Illinois Pre-Existing Condition Insurance Plan (IPXP): Frequently Asked Questions
Updated August 2010
The federal health reform law, known as the "Patient Protection and Affordable Care Act" (the "Affordable Care Act"), establishes a federally-funded temporary high risk pool to provide affordable health insurance coverage to people who have been denied insurance because of pre-existing conditions.
What is the Illinois Pre-Existing Condition Insurance Plan?
The Illinois Pre-Existing Condition Insurance Plan (IPXP) will be a transitional insurance program for uninsured Illinois residents. The IPXP is not a public aid or entitlement program. Enrollees will be required to pay a premium and out-of-pocket costs.
Why is it a "transitional" program?
The IPXP is a "transitional" program because, beginning on January 1, 2014, health insurance companies will be prohibited from denying coverage due to a pre-existing condition. The IPXP is intended to provide an interim coverage alternative to those who have been denied health insurance by health insurance companies.
How is the IPXP being funded?
The federal health reform law, known as the "Patient Protection and Affordable Care Act" (the "Affordable Care Act"), appropriates $5 billion to all the states to fund temporary high risk pools similar to the IPXP in every state. The $5 billion is allotted to the states on a population-based formula. Illinois' share will be an estimated $196 million.
In addition to the federal funds, the IPXP will be funded by premiums paid by enrollees.
Claims and administrative expenses will be forwarded to and paid by the federal government, not the State.
Does funding limit enrollment?
Yes. Based on anticipated funding, actuaries (experts who predict how long limited funding will last) predict that the IPXP may enroll between 4,000 - 6,000 individuals. Variables that impact how many people can enroll include (1) the severity of the illnesses of those who enroll, (2) the benefit structure, and (3) the length of the coverage term.
In other words, if people who enroll have higher medical expenses than the actuaries projected, then we will be able to enroll fewer people. IPXP will be managed in a fiscally prudent manner so that every enrollee is assured coverage until January 2014.
What will be the premiums paid by IPXP enrollees?
The Affordable Care Act requires that premiums not exceed 100% of a standard rate, or in other words, be roughly equivalent to the average premium paid by an individual in the State. The Affordable Care Act prohibits gender rating, or charging more or less depending upon whether the enrollee is a man or woman. The Affordable Care Act also limits the maximum rating difference for age to a ratio of 4 to 1 or, in other words, the difference in premium paid by the oldest enrollee cannot be more than 4 times the premium paid by the youngest enrollee. Other than age, geographic location and tobacco use are the only other factors that can be used to determine the premium rate for an IPXP enrollee.
Federal law is written and passed by Congress and signed into law by the President.
The IPXP monthly premium table and instructions:
IPXP Monthly Premium Table and Instructions $2000.00 deductible
| Premium | Monthly premium table and instructions |
|---|---|
| Deductible | $2,000 |
| Cost Sharing (Co-insurance) | 80/20 |
| Out-of-Pocket Limits | $4,350 for medical (including the $2,000 deductible), $1,600 for pharmacy, with a maximum out-of-pocket limit of $5,950 |
IPXP Monthly Premium Table and Instructions $1000.00 deductible
| Premium | Monthly premium table and instructions |
|---|---|
| Deductible | $1,000 |
How do premiums paid by IPXP enrollees differ from premiums paid by ICHIP enrollees?
IPXP premiums are determined by federal law, as outlined above. Enrollee premiums for the Illinois Comprehensive Health Insurance Plan (ICHIP)—an existing high risk pool first established in the late 1980s—are controlled by State law. Illinois law requires that ICHIP premiums must be at least 125% of the standard rate and not more than 150% of the standard rate. Illinois law requires that premiums be based on sex, age, geography, and specific benefit plan.
Illinois law is written and passed by the General Assembly and signed into law by the Governor.
Who is eligible to enroll in the IPXP?
The Affordable Care Act established eligibility criteria for federally-funded temporary high risk pools like the IPXP. To enroll, a person must:
- Be a U.S. citizen, national, or legal resident;
- Be uninsured for 6 months; and
- Have a pre-existing condition.
The Affordable Care Act specifies that enrollment in an existing high risk pool, like ICHIP, constitutes insurance.
While ICHIP does not require that an enrollee have been uninsured for 6 months, Illinois law requires that certain ICHIP plans exclude coverage for a "pre-existing condition" for 6 months following enrollment. The Affordable Care Act does not allow the IPXP to limit coverage due to a pre-existing condition.
What is a "pre-existing condition" for purposes of the IPXP?
You can establish that you have a pre-existing condition in any one of four ways:
- Provide information showing that you have one of several "presumptive conditions;"
- Provide documentation from a health insurance company stating that you are ineligible for comprehensive coverage due to a medical condition;
- Provide documentation from a health insurance company offering you health coverage with a rider that excludes coverage for your medical condition; or
- Provide a written statement from a physician stating that you have an existing medical condition that may result in denial of comprehensive coverage by a health insurance company.
Illinois law currently allows health insurance companies to deny coverage for reasons that may not constitute a medical condition. The Department is interested in learning the condition(s) for which you have been denied coverage by a health insurance company. To submit your personal experience, please email us at DOI.HealthInsuranceReform@Illinois.gov.
If I'm currently enrolled in ICHIP, should I disenroll and be uninsured for 6 months so that I can be eligible for the IPXP, which is less expensive?
No. Due to limited federal funding, enrollment, by necessity, will be closely managed.
The Department respects and appreciates that premiums for ICHIP, as required by Illinois law (see the May 20, 2010, letter to ICHIP enrollees), are burdensome. However, ICHIP enrollees should not disenroll from ICHIP in order to be eligible for the IPXP:
- IPXP enrollment will be limited due to limited funding. If demand exceeds funding, then enrollment will be closed. Enrollment may be closed and then re-opened throughout the term of the IPXP, and a waiting list may be employed. You may not even be eligible to join the waiting list until you have been uninsured for six months.
- Illinois law prevents someone who voluntarily disenrolls from ICHIP from re-enrolling for 12 months following disenrollment. See 215 ILCS 105/7(e)(3). In other words, if you are unable to enroll in the IPXP, you may lose access to coverage for more than 6 months.
- Especially if you have a pre-existing condition, the absence of insurance coverage may result in the absence or neglect of appropriate and necessary care, the health and financial consequences of which can be severe.
What will be the IPXP benefit design (deductibles, out-of-pocket costs, etc.)?
Initially, the IPXP will offer one standard coverage plan to all enrollees. As the IPXP pays claims and develops a more detailed understanding of the enrollees, additional product designs may be offered.
At present, the IPXP will offer a PPO product with a $2,000 annual deductible, 80/20 cost sharing, and a maximum major medical out-of-pocket annual cost of $2,350. For prescription benefits, the cost sharing will also be 80/20 and the maximum out-of-pocket will be $1,600 per year.
When can I enroll in IPXP?
Applications are available as of August 20, 2010, with coverage expected to begin on September 1, 2010. Applications will be accepted beginning at 10:00AM on August 20, 2010.
Enrollment commences after IPXP: (1) receives a completed application and required documentation, (2) confirms applicant eligibility, and (3) receives premium payment.
How can I enroll in IPXP?
You can fill out and submit an IPXP enrollment application online, or print out a PDF or Word version of the application and mail, fax, or deliver it to:
Health Alliance Medical Plans
Attn: Illinois Pre-Existing Condition Insurance Plan
301 S. Vine St.
Urbana, IL 61801
You can also contact the IPXP using the following phone numbers:
Phone: (877) 210-9167
Fax: (217) 337-3425
TTY: (866) 883-8551
What if I have another question?
If you are a current ICHIP enrollee or your question involves ICHIP, please call ICHIP toll-free at (866) 851-2751 or visit the ICHIP website at www.chip.state.il.us.
If your question involves the IPXP, please visit the Department of Insurance web site at http://insurance.illinois.gov, call the IPXP's toll free number at (877) 210-9167, or email your question directly to IPXPInquiry@healthalliance.org.
For More Information
Call our Consumer Services Section at (312) 814-2427 or our Office of Consumer Health Toll Free at (877) 527-9431 or visit us on our website at http://insurance.illinois.gov