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PPACA: Wis. Federal Risk Pool Figures Filter In

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Wisconsin is finding that the first enrollees in its federal high-risk pool plan tend to be extremely high risk.

Amie Goldman, chairman of Wisconsin’s Health Insurance Risk-Sharing Plan (HIRSP), talked about the HIRSP Federal plan recently at a seminar on the Pre-existing Condition Insurance Plan (PCIP) program organized by the Commonwealth Fund, New York.

Congress included PCIP provisions in the Affordable Care Act, the legislative package that includes the Patient Protection and Affordable Care Act (PPACA), in an effort to provide a reasonably affordable, guaranteed-issue coverage option for people with serious health problems between now Caduceusand 2014, when the Affordable Care Act is supposed to require that carriers offer all coverage on a guaranteed issue, mostly community-rated basis and new individual helath insurance subsidies are supposed to take effect.

States are operating 27 PCIP programs themselves, and the U.S. Department of Health and Human Services (HHS) is running the programs in 23 states and the District of Columbia.

To avoid crowding out private coverage, Congress required PCIP programs to offer coverage only to medically uninsurable people who had been uninsured for at least 6 months. The Affordable Care Act calls for the cost of the coverage to be comparable to the cost of conventional health coverage in the same states. Medically uninsurable people already in a state risk pool program are not eligible to shift into a federal PCIP program.

Experts have estimated that about 5.6 million of the 50 million uninsured U.S. residents will be eligible for the program and that the plans will have enough funding to cover about 400,000 people.

HHS reported Friday that PCIP programs had enrolled 8,011 people as of Nov. 1. Enrollment ranges from 1 in North Dakota to 1,657 in Pennsylvania.

Wisconsin has 18,265 state HIRSP enrollees and believes it has the capacity to enrollee about 8,500 people in the HIRSP Federal program, Goldman said, according to a written version of the PCIP seminar presentation provided by the Commonwealth Fund. Even though the Wisconsin HIRSP Federal program charges some of the lowest PCIP premiums

in the country — $113 for enrollees ages 25 to 29 who choose a $3,500 deductible — it has just 248 enrollees.

In Wisconsin, low-income state HIRSP enrollees can qualify for a HIRSP subsidy program.

So far, Wisconsin has received only 300 HIRSP Federal applications. In September, the state received 674 state HIRSP applications and 101 HIRSP Federal applications.

The median income is lower for HIRSP Federal enrollees, and the average age is just 48, compared with 53 in the state HIRSP.

“Claims data is not yet availabe yet, but contrary to expectations, application data suggests that morbidity of federal members will be as higher or higher than [state] HIRSP members,” Goldman said. “HIRSP Federal members have a 13% prevalence of cancer and 15% prevalence of mental health/[alcohol and other drug abuse] diagnoses.”

One member is waiting for a heart transplant, Goldman said.

Administrators need more data to know whether PCIP enrollment is low because of lack of consumer awareness or more because of problems with the design of the program, Goldman said.


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