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High-Risk Pools For Uninsurable Individuals

Issue Brief
  1. S Cohen and W Yu, “The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the US Population, 2008-2009. AHRQ Statistical Brief #354, January 2012.

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  2. “High-Risk Pools,” State Coverage Initiatives, Robert Wood Johnson Foundation, 2001, available at http://www.statecoverage.org/node/40/cs_states.html

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  3. In the Maryland pool, for example, the list of eligible conditions included behavioral health conditions (bipolar disorder, chemical dependency, dementia, psychotic disorders); blood disorders (aplastic anemia, hemochromatosis, hemophilia, sickle cell disease); cardiovascular conditions (angina pectoris, cardiomyopathy, congestive heart failure, coronary artery disease, coronary insufficiency, coronary occlusion); endocrine disorders (Addison’s disease, cystic fibrosis, diabetes, porphyria, Wilson’s disease); gastrointestinal disorders (ascites, Banti’s disease, cirrhosis of the liver, Chron’s disease, esophageal varices, hepatitis B and C, ulcerative colitis); infectious diseases (HIV/AIDS); musculoskeletal/connective disorders (ankylosing spondylitis, lupus, rheumatoid arthritis, scleroderma); pulmonary disorders (chronic obstructive pulmonary disease, emphysema);  neoplasm (cancer treated or diagnosed within 5 years, Hodgkin’s disease, leukemia, multiple myeloma, non-Hodgkin’s lymphoma, Wilm’s tumor); neurologic conditions (Alzheimer’s disease, ALS, Friedreich’s Ataxia, Guillain-Barre syndrome, Huntington’s disease, hydrocephalus, multiple sclerosis, muscular dystrophy, myasthenia gravis, myotonia, palsy, paraplegia, Parkinson’s disease, quadriplegia, stroke, Tay-Sachs disease); also major organ transplant and pregnancy.

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  4. “High-Risk Pools,” State Coverage Initiatives, Robert Wood Johnson Foundation, 2001, available at http://www.statecoverage.org/node/40/cs_states.html

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  5. Communicating for Agriculture, Comprehensive Health Insurance for High-Risk Individuals, 1996.

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  6. All but eight traditional state high-risk pools have since suspended new enrollment.

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  7. K Schwartz, G Claxton, K Martin, and C Schmidt, “Spending to Survive: Cancer Patients Confront Holes in the Health Insurance System,” Kaiser Family Foundation, 2009.  Available at https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7851.pdf

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  8. NASCHIP, Comprehensive Health Insurance for High-Risk Individuals: A State-by-State Analysis, 2009/2010.

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  9. NASCHIP, Comprehensive Health Insurance for High-Risk Individuals: A State-by-State Analysis, 2011/2012.

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  10. Annual maximums applied under state high-risk pools included: AL: $10,000 for pharmacy benefit; AR: $4,000 for mental health/substance abuse benefit; CA: $75,000 for all benefits; CO: $3,000 for DME benefit; ID: $2,000 for rehab benefit, $5,000 for hospice benefit; $10,000 for DME benefit; IN: $50,000 for mental health/substance abuse, Plan 3 only; KS:  $100,000 for all benefits; LA: $125,000 for all benefits; MS: $100,000 for pharmacy benefit; MT: $5,000 applies to DME, $4,000 applies to rehab benefit; NH: $10,000 applies to pharmacy, $5,000 applies to DME, $3,000 applies to mental health/substance abuse, various day limits apply to skilled nursing, rehab, home health; NC: $100,000 applies to injectable drugs; various day limits apply to skilled nursing, rehab; ND: $6,000 applies to DME benefit; OK: $4,000 applies to mental health and chemical dependency combined; SD: $2,000 applies to substance abuse, $900 applies to mental health treatments for non-biologically based conditions, $8,000 applies to DME benefit; TN: $200,000 for all benefits plus $100,000 for organ transplant; TX: $2,000 applies to rehab, $5,000 applies to home health, $10,000 applies to hospice, various day limits apply to skilled nursing care and mental health care; UT: $300,000 for all benefits; WV: $200,000 for all benefits.  Source: NASCHIP, Comprehensive Health Insurance for High-Risk Individuals: A State-by-State Analysis, 2009/2010.

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  11. To compute net losses for a given state, follow links to NASCHIP charts for Total Revenue by Pool, 2011 and Total Expenses by Pool, 2011; subtract the premium revenue for a state pool (first column in the Total Revenue by Pool, 2011 chart) from the total expenses for a state pool (last column in the Total Expenses by Pool, 2011 chart.)

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  12. NASCHIP, Comprehensive Health Insurance for High-Risk Individuals: A State-by-State Analysis, 2011/2012.

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  13. J Hall and J Moore, The Affordable Care Act’s Pre-Existing Condition Insurance Plan: Enrollment, Costs, and Lessons for Reform, September 2012, available at http://www.commonwealthfund.org/publications/issue-briefs/2012/sep/preexisting-condition-insurance-plan

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  14. PCIP Annual Report, 2012 available at https://www.cms.gov/CCIIO/Resources/Files/Downloads/pcip-report.pdf, and PCIP Annual Report, 2013 available at https://www.cms.gov/CCIIO/Resources/Files/Downloads/pcip_annual_report_01312013.pdf.

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  15. For example, in Colorado, enrollees in the state PCIP experienced 562 hospital admissions per 1,000 and used 5,174 inpatient days per 1,000, while enrollees in Colorado’s traditional high-risk pool experienced 137 hospital admissions per 1,000 and used 735 inpatient days per 1,000.  See PCIP Annual Report, 2012.

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  16. PCIP Annual Report, 2013.

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  17. PCIP Annual Report, 2012 and 2013.

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  18. PCIP Annual Report, 2013. The report notes that various cost containment measures had been adopted prior to enrollment suspension, including switching to a more competitively priced provider networks, negotiating special discounts with hospitals treating a disproportionate share of PCIP enrollees, and requiring use of cost effective preferred pharmacies for specialty drugs.  See also PCIP Data Report, March 2013, available at https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/pcip-expenditures-3-31-2013.pdf

     

     

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