My Policy Hub

Improving health is our policy

ACA Now

1101 - Immediate Access to Insurance for Uninsured Individuals with a Pre-Existing Condition

 
Implementation Status 
Statutory Text 

Summary

Requires HHS to establish, within 90 days of enactment – either directly or through contracts with States or nonprofit entities – a temporary high-risk health insurance pool program available to individuals with pre-existing conditions (as defined by HHS) who have been without creditable coverage for the preceding 6 months.

A qualified risk pool must meet certain rating, out-of-pocket limit and other standards. Sunsets on January 1, 2014, when Exchanges are available, and directs HHS to develop procedures regarding enrollees’ transition to Qualified Health Plans. Appropriates $5B for claims payments in excess of premiums collected as well as administrative costs. Effective March 23, 2010.

#Insurance Reform, #Preexisting Conditions

Implementation Status

 
Summary 
Statutory Text 

The federal government administers Pre-Existing Condition Insurance Plans (PCIPs) in 23 states and the District of Columbia; the remaining 27 states run their own PCIPs. As of January 31, 2013, more than 107,000 individuals nationwide were enrolled. For general information, the www.healthcare.gov site includes a PCIP page. Additional information, including funding allocations by state, is available on the CCIIO website.

2010

On July 30, 2010, HHS issued an interim final rule (IFR) regarding the PCIP program, addressing program administration, eligibility and enrollment and other implementation issues. An August 30, 2012, amendment to the IFR modified HHS’s definition of ‘‘lawfully present’’ in the PCIP program eligibility parameters in light of a new Department of Homeland Security process.

2013

On February 15, 2013, CMS announced it is suspending enrollment in the PCIP and required contractors to refuse applications received after March 2, 2013.

On April 4, 2013, via a Paperwork Reduction Act Notice, CMS requested clearance from the Office of Management and Budget for an information collection package involving a HIPAA Authorization Form to be utilized by applicants or enrollees of the Pre-Existing Condition Insurance Plan (PCIP); the form would enable a designee to “communicate with PCIP about their protected health information (PHI).”

On April 19, 2013, CCIIO posted a link to updated state-by-state enrollment data in the PCIP.

On May 3, via a Paperwork Reduction Act Notice, CMS sought approval for an extension of a previously approved information collection package regarding the Pre-Existing Condition Insurance Plan (PCIP) program (e.g., submission of data on payment invoices and other parameters).

On May 8, CCIIO posted FAQs on PCIP State contracts and extensions. The FAQs address the contract period from June 2013 to December 2013, during which time – in revised contracts – CMS proposed that State-operated PCIPs work within a “fixed contract amount.”

On May 17, CMS released an interim final rule with comment period outlining adjustments to the payment rates for services provided to individuals under the PCIP administered by HHS in order to ensure the financial sustainability of the program until its 2014 expiration. The adjusted rates apply to covered dates of services beginning on June 15, 2013. Under the rule, providers accepting the PCIP payment for most covered services will not be allowed to balance-bill enrollees for the difference between that amount and the otherwise applicable charge. Comments are due on July 22, 2013.

Additionally, in May, HHS posted on the www.pcip.gov website that effective July 1, 2013, 17 States have decided to transfer operation of their state-administered PCIPs to the federally run PCIP.

On August 16, CCIIO updated its Preexisting Condition Insurance Plan fact sheet reflecting state-by-state enrollment data through May 31, 2013, which totaled 108,589 nationwide.

On Dec. 19, in an interim final rule (press release; fact sheet), HHS codified the requirement for insurers to take payment for premiums through Dec. 31, 2013, for coverage on Jan. 1, and urged insurers to further extend that payment deadline (some provided until Jan. 10 or later). HHS also urged insurers to treat out-of-network providers as in-network for acute episodes and to refill prescriptions covered under previous plans. For states using the challenged Healthcare.gov, the Pre-Existing Condition Insurance Plan will have coverage extended through the end of January 2014 (see below for a subsequent extension).

2014

On Jan. 14, HHS announced the federally administered Preexisting Condition Insurance Plan, originally slated to sunset on Dec. 31, 2013, and previously extended to the end of January, will offer coverage through March 31, 2014, to current enrollees who still are seeking coverage.

On Feb. 14, CCIIO posted updated enrollment figures indicating that 77,638 were covered under Preexisting Condition Insurance Plans through Dec. 31, 2013; a table provides state-specific enrollment data.

On March 14, HHS announced that it is allowing enrollees in Federal Preexisting Condition Insurance Plans (PCIPs) to purchase PCIP coverage for April 2014 while they look for other policies, if they have not yet found other options.

On April 24, 2014 CCIIO issued guidance (fact sheet) indicating that enrollees in the federal Preexisting Condition Insurance Plan, ending on April 30, 2014, will have 60 days to enroll in coverage through Federally Facilitated Marketplaces despite the open enrollment period being closed. CCIIO says State-Based Marketplaces are “adopting a similar special enrollment period.”

Statutory Text

 
Implementation Status 
Summary 

SEC. 1101 [42 U.S.C. 18001]. IMMEDIATE ACCESS TO INSURANCE FOR UNINSURED INDIVIDUALS WITH A PREEXISTING CONDITION. (a) IN GENERAL.—Not later than 90 days after the date of enactment of this Act, the Secretary shall establish a temporary high risk health insurance pool program to provide health insurance coverage for eligible individuals during the period beginning on the date on which such program is established and ending on January 1, 2014. (b) ADMINISTRATION.— (1) IN GENERAL.—The Secretary may carry out the program under this section directly or through contracts to eligible entities. (2) ELIGIBLE ENTITIES.—To be eligible for a contract under paragraph (1), an entity shall— (A) be a State or nonprofit private entity; (B) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require; and (C) agree to utilize contract funding to establish and administer a qualified high risk pool for eligible individuals. (3) MAINTENANCE OF EFFORT.—To be eligible to enter into a contract with the Secretary under this subsection, a State shall agree not to reduce the annual amount the State expended for the operation of one or more State high risk pools during the year preceding the year in which such contract is entered into. (c) QUALIFIED HIGH RISK POOL.— (1) IN GENERAL.—Amounts made available under this section shall be used to establish a qualified high risk pool that meets the requirements of paragraph (2). (2) REQUIREMENTS.—A qualified high risk pool meets the requirements of this paragraph if such pool— (A) provides to all eligible individuals health insurance coverage that does not impose any preexisting condition exclusion with respect to such coverage; (B) provides health insurance coverage— (i) in which the issuer’s share of the total allowed costs of benefits provided under such coverage is not less than 65 percent of such costs; and (ii) that has an out of pocket limit not greater than the applicable amount described in section 223(c)(2) of the Internal Revenue Code of 1986 for the year involved, except that the Secretary may modify such limit if necessary to ensure the pool meets the actuarial value limit under clause (i); (C) ensures that with respect to the premium rate charged for health insurance coverage offered to eligible individuals through the high risk pool, such rate shall— (i) except as provided in clause (ii), vary only as provided for under section 2701 of the Public Health Service Act (as amended by this Act and notwithstanding the date on which such amendments take effect); (ii) vary on the basis of age by a factor of not greater than 4 to 1; and (iii) be established at a standard rate for a standard population; and (D) meets any other requirements determined appropriate by the Secretary. (d) ELIGIBLE INDIVIDUAL.—An individual shall be deemed to be an eligible individual for purposes of this section if such individual— (1) is a citizen or national of the United States or is lawfully present in the United States (as determined in accordance with section 1411); (2) has not been covered under creditable coverage (as defined in section 2701(c)(1) of the Public Health Service Act as in effect on the date of enactment of this Act) during the 6- month period prior to the date on which such individual is applying for coverage through the high risk pool; and (3) has a pre-existing condition, as determined in a manner consistent with guidance issued by the Secretary. (e) PROTECTION AGAINST DUMPING RISK BY INSURERS.— (1) IN GENERAL.—The Secretary shall establish criteria for determining whether health insurance issuers and employment-based health plans have discouraged an individual from remaining enrolled in prior coverage based on that individual’s health status. (2) SANCTIONS.—An issuer or employment-based health plan shall be responsible for reimbursing the program under this section for the medical expenses incurred by the program for an individual who, based on criteria established by the Secretary, the Secretary finds was encouraged by the issuer to disenroll from health benefits coverage prior to enrolling in coverage through the program. The criteria shall include at least the following circumstances: (A) In the case of prior coverage obtained through an employer, the provision by the employer, group health plan, or the issuer of money or other financial consideration for disenrolling from the coverage. (B) In the case of prior coverage obtained directly from an issuer or under an employment-based health plan— (i) the provision by the issuer or plan of money or other financial consideration for disenrolling from the coverage; or (ii) in the case of an individual whose premium for the prior coverage exceeded the premium required by the program (adjusted based on the age factors applied to the prior coverage)— (I) the prior coverage is a policy that is no longer being actively marketed (as defined by the Secretary) by the issuer; or (II) the prior coverage is a policy for which duration of coverage form issue or health status are factors that can be considered in determining premiums at renewal. (3) CONSTRUCTION.—Nothing in this subsection shall be construed as constituting exclusive remedies for violations of criteria established under paragraph (1) or as preventing States from applying or enforcing such paragraph or other provisions under law with respect to health insurance issuers. (f) OVERSIGHT.—The Secretary shall establish— (1) an appeals process to enable individuals to appeal a determination under this section; and (2) procedures to protect against waste, fraud, and abuse. (g) FUNDING; TERMINATION OF AUTHORITY.— (1) IN GENERAL.—There is appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, $5,000,000,000 to pay claims against (and the administrative costs of) the high risk pool under this section that are in excess of the amount of premiums collected from eligible individuals enrolled in the high risk pool. Such funds shall be available without fiscal year limitation. (2) INSUFFICIENT FUNDS.—If the Secretary estimates for any fiscal year that the aggregate amounts available for the payment of the expenses of the high risk pool will be less than the actual amount of such expenses, the Secretary shall make such adjustments as are necessary to eliminate such deficit. (3) TERMINATION OF AUTHORITY.— (A) IN GENERAL.—Except as provided in subparagraph (B), coverage of eligible individuals under a high risk pool in a State shall terminate on January 1, 2014. (B) TRANSITION TO EXCHANGE.—The Secretary shall develop procedures to provide for the transition of eligible individuals enrolled in health insurance coverage offered through a high risk pool established under this section into qualified health plans offered through an Exchange. Such procedures shall ensure that there is no lapse in coverage with respect to the individual and may extend coverage after the termination of the risk pool involved, if the Secretary determines necessary to avoid such a lapse. (4) LIMITATIONS.—The Secretary has the authority to stop taking applications for participation in the program under this section to comply with the funding limitation provided for in paragraph (1). (5) RELATION TO STATE LAWS.—The standards established under this section shall supersede any State law or regulation (other than State licensing laws or State laws relating to plan solvency) with respect to qualified high risk pools which are established in accordance with this section.

Contact Us

Impact Health Policy Partners 1301 K Street, NW, Suite 300W
Washington, D.C. 20005

(202) 309-0796
Contact Us