and benefits are:

Eligibility and Timeframe:

  • An individual must be a resident of the Commonwealth of Pennsylvania
  • Citizen or national of the United States or is lawfully present in the United States
  • The individual can not been covered under creditable coverage during the six-month period prior to the date the individual is applying for coverage under the program.
  • The applicant must provide evidence that they have experienced one of the following:
  1. A pre-existing condition, as listed by the state Department of Insurance
  2. Denial of health insurance coverage due to a pre-existing condition.
  3. Coverage that is available only with the exclusion of a pre-existing condition.
  4. Health insurance coverage that was quoted at a substandard rate due to a pre-existing condition
  • An individual is ineligible for coverage in Pennsylvania if they are eligible for other public programs such as Medicare or Medicaid.  Also, high risk pool enrollees can not be eligible for private market health insurance with benefits that are equivalent to at least 90% of the program’s benefits and costs no more that 150% of the program’s premiums.
  • Depending on when details are worked out, applications may begin to be collected within the next week or two.
  • If this is the case, enrollment in the program could still start on schedule and begin by August 1st


  • Includes prescription drug and serious mental health coverage
  • Preventative care is 100% covered in network. This includes annual physical examinations, annual mammograms and gynecological exams
  • For in-network use, there is a $5,000 annual out-of-pocket maximum and no lifetime limit
  • 80% of Emergency room visits are covered after the yearly deductible

Premiums and Deductibles:

  • The average premium will be about $283.20 a month.
  • $1,000 yearly deductible

Click here to download a full copy of the finalized proposal.

Alos, for more complete details, visit PA Department of Insurance website or call the Department’s consumer hotline number at 1-877-881-6388.


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