A new plan offers coverage to people with pre-existing medical conditions
POSTED: 1:30 a.m. HST, Jun 3, 2011
Thousands of uninsured Hawaii residents could get health insurance under a new pre-existing medical condition plan created by the federal Affordable Care Act.
The Commonwealth Fund, a New York-based private foundation that promotes health care access for low-income, minorities and the uninsured, projected an estimated 12,474 local residents suffering from cancer, heart disease, HIV/AIDS, asthma, diabetes and other serious ailments, or even who are pregnant, could qualify for the stopgap program until 2014, when health insurers will be required by the federal health reform law to insure this population with the same rates as their healthier counterparts.
Residents with pre-existing medical conditions often are denied health insurance or can't afford higher premium plans and thereby forgo coverage all together, according to the U.S. Centers for Medicare and Medicaid Services.
"What this program does is it helps the people that have the most pressing need immediately," said David Sayen, Medicare's regional administrator for Hawaii. "I wouldn't characterize candidates for the program as being sick — there are a lot of people who can't get insurance because they had some medical condition but not one that's affecting their health currently."
Under the program, those with pre-existing conditions will be eligible for coverage for a range of medical benefits, including doctor visits, hospital care and prescription drugs.
The federal government has appropriated $5 billion nationwide for the program, which subsidizes premium rates. States were given an option to run their own programs or be a part of a federal program, which Hawaii has chosen.
The federal law will eventually create health insurance exchanges nationwide — offering a variety of health plans varying in cost and coverage. The concept is by spreading risk across an entire population, with a greater number of healthy and sickly in a single pool, health insurance will become affordable for all.
"They're trying to manage the risk," Sayen said. "The statute is based on requiring everyone to have insurance. That's going to make (the pool) so much wider so it would balance out."
Consumers won't be charged a higher premium because of medical conditions, and unlike other programs, eligibility isn't based on income.
Hawaii residents with pre-existing health conditions can choose from three plans, with varying monthly premiums, deductibles and prescription co-payments.
One plan allows consumers to open a tax-exempt health savings account, where they can set aside funds for eligible medical expenses. Each of the three plans provides preventive care paid at 100 percent, with no deductible, if recommended by an in-network doctor. Annual physicals, flu shots, routine mammograms and cancer screenings also are covered.
Consumers will pay a deductible before the plans cover medical services and prescriptions and 20 percent of in-network medical costs. The maximum out-of-pocket payment for covered services in a calendar year is $5,950 in network and $7,000 out of network. The plans have no lifetime maximum or cap on the amount paid out for services and no waiting period before benefits begin.
BREAKING DOWN THE COSTSMonthly premiums for Hawaii residents in the pre-existing condition insurance plan:
GETTING COVERAGEBeginning July 1, residents applying for the pre-existing condition insurance plan must:
>> Provide a letter from a doctor, physician assistant or nurse practitioner dated within the past 12 months stating that they have or, at any time in the past, had a medical condition, disability or illness (applicants no longer have to wait on an insurance company to send them a denial letter).
>> Be a citizen of the United States or a legal resident.
>> Be uninsured for at least six months before applying.
>> Starting this fall, the U.S. Department of Health and Human Services will begin paying agents and brokers who successfully connect eligible people with the program in an effort to increase enrollment. HHS also is working with insurers to notify people about the program when their application for insurance is denied.
For more information about the Pre-Existing Condition Insurance Plan, including eligibility, plan benefits and how to apply, go to www.pcip.gov or call toll-free 866-717-5826.