By David Maly
At year's end, Texas will shut down its high-risk insurance pool for some of the state’s sickest residents, pushing participants to find private coverage in the federal health insurance marketplace created under the federal Affordable Care Act. And patient advocates say those participants should focus on making the transition sooner rather than later to ensure that they don't experience a lapse in coverage or lose access to current health care providers and services.
"Pool policyholders who are in the middle of treatment will especially need to be sure the network offered by their replacement health plan includes their treatment team," Steven Browning, executive director of the Texas Health Insurance Pool, said in an email.
The high-risk pool is financed mainly by patient premiums and assessments paid by health insurance companies and HMOs, along with some funding from federal grant programs. Since 1998, it has provided high-priced coverage to Texans with pre-existing conditions who can’t find coverage elsewhere. The state has deemed the high-risk pool obsolete, as the Affordable Care Act prohibits insurance companies participating in the federal marketplace, which launched on Oct. 1, from denying coverage to Texans with pre-existing conditions. Gov. Rick Perry signed Senate Bill 1367 in June, scheduling the pool’s abolishment.
The pool will close Jan. 1, and the 23,000 people currently participating in the pool must sign up for coverage on the insurance exchange by Dec. 15 or find coverage elsewhere to avoid a lapse in care.
Browning said the pool is making ample efforts to inform its policyholders of the closure and Dec. 15 deadline, including posting information on its website, sending letters and emails and making phone calls. There should be adequate time for those in the pool to get enrolled in a plan by Dec. 15, he said, and the pool is encouraging its patients to use a health insurance agent to sign up for coverage.
“In our various communications to policyholders, and on our website, we are stressing the importance of carefully evaluating the provider networks of the health plans in which they are interested, to be sure they retain adequate access to their physicians and hospitals,” Browning said.
With many of the health plan options in the federal marketplace being cheaper than the high-risk pool and covering additional benefits, Stacey Pogue, a senior policy analyst for the left-leaning Center for Public Policy Priorities, said the situation presents an opportunity for Texans in the pool.
“I think that people are going to have many more options and many better options in the marketplace than they do in the health pool today,” Pogue said. “There is not going to be a person who will be better off financially outside the pool than they would be if the pool stayed open.”
As a condition of the pool, Texans generally pay twice the market rate for coverage, said Pogue. They’ll probably see their health care costs halved in the marketplace, she said, because insurers aren’t allowed to charge people with pre-existing conditions more than other consumers. The marketplace also offers tax credits to help purchase a health plan to everyone who makes 100 percent to 400 percent of the federal poverty line — $11,490 to $45,960 annual income for an individual or $22,550 to $94,200 for a family of four.
Pogue said health plans offered in the federal marketplace could also raise the level of care patients receive, as they must cover “essential health benefits,” some of which, such as maternity care, aren’t covered in the pool.
She doesn’t expect there to be major issues with people meeting the Dec. 15 deadline either, she said, because many high-risk pool policyholders have health conditions that require them to deal with their health insurance on a consistent basis and are more likely to interact with their health care provider.
Lance Lunsford, vice president of communications for the Texas Hospital Association, said that if those in the pool experienced a lapse in coverage, hospitals would still be required by federal law to stabilize and secure them and would probably be able to aid them in securing additional coverage.
Lunsford said one of the big issues for people in the pool will probably be evaluating all the insurance options available.
“Their options may be wider and that may be part of one of the issues that they have,” Lunsford said. “It will be about selecting the right coverage.”