High-Risk Pools

Question: We pay taxes into a state pool for persons who are unable to obtain medical insurance coverage due to pre-existing health conditions (e.g., heart disease, cancer, diabetes). People pay premiums (capped at 135 percent of the standard medical premium in the state) but there is a shortfall because medical spending by policy holders exceeds premiums paid (premiums typically cover about one-half of medical spending). Insurers in the State are assessed (annually) an amount to cover the shortfall. Our insurance company contributes approximately $900,000/annually. Approximately 1,700 persons are served. Is this a community benefit?

Recommendation: Taxes paid by health care organizations into a pool can be included as community benefit if you can document that the patients (members) that benefit from the pool receive improved access to care. If these consumers would have difficulty accessing coverage (especially if they would have qualified for charity care as medically or financially indigent patients) but for the payments to the pool, then the case can be made that these dollars are community benefit.

Please Take Note: The information provided does not constitute legal or tax advice. The material is provided for informational/educational purposes only. Please consult with counsel regarding your organization's particular circumstances.