Living with Diabetes

State High-Risk Pools

Thirty-five states have established "high-risk pools" that offer health insurance coverage to "uninsurable" residents whom private insurers might turn down because of their health status. Approximately 200,000 people are currently enrolled in state high-risk pools across the U.S.

For people enrolled in these programs, high-risk pools offer an important (possibly the only) source of available coverage. High-risk pools typically offer benefits that are comparable to basic private market plans but benefits do vary. Even so, in some states, high-risk pool benefits are limited and there may be a waiting period of 3-12 months on coverage of pre-existing conditions. Sometimes, though not always, high-risk pools will waive the pre-existing condition exclusion period if you had prior coverage. High-risk pool premiums are generally more expensive than coverage sold by private insurers as states set high-risk pool premiums based on a multiple of the average individual private plan premium.

Some states impose specific enrollment caps and limit enrollment in the high-risk pool based on the availability of funds. 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 under HIPAA (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.

Contact the office of your state insurance commissioner to find out what coverage laws exist in your state and where you might look to obtain coverage. Contact information for state insurance departments is available at http://www.naic.org/state_web_map.htm. You can also search for insurance options available to you at: http://finder.healthcare.gov/.

Pre-Existing Condition Insurance Plan (PCIP)

Through the Affordable Care Act, the federal health reform law enacted in March 2010, people with diabetes who have been uninsured for six months or more can access insurance through a new program called the Pre-Existing Condition Insurance Plan (PCIP). PCIP, which is administered by either your state or the U.S. Department of Health and Human Services, became available in 2010 and will continue until the provisions banning discrimination based on pre-existing conditions are fully implemented in 2014.

PCIP programs may vary depending on the state. There are no waiting periods for coverage of pre-existing conditions and out-of-pocket costs are capped. PCIP is available in every state, including states that already had a state-run "high-risk pool" program. Visit the PCIP webpage to learn more about how PCIP works in your state: https://pcip.gov/PCIP_States.html or call 1-866-717-5826.

*Beginning February 16, 2013, the Federally-run PCIP programs are suspending acceptance of new enrollment applications. State-based PCIP programs will stop accepting new enrollment applications after March 2, 2013. All PCIP programs will continue providing coverage to the people currently enrolled.

Note: There is an exception to the enrollment freeze for people who lost PCIP coverage in the past 6 months because they moved out of state, and there may be other exceptions, so you should call the PCIP program in your state for more information or if you think you may be eligible.