HHS Plans Underway for High Risk Pools to Cover Pre-existing Conditions

As a first step in implementing health reform, on April 2 Secretary of Health and Human Services Kathleen Sebelius asked state governors and insurance commissioners to work with the federal government to establish temporary high risk pools to provide affordable insurance for people with pre-existing conditions.

In a letter to governors, Secretary Sebelius laid out several options states will have to use $5 billion in the Patient Protection and Affordable Care Act to bridge the time from July 1, 2010 until January 1, 2014 when the insurance exchanges will be available.

Coverage will need to include at least a floor set of benefits established by the federal government.  Out-of-pocket costs are limited to $5,950 for an individual, and premiums cannot be set at more than the existing standard non-group rates.  There can be no exclusion for pre-existing conditions.

Governors were asked to respond with a letter of intent by April 30, 2010.  If a state does not want to participate in the program, the Department of Health and Human Services will provide the high risk pool services to needy individuals in that state.

In order to be eligible coverage through the high risk pools, individuals must,

  • Be a citizen or national of the United States or lawfully present in the United States.
  • Not have had credible coverage for the six months before applying for coverage.
  • Have a pre-existing condition.  The Secretary will provide guidance as to what determines pre-existing conditions.

States will have the option to,

  • Operate a new high risk pool alongside a current state high risk pool.
  • In states without high risk pools, establish a new one.
  • Build upon other existing programs designed to cover people with pre-existing conditions.
  • Contract with a current HIPAA carrier of last resort or other carrier, to provide subsidized coverage for the eligible population, or
  • Do nothing, in which case HHS would carry out a coverage program in the state.

Writing to governors, Secretary Sebelius stressed willingness to be flexible in getting the program off the ground.

In reviewing the existing state high risk pools, there is much common ground in the benefits currently provided. Since HHS is considering establishing a floor set of benefits that all the new high risk pool programs must cover, we anticipate that these benefit requirements would take into account benefit lists currently used by existing state high risk pools. Similarly, states would have the option to follow pre-existing condition criteria for determining eligibility established by the Secretary, or propose their own, subject to Secretarial approval. We are committed to working with states to identify other areas where flexibility is appropriate.


  1. Kate Murphy says

    If states opt out of providing a high risk pool, the federal government will have a program to cover pre-existing conditions. So far details haven’t been provided about the federal plan, but watch for them.

  2. Susan S says

    We live in Virginia and our rates increased to $1,500 per month for insurance so we had to drop coverage. We both have preexisting conditions and our Governor decided to opt out for high risk. Now what do we do? Please help!!! thank you.

  3. Kate Murphy says

    The national high risk pool — or a new pool in your state — should be available on July 1, 2010 according to Secretary Sebelius.

    Actually, the law says that pools must be ready 90 days after enactment, which was March 23 which would be sometime in late June.

  4. Kathy says

    When does the national pool for pre-existing conditions begin for adults. Our state does not have one of its own. My adult son has arthritis which is excluded from his private plan. The treatment will be over a thousand dollars a month. This is the medication cost only and does not include and testing or phys visits. All meds, phys visits, lab tests, xrays are out of pocket. Thank you in advance for any information to help.

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