Coverage deadline looms for risk-pool participants

Dec. 12--For someone who requires surgeries, specialists or expensive medication on a regular basis, a break in health insurance coverage could lead to bankruptcy.

And that break could happen if participants in the high risk-pools don't select new insurance plans by Dec. 23. That's the federal government's deadline to ensure that coverage begins Jan. 1.

High-risk pools are insurance plans set up specifically for people with health issues labeled as pre-existing conditions. Their medical expenses are often higher than the average person and can be difficult to cover, so they have had the choice of joining the Missouri Health

Insurance Pool or the federal

Pre-Existing Condition Plan.

On Dec. 31, the Missouri Health Insurance Pool will terminate its care of 4,300 residents, and the federal Pre-Existing Condition Insurance Plan will stop its coverage of more than 2,100 Missourians.

The nonprofit state pool has operated since 1991 and helped thousands of people with pre-existing conditions gain health care coverage. Another option was the federal plan, which was formed in 2010 to provide policies for Americans with pre-existing conditions who were denied coverage for at least six months before applying.

But under the Affordable Care Act, insurance carriers can no longer turn away consumers or charge them more because of their health status. Consumers may find plans on the new marketplace to be cheaper than what they paid in a high-risk pool.

A vote by the Missouri Legislature decided that the Missouri pool -- run by the Missouri Department of Insurance -- would close permanently at the end of the year. The federal plan was always intended to be short-term. It was formed as a temporary bridge to the Affordable Care Act marketplace.

To prepare for the change, the federal and state pools sent a series of letters to participants warning that their plans were ending and listing their options, including coverage through the federal marketplace.

Ann Mandelstamm, 74, has medical and financial power of attorney for her deceased friend's son, who is in the state pool for a major mental illness. She said the prospect of a break in his coverage has made her lose sleep.

"I'm more than a friend," she said. "I have legal responsibilities. He cannot advocate for himself."

Mandelstamm, who lives in St. Louis, began an application in early November on HealthCare.gov. After seeing only two providers listed -- Coventry and Anthem Blue Shield and Blue Cross -- she called nearly 40 psychiatrists, and none would accept Anthem's Pathway X plan.

While shopping for other options, both on and off the marketplace, Mandelstamm realized she had incorrectly filled out the income portion of the application. This made her friend ineligible for subsidies.

When she called HealthCare.gov's hotline, she was told no changes could be made to the application without proof that she has power of attorney.

Mandelstamm mailed a copy of her power of attorney on Nov. 21 and selected a Coventry plan on the marketplace the same day. She has yet to be given authorization to change the income amount.

"It's been a very, very difficult thing, and we're not finished yet," she said, but Mandelstamm paid the first premium Dec. 2 because she believed she couldn't afford to wait any longer.

"I had to get something done, and ... I was afraid there would be this huge push of people desperate to get insurance before the end of the year."

Even without the subsidies, though, Mandelstamm said the marketplace is slightly cheaper than the state program.

The gold plan she selected costs $787 a month with a $1,750 deductible, and the first five psychiatric visits include a $50 co-pay.

The Anthem plan through Missouri's risk pool charged more than $800 a month and offered no psychiatric coverage before the $2,500 deductible.

"It's not tons better," she said. "It's still expensive, but it's a little better."

One woman in Richmond Heights believes switching to the federal marketplace will save her more than $10,000 a year.

Jean Jackson, 61, said she was scared after being notified that her coverage would end. She has Crohn's disease, and her Anthem premiums through the state amounted to $941 a month with a $2,500 deductible and $7,500 co-insurance.

Yet when she accessed the online federal marketplace in late October, Jackson discovered a silver Anthem plan for $579 a month with a $3,000 deductible and $600 co-insurance.

She said even though she's not eligible for subsidies, she's relieved by the prices. She is not pleased with the narrow network, though, because Barnes-Jewish Hospital is not included.

Sidney Watson, a professor at St. Louis University Law School and an expert in health law, said the marketplace should be much more affordable for people with pre-existing conditions but that narrow networks could be worrisome.

"People in high-risk pools typically have ongoing health issues, and they're going to want to check which networks their physicians are in," she said. "They're going to need a wider network."

Also, Jackson selected her plan in late October, and though Anthem confirmed that her application has been processed, she has yet to receive her first bill.

"I'm being positive, but I will breathe a sigh of relief when I get the bill," she said. "Because then I'll only have to mail them the check, and I'll get the welcome packet."

Not everyone is seeing savings.

Audrey Chaney, 59, joined the federal Pre-Existing Condition Plan in early 2011 after complications from a hernia surgery. Her premiums have fluctuated in the risk pool from $550 to $422.

Not eligible for subsidies, the St. Louis resident found a gold Coventry plan on the federal marketplace for $556 a month, including dental coverage.

Chaney, who works part time and whose husband is retired, said she doesn't find it affordable.

"I was kind of thinking that maybe the premiums would be a lot less," she said. "But it's pretty much the same level."

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