High-Risk Pools

Thirty states have established government programs called “high-risk pools” that offer health insurance coverage to "uninsurable" residents whom private insurers might turn down because of their health status. Approximately 175,000 people are enrolled in high-risk pools across the U.S. For people enrolled in these programs, high-risk pools offer an important (often the only) source of available coverage.

Health insurance coverage available from a high-risk pool

High-risk pools typically offer coverage similar to that sold by private insurers. Even so, in some states, high-risk pool benefits are limited (for example, imposing high deductibles or limiting coverage for certain services such as mental health care or maternity care). Also, like private insurance companies, high-risk pools will impose a waiting period of 6-12 months on coverage of pre-existing conditions. Sometimes, though not always, high-risk pools will waive the pre-existing condition exclusion period if you have prior coverage.

Cost to purchase a policy through a high-risk pool

High-risk pool premiums are always more expensive than coverage sold by private insurers. This is because states set high-risk pool premiums at some multiple of average private plan premiums. In most state high-risk pools, premiums are 1.5 to 2 times higher than those charged by private insurance companies. In addition, all state high-risk pools adjust premiums for age. This makes coverage especially expensive for people in their 50s or early 60s.

Eligibility for the high-risk pool

Usually there is more than one way to become eligible for your state's high-risk pool. These may include:

• If you receive a notice of rejection from a health insurer
• If you receive a notice of benefit reduction or specific condition exclusion
• If you receive a notice of premium rate increase or surcharge exceeding the pool rate
• If you have a qualifying condition (i.e. AIDS, cancer, diabetes)
• If you are eligible for Trade Adjustment Assistance because you lost employment due to increased imports, you may be eligible for a tax credit. In some states, this tax credit can be used for the HRP
• If you have been involuntarily terminated from a health insurance plan or
• If you are HIPAA-eligible. Note: You are HIPAA-eligible if you have had at least 18 months of prior continuous health coverage, at least the last day of which was in a group health plan; you have exhausted COBRA; you are not eligible for Medicare, Medicaid or a group health plan; you don't have other coverage; and you apply for new coverage (such as the high-risk pool) within 63 days of losing your prior coverage. If your state has designated the high-risk pool for HIPAA coverage, then it will not impose a pre-existing condition exclusion period on you when you are HIPAA-eligible.

Some states impose specific enrollment caps and limit enrollment in the high-risk pool based on the availability of funds. In a few of these states, there have been waiting lists in recent years. Many other states that do not have enrollment caps have laws that authorize state high-risk pools to institute a waiting list if funding for the program is insufficient. However, if you are federally eligible (and if the state designates its high-risk pool for federally eligible individuals) the pool must accept you when you apply even if it is otherwise closed to new enrollment.

Is there a high-risk pool in my state?

Find out if there is a high-risk pool in your state.

More information about high-risk pools is available in Georgetown University's health insurance consumer guides.

This information was drawn from “Health Insurance Resource Manual” prepared for the American Diabetes Association by Georgetown University's Health Policy Institute, ©2003, Georgetown University. All rights reserved.