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.