Dozens of patients cut from state's high-risk insurance pool

With premiums that can top $20,000 a year, patients don't exactly clamor to join the state's high-risk health-insurance pool — a public insurer of last resort for patients with cancer, AIDS and other serious diseases.

Yet since the high-risk pool was created two decades ago, the first-ever mandatory check to verify that current members are eligible for the highly subsidized coverage has ended with dozens of them getting purged — including some who may simply have been too ill or too distracted to turn in their paperwork.

Since Jan. 1, a third of the 82 members of the Washington State Health Insurance Pool whose coverage was terminated have been reinstated after they belatedly provided proof of eligibility.

Until 2008, the health plan mailed annual eligibility forms but did not take action against people who did not comply. Now its administrators find themselves in an unaccustomed position of stripping coverage from some of Washington's sickest residents. Some whose coverage was canceled may not realize it until they show up at a pharmacy or a doctor's office, said Kären Larson, executive director of the high-risk pool.

It's possible, though unlikely, Larson said, that patients may be unable to fill their prescriptions or receive treatment until their information is sorted out.

Jeanne Sather, a Seattle writer and blogger who has advanced breast cancer, said she lost — then regained — her coverage because of a paperwork snafu. Sather said she twice had to send proof of her Medicare coverage but still ended up receiving a cancellation notice.

A seasoned patient's advocate, Sather fired off e-mails to both the high-risk pool and the state Insurance Commissioner's Office. She quickly got her coverage restored — but not before she worked up a fury.

"You have to remember that people like me are sick," Sather wrote in one e-mail. "So making trips to Kinko's to make copies uses up precious energy and time. I deeply resent being asked to do something like this."

By law, the high-risk pool is open only to residents of the state. It also must ensure that members who have dual coverage with Medicare tap those federal benefits first. Last year, a state audit recommended that the pool obtain proof of eligibility from all its 3,300 members.

Larson said cutting off coverage for people who may be gravely ill wasn't done lightly. The health plan until now had been more lax about confirming eligibility, she said, because it wanted to avoid needless cancellations.

"All health plans have trouble staying in touch with their members," Larson said. "People move. They get new phones and they don't tell you."

Larson said the latest termination notices came only after repeated attempts to contact members proved fruitless.

"We bent over backward to make sure" policies weren't improperly canceled, she said. But if members didn't respond to four letters and a telephone call, "we didn't really have any choice but to terminate them."

Larson said members who submit proof of eligibility by Jan. 31 can have their coverage reinstated with no interruption in coverage. After that, members must go through a formal appeals process to be reinstated.

The high-risk pool provides coverage for people who can't buy individual insurance from Regence BlueShield, Premera Blue Cross, Group Health Cooperative and other commercial insurers. Washington permits insurers to screen out the sickest 8 percent of the applicants. In return, the insurers pay a subsidy — totaling nearly $40 million last year — to help offset the cost of operating a separate pool.

Premiums for the high-risk coverage start at $151 a month and can be as much as $1,917 a month, depending on a member's age, disability status and coverage type.

But as pricey as they might be, the premiums cover only about 30 percent of the patients' medical and prescription expenses. The cost of subsidies from commercial insurers is borne indirectly by everyone in Washington who buys an individual or group policy from them, said Pete Cutler, special assistant to the insurance commissioner.

Cutler, who sits on the high-risk pool's board, said he was surprised to hear about the volume of cancellations.

Still, he defended the verification attempts, saying that the state needs to ensure that it's "not providing subsidized coverage for those who are ineligible for it."

Kyung Song: 206-464-2423