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Lawsuit over Ohio’s High Risk Pool Eligibility Rules

UPublish story by Tracy McManamon

Ohio Health Insurance

Medical Mutual of Ohio has filed a lawsuit against state and federal officials over rules related to a high risk insurance pool for people with pre-existing conditions. Created by federal health care law, the high risk insurance pool program is focused on providing coverage to people with pre-existing conditions.

Ohio is one of the states operating its own high risk insurance pool. Medical Mutual, a nonprofit Ohio health insurance company, was chosen to run the program which currently covers about 3,500 Ohioans.

Confusion arose as to whether 14 high-need people should get coverage under the state’s program. While the Centers for Medicare & Medicaid Services (CMS) directed that these 14 people be dropped from Ohio’s temporary high risk pool, the Ohio Department of Insurance wanted the program to cover them.

Medical Mutual was prompted to file the lawsuit in a federal court to clear the uncertainty on who had the authority to make the final decision on eligibility for enrollment into the program. Though federal authorities finally provided the guidelines on coverage for the 14 people, Medical Mutual has not dismissed the lawsuit, saying that eligibility issues could come up for others too.

Healthcare Law and Pre-existing Conditions

A health problem that an individual has before applying for a health insurance plan can be considered a pre-existing condition. Heart disease, high blood pressure, cancer, asthma and type 2 diabetes are health issues that could qualify as pre-existing conditions. The health insurance company can accept the applicant and fix an exclusion period ranging from six to 18 months during which coverage is not provided for the pre-existing condition.

Healthcare reform seeks to change this. Starting 2014, companies cannot deny Ohio individual health insurance to eligible residents with pre-existing conditions. The state set up a temporary high risk pool administered by Medical Mutual of Ohio to meet their requirements until 2014 when the risk pool would end and the state’s health insurance exchange would begin operating, ending many discriminations in Ohio health insurance coverage.

Need to Resolve Any Conflict

The Ohio pre-existing condition insurance plan provides several health benefits, such as primary and specialty care, hospital care, and prescription drugs. The conflict between the high risk pool administrator and CMS on pre-existing condition health insurance in Ohio continued for over a month and is likely to have proved extremely traumatic for the 14 affected persons, many of whom suffer serious health problems. It is important that legal issues are resolved quickly so that high risk individuals can keep their Ohio health insurance coverage till the provisions of healthcare law become effective in January 2014.

About the Author

Tracy McManamon has been a licensed insurance consultant dealing in Ohio health plans for over 25 years. He helps his clients understand the costs and benefits of various policies so that they can make an informed decision and get health insurance in Ohio with comprehensive coverage at competitive price. For more details, call toll free 877-549-1212 or visit

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