Residents in high-risk pool may benefit from heathcare act

Posted Saturday, Oct. 19, 2013  comments  Print Reprints

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At year’s end, Texas will shut down its high-risk insurance pool for some of the state’s sickest residents, pushing participants to find private coverage in the federal healthcare exchange created under the federal Affordable Care Act.

Among the 23,000 Texans making the transition is Southlake resident Dianne Stone, 62, who turned to the Texas Health Insurance Pool after coverage through her husband’s former employer ran out. Ken Stone, 72, said his wife had surgery for a nerve problem while she was covered under COBRA, the federal program that allows workers who leave an employer to continue their health benefits for at least 18 months.

But after that, she had to find her own health insurance, said Ken Stone, a retired Apple Inc. computer expert who’s handling the the search for insurance through the exchange.

“Everything’s fine now,” Ken Stone said of his wife’s health. “But the insurers look at you, and they see that pre-existing condition,” he said.

All plans sold through the exchange must cover pre-existing conditions without charging a higher premium.

After checking out the plans offered through the Health Insurance Marketplace that opened Oct. 1, Ken Stone said “I think it’s going to be more, how much more I don’t know yet.” He said his wife’s current policy costs $559 a month.

Dianne Stone doesn’t qualify for a discount presently and won’t get a subsidy through the exchange, either. Ken Stone said he’s still evaluating the plans on the exchange and wants to compare Blue Cross Blue Shield plans in particular, since that insurer already provides Dianne’s high-risk policy.

Patient advocates say the Stones are doing the right thing in planning their switch sooner rather than later. Policies must be bought on the exchange by Dec. 15 in order to go into effect Jan. 1, 2014, when the state’s high-risk pool goes away.

The benefit of starting early is exactly what the Stones are doing: to give them plenty of time to evaluate the plans on the exchange. Cost is just the start; equally important are the doctors and hospitals in the insurer’s networks.

“Pool policyholders who are in the middle of treatment will especially need to be sure the network offered by their replacement health plan includes their treatment team,” Steven Browning, executive director of the Texas Health Insurance Pool, said in an email.

The high-risk pool is financed mainly by patient premiums and assessments paid by health insurers, along with some funding from federal grant programs. Since 1998, it has provided high-priced coverage to Texans with pre-existing conditions who can’t find coverage elsewhere.

Texas and 14 other states are discontinuing their high-risk pools at year’s end, according to the National Association of State Comprehensive Health Insurance Plans. Gov. Rick Perry signed Senate Bill 1367 in June, scheduling the pool’s abolishment.

Ken Stone said the pool has been good about alerting them to the change, saying that “every month they send us a letter stating it will no longer be in effect.”

Browning said that besides sending letters, the pool posts information on its website, sends emails and makes phone calls. He said the pool encourages its patients to use a health insurance agent to sign up for coverage.

With many of the healthcare plan options in the federal marketplace being cheaper than the high-risk pool and covering additional benefits, Stacey Pogue, a senior policy analyst for the left-leaning Center for Public Policy Priorities, said the situation presents an opportunity for Texans in the pool.

“I think that people are going to have many more options and many better options in the marketplace than they do in the health pool today,” Pogue said. Texans in the pool generally pay twice the market rate for coverage, said Pogue.

Premium costs in the pool can be reduced if the patient is from a low-income household, but even more generous tax subsidies based on income are available through the exchange.

The exchange offers tax credits to households from 100 percent to 400 percent of the federal poverty level — $11,490 to $45,960 annual income for an individual, and $22,550 to $94,200 for a family of four. The high-risk pool’s discount phases out at 300 percent of federal poverty level.

Pogue said healthcare plans offered in the federal marketplace could also raise the level of care patients receive, as they must cover “essential health benefits,” some of which, such as maternity care, aren’t covered in the pool.

She doesn’t expect there to be major issues with people meeting the Dec. 15 deadline. She said many high-risk pool policyholders have health conditions that require them to deal with their health insurance on a consistent basis, making them more likely to interact with their healthcare provider.

Lance Lunsford, vice president of communications for the Texas Hospital Association, said that if patients in the pool experience a lapse in coverage, hospitals are still required by federal law to stabilize them and would probably help them secure coverage. He said one of the big issues for people in the pool will probably be evaluating the insurance options available.

“Their options may be wider and that may be part of one of the issues that they have,” Lunsford said. “It will be about selecting the right coverage.”

Staff writer Jim Fuquay contributed to this report.

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