6a High Risk Pool Q&A

Q1. What is the purpose of the Georgia Personal Responsibility High Risk Pool?
A1. The purpose of the personal responsibility high risk pool is to provide access to coverage for otherwise uninsurable individuals and stabilize premiums for small groups. Insurers participation in the Personal Responsibility High Risk Pool is voluntary.
 

Q2. What is the Georgia Health Underwriting Authority?

A2. The “Georgia Health Underwriting Authority” is a public/private partnership to establish, operate and manage the Personal Responsibility High Risk Pool. For public administration and public management responsibilities the Georgia Health Underwriting Authority is assigned to the Department of Insurance.

 
Q3. What citizens of Georgia are eligible for coverage in the High Risk Pool?
A3.  Anyone who as a part of a group application for a group 10 or fewer employees for Comprehensive Major Medical coverage has a medical condition or history that causes the group plan to be rated at a premium level of at least 25% or higher than otherwise standard rates.  In adddition, an individual who has applied to a Georgia licensed insurer for an individual Comprehensive Major Medical policy and has been rejected for coverage, unable to agree on alternatives that allow for a premium of less than 25% over standard premium rates, include contract benefit limits of 25% or more of the policy value, or any combination thereof.
 
Q4. Are there limitations for individuals eligible for the Personal Responsibility High Risk Pool?
A4. Yes. Any individual person must be a resident of this state for at least twelve months prior to the application to an insurer. In addition, the follow are also excluded from the High Risk Pool: 

    (1) Any person who is eligible for health care benefits under Article 7 of Chapter 4 of Title 49, the "Georgia Medical Assistance Act of 1977";
    (2) Any person who is eligible for another state or federal plan of coverage or program, including but not limited to Medicare, Tri-Care, or Veterans Health Care; 
    (3) Inmates of public institutions and persons eligible for public programs;
    (4) Any person who is eligible for self-insured employer coverage; 
    (5) Any person who terminated coverage in the Personal Responsibility High Risk Pool within the previous 12 months;
    (6) Any person on whose behalf the Personal Responsibility High Risk Pool has previously paid out $1,000,000.00 in benefits; and
            (a) Any person who ceases to meet the Personal Responsibility High Risk Pool eligibility requirements may be terminated at the end of the earlier of the policy period or enrollment in other coverage.
          (b) Personal Responsibility High Risk Pool coverage cannot be rescinded unless the application was approved due to fraud or material misrepresentation.
 
Q5. What is "Comprehensive Major Medical" ?
A4. 'Comprehensive major medical' means a plan with at least a $1 million coverage lifetime maximum; a cost sharing out-of-pocket maximum no greater than that applicable in any given year to a high deductible health plan as defined under Section 233 of the federal Internal Revenue Code, with applicable annual indexing; and provides health care services which an enrolled population might reasonably require in order to be maintained in good health, including, as a minimum but not restricted to, preventive care, emergency care, inpatient hospital and physician care, outpatient medical services, mental and behavioral health services, and prescription drug services."
 
It does not include short-term disability, fixed indemnity, limited benefit, or credit insurance coverage issued as a supplement to liability insurance, insurance arising out of a workers' compensation or similar law, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.
 
Q6. How can one be accepted into the High Risk Pool?

A6. If an applicant is determined to be uninsurable they will automatically qualify for the Personal Responsibility High Risk Pool, if the pool is accepting new applicants and can then select among the plans offered and the premiums then charged by the Personal Responsibility High Risk Pool.  If the applicant is determined to be uninsurable and the Personal Responsibility High Risk Pool is not accepting new applicants, the applicant can choose to be placed into a queue for future acceptance. If the pool opens to new entrants, applicants will be offered coverage in the order they were placed in the queue.

Q7. What if the applicant is determined NOT to be uninsurable?
A7. If the appplicant is a member from a group of ten or fewer employees is determined not be uninsurable, the applicant will be helped in securing coverage with an insurer at rates appropriate to the health status and history of the group. If the applicant as an individual is determined to not be uninsurable, the individual will be helped in securing coverage at rates appropriate to the health status and history of the qualifying individual.

Q8. What are the requirements for new and existing employer group members to be eligible for the High Risk Pool?
A8. Employer groups of 10 or fewer employees must not have been uninsured for a period of at least six months, except for employer groups insured renewing with the same insurer, at the first annual policy anniversary for each group of 10 or fewer employees, insurers may at their option apply to the Georgia Health Underwriting Authority for a qualifying eligible member(s) and/or associated family member(s) to be considered for the Personal Responsibility High Risk Pool.

Q9. What are the requirements for new individuals to be eligible for the High Risk Pool?
A11. Individuals who are uninsurable based upon generally accepted underwriting practices and standards. In addition, individuals must: 
    (1) have been uninsured for a period of at least six months, and 
    (2) have been rejected by an insurer for individual Comprehensive Major Medical coverage, or have been unable to purchase an individual Comprehensive Major Medical plan at less than 25% additional charge over standard premiums or have been unable to purchase an individual Comprehensive Major Medical plan without a major coverage exclusion of more than 12 months, and
    (3) Must meet other standards as set by the Georgia Health Underwriting Authority.

Q10. What Insurers are eligible to provide coverage in the High Risk Pool?
A10. Any insurance company authorized to transact accident and sickness insurance business in this state, any nonprofit medical service corporation, any nonprofit hospital service corporation, any health care plan, and any health maintenance organization authorized to transact business in this state.   

Q11. Is the Insurer Participation in the High Risk Pool entirely Voluntary?

A11. Yes.  Nothing requires insurers to contract with the Georgia Health Underwriting Authority to particpate in the High Risk Pool. Access to the Personal Responsibility High Risk Pool is limited to those insurers contracting with the Georgia Health Underwriting Authority for reviewing both qualifying eligible members and qualifying eligible individual applications.

 

Q12. What are the Insurer's Obligations as Participants in the High Risk Pool?

A12. Insurers must agree to participate for both qualifying eligible group members and qualifying eligible individual applicants. Participating insurers must accept the determinations by the Georgia Health Underwriting Authority of uninsurable and not uninsurable decisions for eligible qualified members and qualifying eligible individuals.  Participating insurers submitting qualified eligible members who are determined to be uninsurable and accepted into the Personal Responsibility High Risk Pool can exclude those individuals from any otherwise group requirements for underwriting, acceptance, or renewal of the group policy.

 

Participating insurers are not obligated to offer coverage to any group if a qualified eligible member determined by the Georgia Health Underwriting Authority to not be uninsurable. Participating insurers submitting qualifying eligible individuals, who are determined to be uninsurable and are accepted into the Personal Responsibility High Risk Pool, will no longer be obligated to offer coverage to that applicant.

 

Participating insurers, who decline coverage or unable to offer coverage at less than 25% over standard rates, with reduced coverage of 25% or more, or a combination thereof for qualifying eligible individuals, agree to accept up to an equal number of qualified eligible individuals determined by the Georgia Health Underwriting Authority to not be uninsurable.

 

Q13. How will the High Risk Pool Affect Insurers Underwriting?
A13. An insurer's participation in the High Risk Pool Nothing will not change, impose, or impinge on an insurer’s ability to set or use individual or group underwriting standards as defined by each insurer.

Q14. Can Insurers terminate after joining the High Risk Pool?

A14. Yes. Insurers can terminate the agreement with the Georgia Health Underwriting Authority with at least a 180 day notification in writing to the Georgia Health Underwriting Authority. The Insurer will retain coverage for those lives covered while inder contract to the High Risk Pool. The Georgia Health Underwriting Authority can immediately suspend or terminate the agreement with any insurer if the insurer fails to meet participation standards. 

 

Q15. How will theGeorgia Health Underwriting Authority fund their operations?
A15. The Georgia Health Underwriting Authority shall operate as a self-sufficient entity deriving operating funds from:
    (1) membership fees charged contracting insurers; 
    (2) processing fees charged contracting insurers based upon time and expense required to review qualifying eligible member applications. The Georgia Health Underwriting Authority can refund in whole or in part fee paid by insurers if the applicant is determined to be uninsurable; 
    (3) processing fees charged contracting insurers based upon the time and expense required to review qualifying eligible individual applications. The Georgia Heath Underwriting Authority can refund in whole or in part fees paid by insurers if the applicant is determined to be uninsurable. 
    (4) processing fees to be paid by qualifying eligible members who directly request a review by the Georgia Health Underwriting Authority. The Georgia Underwriting Authority can refund in whole or in part fees paid by qualified individuals or members if the applicant is determined to be uninsurable.
    (5) processing fees to be paid by qualifying eligible individuals who directly request a review by the Georgia Health Underwriting Authority. The Georgia Underwriting Authority can refund in whole or in part fees paid by qualified individuals if the applicant is determined to be uninsurable.
    (6) The Georgia Health Underwriting Authority is authorized to request state funding for initial organization and operation expenses of the Georgia Health Underwriting Authority. 
    (7) The Georgia Health Underwriting Authority is authorized to seek federal or private grants to support the establishment or operations of the Authority and the Personal Responsibility High Risk pool. 
    (8) Other revenue opportunities as approved by the authorities governing board.

 

Q16. How will the Personal Responsibility High Risk Pool fund any claims losses?
A16.  The High Risk Pool will be funded substantially from uninsured individuals who lose part or all of their Georgia state income tax standard personal or family exemptions due to voluntarily choosing to be uninsured. The Department of Revenue will calculate the increased state income tax from returns showing the loss of exemptions and submit 80% of that tax amount to cover claims and other expenses of the Personal Responsibility High Risk Pool.

In addition,

(a) all premiums paid by covered lives shall be used solely for the administration and payment of claims under the policies of the personal responsibility high risk pool.

(b) commissions of at least 4% on all policies placed with the Personal Responsibility High Risk Pool. The pool insurer or administrator will be under no contractual obligation to compensate another agent, broker, or third party for the placements made through the Georgia Health Underwriting Authority.

(c) In assisting qualified eligible members or qualified eligible individuals with securing private insurance who are determined to be not uninsurable the Georgia Health Underwriting Authority shall be compensated with a commission of at least 5% of the premiums paid for the length of the contract or alternatives subsequently chosen. The insurer will be under no contractual obligation to compensate another agent, broker, or third party for the sale of the policy made through the Georgia Health Underwriting Authority.

(d) Subsequent to the acceptance of the qualifying eligible member or qualifying eligible individual for a health insurance the policy will be consider a “Home Office” account. The Georgia Health Underwriting Authority shall not have any further obligations to the member or individual for policy maintenance or claims support.

(e) The personal responsibility high risk pool shall be authorized to receive donations or gifts from individuals, private organizations, foundations, or other sources and shall be authorized to receive state funds or any federal funds which may become available. Any funds received as donations or gifts shall be deemed trust funds to be held and applied solely for the purposes of this chapter.

 

(f) The personal responsibility high risk pool is authorized to receive directed funds from third parties to Health Savings Accounts for specific individuals, if such an account is properly established by the individual.

 

(g) A “Personal Responsibility High Risk Pool” Tax Credit totaling $10,000,000 per year for ten years is authorized for the operations and payment of benefits under the personal responsibility high risk pool.

 

(h) The General Assembly shall authorize up to $10,000,000 per year for the operations and payment of benefits under the personal responsibility high risk pool.
 
 
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