To be eligible for the pools, individuals must be citizens or lawfully residing in the U.S.; not have been covered under creditable coverage for the six months prior to applying to the pool; and have a pre-existing condition, as defined in guidance to be issued by HHS.

The benefits that must be included in the coverage include an actuarial value (estimate of the likely percentage of health care expenses the policy will pay) of at least 65 percent of total allowed costs; an out-of-pocket limit (outside of premium cost) of $5,950 for an individual; and no pre-existing condition exclusions. The premium rate must be set at a standard rate for a standard (non-high risk) population and have an age-rate variation not greater than 400 percent (where rates for older persons can be higher regardless of health status). Several states already have even more limited age-rate variations or prohibit age and gender rate variations altogether.


WHO'S IN, WHO'S OUT?

Thus far, states that notified HHS that they have opted not to participate (and therefore state residents could still have the opportunity to obtain coverage through the federal program) include Alabama, Arizona, Delaware, Florida, Georgia, Hawaii, Idaho, Indiana, Louisiana, Minnesota, Mississippi, Nebraska, Nevada, North Dakota, South Carolina, Tennessee, Texas, Virginia, and Wyoming.

States that will operate the high-risk pools include Alaska, Arkansas, California, Colorado, Connecticut, District of Columbia, Illinois, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Dakota, Vermont, Washington, West Virginia, Wisconsin.

In other reform news, HHS Secretary Kathleen Sebelius has again acted on the issue of premium rates. In a letter to state governors and insurance commissioners, she is asking for review of any increases in rates from WellPoint, Inc. The California Department of Insurance has determined that WellPoint's affiliate Anthem Blue Cross' proposed rate increase of up to 39 percent was unreasonably high. (See, DM 11607) Anthem has withdrawn the proposed rate increase.

Read more details:

Jenny Backus' remarks: http://www.hhs.gov/news/press/2010pres/04/20100430c.html

Secretary Sebelius letter: http://www.hhs.gov/news/press/2010pres/05/20100505a.html

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