Louisiana Health Plan is the state health insurance pool, which offers coverage to individuals who have lost their benefits and have tremendous difficulty trying to regain them. This applies to individuals with pre-existing conditions, and those who have exhausted group plan continuation benefits and COBRA coverage, and are otherwise HIPAA eligible. Both the high-risk and the HIPAA pools offer comprehensive coverage like that of a private health plan. There are deductibles, copays, coinsurance, and premiums. For those with health conditions, they will find a much lower premium and coverage devoid of exclusions, compared to the individual market.
The private individual market can be a cruel place when you have medical problems, as rate ups and letdowns happen quite often in a state with no limit on exclusion periods and other liberties. In the wake of the Affordable Care Act changing this issue, Louisiana also has a federal high risk pool for those with conditions, the Pre-Existing Condition Insurance Plan. PCIP offers a different set of options for people with conditions from the state plan, giving more people the ability to get coverage. These plans offer a temporary solution until the ACA makes it possible for PCIP eligibles to buy a plan without issue on the individual market. Before PCIP, the Louisiana Health Plan did the same, though with a waiting period for certain benefits.
Louisiana Health Plan Eligibility
Depending on which category you fit into, you will have different criteria to qualify. High-risk individuals must present documentation of their rejection from an insurer, elevated premium rates, or a physician’s letter recognizing their condition. For both the federal and state pools, applicants must be uninsured for a minimum of six months prior to enrollment. HIPAA eligible applicants must meet a whole slew of qualifications, all of which have to do with not being able to receive health insurance, a record of creditable coverage, using up all continuation coverage, and applying at the right time – within 63 days of benefits ending.
A waiting period of six months is applied to individuals with pre-existing conditions for coverage of such conditions, while no waiting period is required of HIPAA pool members. Income is not a factor when applying for the Louisiana Health Plan.
Louisiana Health Plan Coverage
Individuals have the option of four deductible levels, all of which contain the same amount of coverage. Annual deductible options are $1,000, $2,000, $3,500, and $5,000, each with its own prescription deductible ranging from $100 to $500. Coinsurance on approved covered services is 80/20 with in-network providers, and 60/40 with out-of-network providers. For other services without pre-certification, the plan covers half of the expenses. As mentioned, those who enroll in the high-risk pool must wait six months before they can receive coverage on care related to their condition, which will be 50 percent after deductible. Preventive care is offered at no cost, as with all health plans.
Each plan offers a traditional major medical plan, with all covered services you expect from a PPO on the private market. This includes inpatient and outpatient hospital care, surgery, physician services, emergency care, wellness exams, medical supplies, prescription medications, and more. Prescriptions are covered for a copay for retail and mail order, and coinsurance for specialty pharmacy benefits after meeting your deductible. Out-of-pocket maximums vary based on where you receive your care. The in-network out-of-pocket limit for $1,000 deductible plans is $3,500, and $4,500 for all other deductibles. Out-of-network, limits are either $7,000 or $9,000.
Summary of Benefits
The temporary federal high risk pool in Louisiana is not run by the Louisiana Health Plan, though it offers a similar concept. Those with pre-existing conditions can purchase a health plan that does not issue exclusions or waiting periods to treat their condition. In order to qualify, residents must have six months consecutively without insurance, and proof of their rejection from an insurer, notice of increased rates, or letter from a doctor stating they have an eligible condition. PCIP plans are different from those offered through Louisiana Health Plan, and will no longer be available in 2014.
To find out more about PCIP in Louisiana, visit the PCIP website.
How to Apply
In order to apply for benefits and find out if you qualify, call the Louisiana Health Plan at 800-736-0947. By phone, they can help you determine if you are eligible and mail you an application. You can also download an application online for the program that is relevant to you, whether HIPAA or High Risk Pool. When completed and you have provided all requested documentation, you may send your application to the Louisiana Health Plan.
Send or fax your completed form and attachments to:
Louisiana Health Plan
P.O. Box 83880
Baton Rouge, LA 70884-3880
Fax: (225) 927-3873
Contact Louisiana Health Plan
800-736-0947 or 225-926-6245 in Baton Rouge
1. Louisiana Health Plan. “Eligibility Requirements for Each Pool.” www.lahealthplan.org. PDF.
2. Louisiana Health Plan. “Louisiana Health Plan Brochure.” www.lahealthplan.org. PDF.