Summary of High-Risk Pool Program in PA

The high-risk pool will cover about 5,100 people annually from 2010-2013. In 2014, people with pre-existing conditions will be able to buy insurance through the new exchange established by the Affordable Care Act.

Eligibility:

An individual must be a resident of the Commonwealth of Pennsylvania and meet all of the following criteria:

Is a citizen or national of the United States or is lawfully present in the United States, as required by the federal Affordable Care Act.
Has not been covered under creditable coverage during the six-month period prior to the date the individual is applying for coverage under the program.
Has evidence that the individual has one of the following:

A pre-existing condition, as listed by the state Department of Insurance.
Denial of health insurance coverage due to a pre-existing condition.
Coverage available only with the exclusion of a pre-existing condition.
Health insurance coverage quoted at a substandard rate due to a pre-existing condition.

An individual is ineligible for the high-risk pool in Pennsylvania if eligible for Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) or private market health insurance with benefits that are equivalent to at least 90% of the program’s benefits and cost no more that 150% of the program’s premiums.
Benefits:

Includes prescription drug and serious mental health coverage.
Preventive 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.
$1,000 yearly deductible.

Premiums:
The average premium will be about $283.20 a month. Enrollment is scheduled to open July 21st.
Complete details are in the Approved State Proposal to Operate a High Risk Pool which is available under “Health Care Reform & You” on the Department of Insurance website, www.insurance.pa.gov. The Department’s consumer hotline number is 1-877-881-6388, email ra-in-consumer@state.pa.us.