Here & Now

Amie Goldman Discusses Pre-Existing Conditions Coverage

Zac Schultz:

The health care exchanges for the Affordable Care Act will open up on October 1, and there are a lot of people who will be buying their insurance in the exchange and have no idea what to expect. Joining us now to talk about one rather large group of those people is Amie Goldman, CEO of the Health Insurance Risk-Sharing Plan, or HIRSP. Amie Goldman, thanks for being here.

Amie Goldman:

Thanks for having me, Zac.

Zac Schultz:

Let’s start with what is HIRSP and who is a member of HIRSP?

Amie Goldman:

Sure. HIRSP is Wisconsin’s high-risk insurance pool. It’s been around for over 30 years in Wisconsin. We provide health insurance to individuals who otherwise wouldn’t have insurance. So it could be that someone is self-employed, works for an employer that doesn’t offer health insurance and they have a preexisting condition or a health condition that precludes them from accessing coverage in the private market. We also serve people who lose access to their employer-sponsored coverage, and under federal law are offered continuation rights under HIPPA. People have heard of it a lot in the context of privacy, but it also guarantees portability and continuation of health insurance. We serve people who are on Medicare due to disability. We offer a policy that’s a supplement to the coverage available under Medicare. Those are the three primary groups.

Zac Schultz:

This is going away. So what happens to everybody who’s being served this way once the exchange opens up?

Amie Goldman:

Yeah, so our members’ coverage will stay in effect through December, and we are working now to help them prepare for transitioning to other coverage effective January 1. So some of our members may be eligible for the expanded coverage under BadgerCare for childless adults. The majority will be moving to the private insurance market, some accessing premium tax credits through the new health care marketplace or exchange, and some may just be going to the commercial market.

Zac Schultz:

A lot of the people here are some of those that have been talked most about, those with preexisting conditions that otherwise couldn't buy insurance. Now that these plans will be accessible, are there going to be plans that fit their needs?

Amie Goldman:

We do think so. The coverage under HIRSP has always been modeled around the coverage that’s available in the marketplace, with some differences. For instance, we offer prescription drug coverage, which is really important for the people that we serve. That’s not typically offered in the individual insurance market. But under the Affordable Care Act, all coverage beginning January 1 will offer prescription drug benefits. So as we look at the coverage that’s there today and then some of the new requirements that are part of the federal law, we’re confident that the coverage itself in terms of the benefits will be comparable.

Zac Schultz:

What about the cost?

Amie Goldman:

That’s a good question. You know, we don’t know much about the cost yet. Last week the 13 insurers that had applied to offer coverage through the new marketplaces were made public. Information about the premiums is not yet available. But as we look at our membership and their income, we think the majority of them will be eligible for those premium tax credits that I mentioned earlier, which should offer them actually the opportunity to purchase coverage that’s less expensive than what we pay today– They pay today, excuse me, because of those tax credits.

Zac Schultz:

Just this week it became known the federal government was delaying a limit on out-of-pocket cost, including deductibles and co-pays, meaning some patients could have to pay that $6,300 deductible of their medical expenses, and then do it again for prescription costs. As you mentioned, prescription costs are a big concern. Does that mean these are the people that are most likely to end up paying double?

Amie Goldman:

Yeah, I'm glad you asked that question Zac. As soon as that came out, we were asked that question as well. Actually in looking at that regulation, it’s specific to group insurance plans, employer-sponsored plans. So the total out-of-pocket of an expected $6,300 will be in place for the individual market in January. So our members that are transitioning should have just that one out-of-pocket for their medical and drug expenses combined.

Zac Schultz:

Are people optimistic? Are they more concerned than other people may be?

Amie Goldman:

Yeah. I think we’ve been getting a lot of questions. We have a Facebook page. We did a live Q & A, and we were really overwhelmed by the response in terms of the number of people that tuned in for that. Questions of course come in through our customer service line and our email and so on. And so, you know, people are concerned, and understandably concerned. You know, we really struggled with wanting to make sure that people had as much notice as possible that this change was happening. But knowing that when we told them this change was coming, that we wouldn’t have all the information we’d want to have to help them. So we answer the questions the best we can. We have weekly email updates that we send out to our members and other interested parties. I can plug our website, www.hirsp.org. There’s a button where you can get on the list. So as information becomes available, we’re working really hard to keep our members updated. But they have a lot of questions about their doctors, will they be able to continue to see their doctor? What will the cost be? What coverage is available? Will they be able to have coverage out-of-state? We insure a lot of early retirees, some of whom spend time out of Wisconsin in the winter. Lots and lots of questions are being asked.

Zac Schultz:

I'm sure there are many more to come.

Amie Goldman:

Yes.

Zac Schultz:

All right. Amie Goldman, thank you very much for joining us. We appreciate it.

Amie Goldman:

Thank you for having me.