Who is eligible for a state's high-risk pool for health insurance?

Usually there is more than one way to become eligible for your state's high-risk pool (HRP) for health insurance coverage. These may include:

• If you receive a notice of rejection from a health insurer
• If you receive a notice of benefit reduction or specific condition exclusion
• If you receive a notice of premium rate increase or surcharge exceeding the pool rate
• If you have a qualifying condition (i.e. acquired immune deficiency syndrome [AIDS], cancer, diabetes)
• If you are eligible for Trade Adjustment Assistance because you lost employment due to increased imports, you may be eligible for a tax credit. In some states, this tax credit can be used for the HRP
• If you have been involuntarily terminated from a health insurance plan or
• If you are Health Insurance Portability and Accountability Act of 1996 (HIPAA)-eligible. Note: You are HIPAA-eligible if you have had at least 18 months of prior continuous health coverage, at least the last day of which was in a group health plan; you have exhausted the Consolidated Omnibus Budget Reconciliation Act (COBRA); you are not eligible for Medicare, Medicaid or a group health plan; you don't have other coverage; and you apply for new coverage (such as the high-risk pool) within 63 days of losing your prior coverage. If your state has designated the high-risk pool for HIPAA coverage, then it will not impose a pre-existing condition exclusion period on you when you are HIPAA-eligible.

Some states impose specific enrollment caps and limit enrollment in the high-risk pool based on the availability of funds. In a few of these states, there have been waiting lists in recent years. Many other states that do not have enrollment caps have laws that authorize state high-risk pools to institute a waiting list if funding for the program is insufficient. However, if you are federally eligible (and if the state designates its high-risk pool for federally eligible individuals) the pool must accept you when you apply even if it is otherwise closed to new enrollment.