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TEMPORARY COVERAGE EXPANSION PROGRAMS
Temporary High-Risk Pool
No later than 6/23/10, a temporary high-risk pool program will be implemented to provide coverage for individuals with preexisting conditions. The program will be run by a State or non-profit private entity. The pool will terminate on 1/1/14.
Issued coverage will have a cost-share by the plan of at least 65% and have a maximum out-of-pocket limit of the applicable yearly HSA limit. The plan must comply with the newly instituted rating rules.
Individuals are eligible if they have not had creditable coverage for at least 6 months prior to their application to the pool and have a preexisting condition.
Criteria will be developed to determine whether insurers or employer-sponsored plans (including self-insured) have discouraged individuals from remaining in their plan.
Effective date – No later than 6/23/10
Reinsurance for Early Retirees
No later than 6/23/10, a reinsurance program will be implemented to provide reimbursement to participating employer-sponsored plans (including self-insured) for a portion of the cost of providing coverage to early retirees (and their dependents). The program will terminate 1/1/14 (the date of implementation of the exchanges).
An early retiree must be age 55 and older, not eligible for coverage under the Social Security Act and not an active employee.
In order to participate, plans must submit an application to HHS, maintain programs to lower costs for high-cost conditions and provide the actual cost of medical care involved to be certified by HHS.
In order to receive payments, plans must:
- Submit claims for reimbursement that document actual costs of the items and services that the plan is seeking reimbursement for eligible reimbursable treatments and services.
Plans will receive an 80% reimbursement for claims that exceed $15,000, but are less than $90,000. Any payment is required to lower costs of the plan. Payments are prohibited from being used simply as revenue.
Effective date – No later than 6/23/10
(Please note: This document was produced by the Self-Insurance Institute of America to provide an overview of the Patient Protection and Affordable Care Act, as modified by the Health Care and Education Reconciliation Act. It does not cover every aspect of the legislation, and certain provisions of the law may change or be modified by additional rules and regulations. This document does not constitute legal or tax advice.)