Lifetime limits ban may not apply to you
Louise, an Angie's List member from Chicago, was diagnosed with cancer in 1998. Ten years later, her husband was diagnosed.
"It's under control," says Louise — who requested her last name not be used for privacy reasons — but her husband requires medication, including a chemotherapy drug costing $8,800 a month.
So she was floored to learn the new federal health care law's ban on lifetime limits for group insurance and new individual plans won't apply to them. The high risk pool in Illinois is one of 35 around the country not covered, and with the exception of those in Indiana, Kentucky and New Mexico, all have coverage limits. The pools came before and are separate from the new federally funded temporary high risk pools that don't have coverage maximums.
Your guide to the federal health care law
At a minimum, emergency services, prescription drugs, lab services and chronic disease management can't be capped for plans covered under the new federal pools.
"It does not prevent insurers from placing lifetime or annual limits on benefits that are not considered essential," says Schwartz of the Kaiser Family Foundation.
But for people like Louise enrolled in the original state high risk pools, many funded directly or indirectly by state revenue, no such guarantee exists.
"The very people who are at highest risk for [hitting a lifetime limit] are unprotected," says Louise, who has a plan limit of $5 million.
Louise, 57, worries about the possibility of hitting the coverage maximum, particularly if her 60-year-old husband's health declines and he requires more involved treatment. They can't make the switch to federally funded high risk pools that have no lifetime limits unless they go six months uninsured.
Of 16,000 people in Illinois' high risk pool, only seven current enrollees have expenditures exceeding $1.5 million, says Michael McRaith, the state's insurance department director.
"But that doesn't make it any less important for those few people with the severe and constant need for health care," he says. Still, many in other states face maximums below $2 million — a few pools cap coverage at less than $1 million.
The U.S. Department of Health and Human Services wouldn't say why the pools were exempted from the lifetime limits ban, but considering the dire fiscal problems most states face, McRaith thinks it's understandable the pools would be allowed to have coverage limits.