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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.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.