Risk pools are state-sponsored programs to help people with a history of medical problems in their family to purchase coverage. These pools are for people who can afford to buy health insurance, but are not able to get underwritten in the private market because of a pre-existing health condition. These programs can vary significantly from state to state in price, benefits and number of people served. Often insurance companies doing business in the state are required to contribute to the pool to keep it in the black. In the best cases, they allow people to be able to switch jobs or become self-employed without the fear of losing their health insurance coverage
Pre-Existing Condition Insurance Plan:
Eligible residents of Florida can apply for coverage through the Pre-Existing Condition Insurance Plan program run by the U.S. Department of Health and Human Services.
To qualify for coverage:
You must be a citizen or national of the United States or lawfully present in the United States. You must have been uninsured for at least the last six months before you apply. You must have a pre-existing condition or have been denied coverage because of your health condition.
PCIP covers a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs. All covered benefits are available for you, even if it’s to treat a pre-existing condition.
Below are the monthly PCIP premium rates for Florida by the age of an enrollee.
Age Standard Option Extended Option HSA Option
0 to 18: $196 $263 $203
19 to 34: $294 $395 $305
35 to 44: $352 $474 $366
45 to 54: $450 $605 $467
55+: $626 $842 $650
In addition to your monthly premium, you will pay other costs. In 2011, you will pay a $1,000 to $3,000 deductible, which varies by your plan option. A plan option may have a separate drug deductible. After you pay the deductible, you will pay a $25 copayment for doctor visits, $4 to $40 for most prescription drugs, and 20% of the costs of any other covered benefits you get. Your out-of-pocket costs cannot be more than $5,950 per year. These costs may be higher, if you go outside the plan’s network. Today, many insurance companies spend a substantial portion of consumers’ premium dollars on administrative costs and profits, including executive salaries, overhead, and marketing. Thanks to the Affordable Care Act consumers will receive more value for their premium dollar because insurance companies will be required to spend 80 to 85 percent of premium dollars on medical care and health care quality improvement, rather than on administrative costs, starting in 2011. If they don’t, the insurance companies will be required to provide a rebate to their customers starting in 2012.
On November 22, 2010, the Obama Administration issued a regulation implementing this policy, known as the “medical loss ratio” provision of the Affordable Care Act. This regulation will make the insurance marketplace more transparent and make it easier for consumers to purchase plans that provide better value for their money. Additionally, this regulation will help consumers get a good value for their health insurance premium.
How These New Rules Will Help You – Ensuring Value for Consumers
The new medical loss ratio rules will hold insurance companies accountable and increase value for consumers by: Establishing Transparency and accountability. Beginning in 2011, the law requires that insurance companies publicly report how they spend premium dollars. This information will provide consumers with meaningful information on how their premium dollars are spent, clearly accounting for how much money goes toward actual medical care and activities to improve health care quality versus how much money is spent on administrative expenses like marketing, advertising, underwriting, executive salaries and bonuses.
Insurance companies that are not meeting the medical loss ratio standard will be required to provide rebates to their consumers. Insurers will be required to make the first round of rebates to consumers in 2012. Rebates must be paid by August 1st each year. Enrollees owed a rebate will see a reduction in their premiums, receive a rebate check, or, if the enrollee paid by credit card or debit card, a lump-sum reimbursement to the same account that the enrollee used to pay the premium. In some cases, the rebate may go to the employer that paid the premium on the enrollee’s behalf. Regardless of whether the rebate is provided to enrollees directly or indirectly through their employer, each enrollee must receive a rebate that is proportional to the premium amount paid by that enrollee.
Trisha M. Pacenti RN,BSN
Source: Government Health Care