Pre Existing Condition Insurance Plan (PCIP)

July 2011 PCIP Program Changes: New Rates

As of July 1, 2011, some PCIP enrollees in the federally-administered plan will see a reduction in their monthly premium depending on the state they live. PCIP applicants will continue to have a choice of three plan options – the Standard Plan, the Extended Plan, and the HSA Plan and there will be no other changes to benefits. Current enrollees will not have the opportunity to switch plans at this time. To see the premium rates for your state effective July 1, 2011, go to the State Plans.

Eligibility

There are a few requirements to meet before you can enroll in the Pre-Existing Condition Insurance Plan – regardless of whether your program is run by the U.S. Department of Health and Human Services or your state. Applicants must:

• Be a citizen or national of the United States or reside in the U.S. legally.
• Have been without health coverage for at least the last six months. Please note that if you currently have insurance coverage that doesn’t cover your medical condition or are enrolled in a state high risk pool, you are not eligible for the Pre-Existing Condition Insurance Plan.
• Have a pre-existing condition or have been denied coverage because of your health condition.

Different states may use different methods of determining whether you have a pre-existing condition and whether you have been denied insurance coverage. If you live in a state that guarantees insurance coverage, the state may consider you to have been denied coverage if you were offered coverage at an unreasonable price or you have a medical condition. So, you need to check on how to establish eligibility in your state.

Check out the State Plans page to learn more about how the Pre-Existing Condition Insurance Plan works in your state.

How to Apply in States Where the Pre-Existing Condition Insurance Plan is Run by the U.S. Department of Health and Human Services

If the Pre-Existing Condition Insurance Plan in your state is run by the U.S. Department of Health and Human Services, go to the Apply page to apply. Or you can call 1-866-260-9829 and ask for an application.To apply, you will need to provide a copy of one of the following documents, which we will use to make a decision on your application:

• A letter from a doctor, physician assistant, or nurse practitioner dated within the past 12 months stating that you have or had a medical condition, disability, or illness. This letter must include your name and medical condition, disability, or illness and the name, license number, state of licensure, and signature of the doctor, physician assistant, or nurse practitioner.
• A denial letter from an insurance company licensed in your state for individual insurance coverage (not health insurance offered through a job) that is dated within the past 12 months. Or, you may provide a letter dated in the past 12 months from an insurance agent or broker licensed in your state that shows you aren’t eligible for individual insurance coverage from one or more insurance companies because of your medical condition.
• An offer of individual insurance coverage (not health insurance offered through a job) that you did not accept  from an insurance company licensed in your state that is dated within the past 12 months. This offer of coverage has a rider that says your medical condition won’t be covered if you accept the offer.
• If you are under age 19 OR if you live in Massachusetts or Vermont, an offer of individual insurance coverage (not health insurance offered through a job) that you did not accept from an insurance company licensed in your state that is dated within the past 12 months. This offer of coverage must show a premium that is at least twice as much as the Pre-Existing Condition Plan premium (the monthly payment you make to an insurer to get and keep insurance) for the Standard Option in your state. To find out if the premium you were offered but did not accept is twice as much as the premium in the Pre-Existing Condition Insurance Plan for the Standard Option in your state, check out the State Plans page.

How to Apply if the Pre-Existing Condition Insurance Plan is Run by Your State

If your state is running its own Pre-Existing Condition Insurance Plan, the State Plans page will help connect you to information about how and where to apply in your state.

Benefits

The federally-administered Pre-Existing Condition Insurance Plan offers three plan options – the Standard Plan, the Extended Plan, and the HSA Plan. These plans have different levels of premiums, calendar year deductibles, prescription deductibles and prescription copays The HSA Plan Option provides an opportunity to open a Health Savings Account, a tax-exempt account where you can deposit funds for eligible medical expenses. Each of the three plan options provides preventive care ( paid at 100%, with no deductible) when you see an in-network doctor and the doctor indicates a preventive diagnosis. For other care, you will pay a deductible before PCIP pays for your health care and prescriptions. After you pay the deductible, you will pay 20% of medical costs in-network. The maximum you will pay out-of-pocket for covered services in a calendar year is $5,950 in-network/$7,000 out-of-network. There is no lifetime maximum or cap on the amount the plan pays for your care.

The Pre-Existing Condition Insurance Plan covers a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs. All covered benefits are available for you, even to treat a pre-existing condition.