As a result of the federal Affordable Care Act of 2010, California has a contract with the federal Department of Health and Human Services to establish a federally-funded high risk pool program to provide health coverage for eligible individuals. The program will last until December 31, 2013 when the national health reform is set to begin. After that date, there will no longer be a need for high risk pools because federal rules will not allow insurers to reject persons with pre-existing conditions or charge them higher rates than those without such conditions.
The federally-funded program is called the California Pre-Existing Condition Insurance Plan (PCIP). The PCIP offers health coverage to medically-uninsurable individuals who live in California. The program is available for individuals who have not had health coverage in the 6 months prior to applying. The California PCIP is run by the Managed Risk Medical Insurance Board (MRMIB).
What is a Pre-Existing Condition Insurance Plan (PCIP)?
The Pre-Existing Condition Insurance Plan (PCIP) is a federal program that offers health coverage to medically-uninsurable individuals who live in California. As a result of the federal health care reform, California now offers a federally-funded health coverage program called PCIP. This program is available for individuals who did not have health coverage in the 6 months prior to applying.
In order for a person to qualify for the PCIP, a person must have met the following eligibility requirements:
- You must be California resident.
- You must have no health insurance coverage for the past 6 months, prior to application being received. This means in the last 6 months you were not enrolled in an individual or job-based health plan, including COBRA or Cal-COBRA, or enrolled in Medicare Part A and/or Part B, or in No-Cost Medicaid/No-Cost Medi-Cal.
- You must be a U.S. Citizen, U.S. National, or lawfully present individual.
- U.S. Citizens or U.S. Nationals must provide their Social Security Number.
- You must have been denied individual insurance coverage within the past 12 months, for a pre-existing condition as shown by:
- Rejection letter from a health insurance company in the last 12 months, or
- Offered coverage with premiums higher than those of the Major Risk Medical Insurance Program (MRMIP) preferred provider organization (PPO) in the geographic region where the individual is seeking coverage.
How Can I Apply for PCIP?
To apply for PCIP, you must complete both the PCIP Supplemental Application (PDF 149kb) and the Major Risk Medical Insurance Program (MRMIP) Application (PDF 879kb)
When you review the information, it is important that you carefully review the PCIP Supplemental Application Overview and the MRMIP Handbook, in order for you to make important decisions regarding your health care needs! The PCIP Supplemental Application Overview has information that compares the differences between the PCIP and MRMIP programs.
The PCIP Supplemental Application contains a Checklist. The Checklist is helpful for you to have when filling out your application. It tells you each step you need to complete. The Checklist explains the supporting documents and monthly premium you need to send with your application.
All questions on both forms must be answered. In addition, both applications along with a check for your first month’s premium and all necessary documents should be mailed to:
Pre-Existing Condition Insurance Plan
P.O. Box 537032
Sacramento, CA 95853-7032If you have questions when you fill out the applications, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.
Who Can Apply for PCIP?
- Any person 18 years of age or older. These individuals must apply for coverage for themselves;
- Parents (natural or adoptive) or step-parents applying for children who are under 18 years old. Parents or step-parent cannot apply for children 18 years of age or older;
- Legal guardians, foster parents, or caretaker relatives applying for a child who is under 18 years old, living in their home;
- An emancipated minor. This is a person who is under 18 years old who does not live with their parent, legal guardian, stepparent, or caretaker relative. Emancipated minors must apply for themselves.
If you have questions when you fill out the applications, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.
Does PCIP offer dependent coverage?
No, PCIP does not offer dependent coverage. PCIP requires that each individual applying for the PCIP must complete their own application. An applicant for the PCIP can be:
- Any person 18 years of age or older. These individuals must apply for coverage for themselves;
- Parents (natural or adoptive) or step-parents applying for children who are under 18 years old. Parents or step-parent cannot apply for children 18 years of age or older;
- Legal guardians, foster parents, or caretaker relatives applying for a child is who under 18 years old, living in their home;
- An emancipated minor. This is a person who is under 18 years old who does not live with their parent, legal guardian, stepparent, or caretaker relative. Emancipated minors must apply for themselves.
If you have questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.
How much will the monthly premium cost for PCIP?
The PCIP monthly premium costs are based on the applicant’s age and the region where the applicant lives in California. Refer to the premium rate table for specific monthly rates based on your age and where you live.
Click here for the PCIP Premium Chart (PDF 30kb).
If you have questions on the premium cost, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.
How do I know if I am eligible for PCIP?
You are eligible for PCIP if the following requirements are met:
- You must be a California resident.
- You must have no health insurance coverage for the past 6 months, prior to application being received. This means in the last 6 months you were not enrolled in an individual or job-based health plan, including COBRA or Cal-COBRA, or enrolled in Medicare Part A and/or Part B, or in No-Cost Medicaid/No-Cost Medi-Cal.
- You must be a U.S. Citizen, U.S. National, or lawfully present individual.
- U.S. Citizens or U.S. Nationals must provide their Social Security Number.
- You must have been denied individual insurance coverage within the past 12 months, for a pre-existing condition as shown by:
- Rejection letter from a health insurance company in the last 12 months, or
- Offered coverage with premiums higher than those of the Major Risk Medical Insurance Program (MRMIP) preferred provider organization (PPO) in the geographic region where the individual is seeking coverage.
If you have questions on PCIP eligibility requirements, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.
Will I qualify for the PCIP if I currently have Share of Cost (SOC) Medi-Cal?
To qualify for the PCIP, you must not have had creditable health insurance coverage in the last six months prior to applying for the PCIP. Share of cost Medi-Cal is not considered creditable coverage. Therefore, if you have share of cost Medi-Cal, you may be eligible for the PCIP program.
Share of Cost Medi-Cal is a monthly dollar amount a person is required to pay for their health care expenses. If you qualify for Medi-Cal with a share of cost, you will have to pay money for your medical care for that month. The amount you have to pay will be up to the share of cost amount. If you have to pay a share of cost amount, then Medi-Cal will pay for the remaining costs for that month. If you have no medical expenses, there is no Medi-Cal share of cost amount that you must pay.
To learn more about Medi-Cal with a share of cost, click on link below and contact a County Medi-Cal office near you:
http://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx.
What are acceptable U.S. Citizenship and U.S. National documents for PCIP?
Proof of U.S. Citizen/U.S. National as shown by:
- U.S. Passport;
- Birth certificate;
- Naturalization/Citizenship certificate;
- American Indian or Alaska Native enrollment document from a federally recognized tribe;
- A Certificate of Degree of Indian Blood (CDIB) from the Bureau of Indian Affairs; or
- A letter of Indian Heritage from a California Indian Health Service Clinic.
If you are not a U.S. Citizen or U.S. National, please send acceptable immigration documents which show that you lawfully reside in the U.S. We need immigration documents that show the expiration date. The documents can not be expired. Send copies of the front and back sides of the immigration documents. Click here for a list of acceptable immigration documents.
What are acceptable immigration documents for PCIP?
The following is a list of immigrant statuses and documents we need from you that is issued by the U.S. Citizenship and Immigration Services (CIS), formerly the Immigration and Naturalization Service (INS).
- Send documents showing that you lawfully reside in the U.S. Send copies of unexpired immigration documents. Please make sure the document shows the expiration date and is not expired. Send copies of the front and back sides. Click here for a list of acceptable immigration documents.
How do I pay my PCIP monthly premiums, once I am enrolled?
Once you are enrolled in PCIP, you will receive a billing statement for your monthly PCIP premiums in the mail. We must receive your premium payment by the 15th of each month. There are different ways to pay monthly premiums:
- You can send us a:
- Personal check,
- Cashier’s check, or
- Money order.
Make your payment to the “Managed Risk Medical Insurance Board (or MRMIB).” Make sure you write your Member Number on the check. Mail your payment to:
PCIP – Finance Unit
PO Box 537031
Sacramento, CA 95853-7032 - OR, you can pay by Electronic Fund Transfers (EFT) from your bank account. You will fill out a form giving PCIP permission to automatically withdraw money from your bank account each month. EFT withdrawals will occur on the 4th of each month, once your EFT request is processed and approved. To sign up for EFT, follow the steps shown on the back of your monthly billing statement. Or, you can download the PCIP EFT Form. You will need to send PCIP the complete EFT form with a voided check or savings deposit slip from the bank account.
The form can be mailed to:
PCIP – Finance Unit
PO Box 537031
Sacramento, CA 95853-7032In order to allow PCIP enough time to process your EFT form, you must continue paying your premiums in another way with either a personal check, cashier’s check or money order (by the due date) until the EFT withdrawal is in effect. It can take up to 6-8 weeks before the EFT is withdrawn from your account after you sign up.
Important Reminder! If you are disenrolled from PCIP because your premiums are past due, you will have to wait 6 months to qualify for PCIP again.
If you have questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.
Which plans will be available for PCIP?
There is only one PCIP PPO Provider Network plan. This is a PPO Network that has contracted health providers in all 58 counties statewide. For specific questions about the PCIP PPO Provider Network, call 1-877-629-1500, Monday – Friday from 6 a.m. to 6 p.m.
Or you may visit the PCIP providers for specific information related to the providers that will be available.
How can I find a PCIP PPO Network Provider?
To find out what providers area available through the PCIP PPO Network, click here to visit the PCIP PPO Network.
If you have specific questions about finding a PCIP PPO Network, please call the PCIP PPO Network toll-free telephone line at 1-877-629-1500, Monday – Friday, from 6 a.m. to 6 p.m. The call is free.
Does PCIP cover dental and vision care?
No. There is no dental or vision coverage included in PCIP. If you need this coverage, you will need to obtain it separately.
If you have other PCIP related questions, please give us a call at a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.
What are the health benefits offered in PCIP?
There is a wide variety of services provided in PCIP; including preventive care, hospital care, physician office visits, prescription drugs, laboratory and x-ray services, and home health / hospice care.
Review the comprehensive list of services offered by the PCIP.
What is the co-payment for PCIP services?
The co-payments vary if the provider is “in network” or “out of network”.
For in-network providers, the co-payments are:
- Preventive Care Services: No Charge
- Physician Office Visits: $25* co-payment
- Prescription Drugs: $5* for generic, $15 – $30* for brand
- All other services: 15%* of negotiated fee rate
For out-of-network providers, the co-payments are:
- Preventive Care Services: 50%* of customary and reasonable charges and any additional charges.
- Physician Office Visits: 50%* of customary and reasonable charges and any additional charges.
- Prescription Drugs: 50% reimbursement at non-participating pharmacies subscriber pay full cost of prescription.
- All other services: 50%* of customary and reasonable charges and any additional charges.
*deductible applies
Is there an annual deductible for PCIP?
Yes. The annual deductible is different based on whether the services are provided “in-network” or “out of network”.
In-Network Annual Deductibles are:
- Annual Deductible for Services: $1,500 per subscriber for services
- Annual Deductible for Brand Name Prescriptions: $500 per subscriber
Out-of-Network Annual Deductibles are:
- Annual Deductible for Covered Services: $3,000 per subscriber for services, does not count towards in-network deductible.
- Annual Deductible for Brand Name Prescriptions: $500 per subscriber for prescriptions, does not count towards in-network annual deductible for Brand Name Prescription Drugs.
More information is available in the PCIP Plan Benefits.
Does PCIP have a cap on how much I have to pay out of pocket each year?
Yes. The annual maximum out of pocket costs are different based on whether the covered services are provided “in-network” or “out of network”.
- Annual Out of Pocket Maximum In-Network: $2,500 per subscriber.
- Annual Out of Pocket Maximum Out of Network: There is no annual maximum.
How long does it take to process my PCIP Application?
If your application is complete with all the required documentation and processed by the 10th of the month, coverage will begin the 1st day of the following month. Incomplete information will result in a delay of coverage or a denial of coverage.
What is the difference between my PCIP Member Number and Subscriber ID Number?
Your PCIP Member Number and Subscriber ID number are the same. Both numbers begin with “PC” and have 7 numeric values following it. It is a unique number that was assigned to you when you apply or are enrolled into PCIP.
This number is shown on all letters that PCIP sends you and is also on your PCIP Identification Card. It is important that you have your PCIP Member Number or Subscriber ID number when calling PCIP or when you access PCIP benefits that are available to you.
If you have questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.
How can I appeal a PCIP eligibility decision?
If you think we made a mistake, you can appeal the decision. Send us a letter, telling us the factual reason why you think our decision is wrong. Or, you can complete an Appeals Form which you can download from our website. Include any other information you think will be helpful in our review. Write your Member Number on every document you send us.
We must receive your written appeal within 30 days from the date we sent you the eligibility decision letter. You can send your appeal to:
Pre-Existing Condition Insurance Plan
P.O. Box 537032
Sacramento, CA 95853-7032We cannot review a decision over the phone. Once we receive your written appeal or Appeal Form, we will send you a letter telling you the results of our review.
If you have questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.
Can insurance brokers/agents assist people in applying for PCIP?
Yes, they can assist people apply for PCIP. Insurance agents/broker’s information must be included on the application in order for them to be paid for their assistance. Insurance agents/brokers are eligible for a $50 reimbursement for each person they assist who is successfully enrolled into PCIP.
The insurance broker/agent information required on the application are:
- Agent Name,
- CA license number,
- Tax ID/SSN,
- Full address (street address, city, state, and zip code),
- Phone number, and
- Agent’s signature.
If you have questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.
How much will insurance brokers/agents receive for assisting people enroll into PCIP?
Insurance agents/brokers are eligible for a $50 reimbursement for each person they assist who is successfully enrolled into PCIP.
Insurance agents/broker’s information must be included on the application in order to be paid for their assistance. The required information needed are:
- Agent Name,
- CA license number,
- Tax ID/SSN,
- Full address (street address, city, state, and zip code),
- Phone number, and
- Agent’s signature.
If you have questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.
When will payments begin for insurance brokers/agents?
Reimbursement payments will be issued in arrears. PCIP will begin issuing reimbursement checks sometime in November 2010.
If you have questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.
Will PCIP cover any medical expenses that I received before my coverage begins?
The PCIP program will not cover any medical expenses incurred, prior to the effective date of coverage.
If you have questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.
I am currently interested in enrolling in MRMIP only? Is it possible for me to enroll in MRMIP without being considered for PCIP?
Yes, if you are only interested in the MRMIP program, you can apply for the MRMIP. However, we also encourage you to apply for the PCIP program, so that you are aware of your coverage options. As a result of the federal health care reform, California now offers a federally-funded health coverage program called PCIP. The PCIP offers health coverage to medically-uninsurable individuals who live in California. This program is available for individuals who have not had health coverage 6 months prior to applying for PCIP.
Important Notice: If you are currently or will be enrolled in the MRMIP, you will not qualify for the PCIP. The PCIP requires that an individual not have health insurance coverage for at least six (6) months, prior to receiving your application.
For a comparison of both programs click here.
The MRMIP is a separate state program that has different eligibility rules, benefits, annual deductibles, annual/lifetime cap, and monthly premiums costs compared to the PCIP program. The MRMIP has enrollment cap which limits the number of individuals that can be enrolled. For more information about the MRMIP waiting list, please call 1-800-289-6574, Monday – Friday from 8:30 a.m. – 7:00 p.m. The call is toll free!
Both of these health coverage programs are administered and overseen by the State of California. If you apply for the PCIP program, we will review your application for both the PCIP and MRMIP programs to inform you of your coverage options. If you qualify for both programs, you will be enrolled in the program that you indicate on question #13 of the PCIP Supplemental Application.
The PCIP Supplemental Application contains a Checklist. The Checklist is helpful for you to have when filling out your application. It tells you each step you need to complete. The Checklist explains the supporting documents and monthly premium you need to send with your application.
For more information about the MRMIP program, please visit the website at www.mrmib.ca.gov.
If you have any PCIP questions, please give us a call at a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. or, on Saturday, from 8 a.m. to 5 p.m.
What does it mean that I cannot have health coverage for the last 6 months, in order to qualify for PCIP?
The Pre-Existing Condition Insurance Plan (PCIP) requires that a person not have had health coverage in the 6 months prior to applying. This means that a person who was enrolled and had coverage through one of the following in the last six months is not eligible for PCIP:
- Individual or job-based health insurance, including COBRA or Cal-COBRA;
- Medicare Part A and/or Part B;
- No-Cost Medicaid (No-Cost Medi-Cal);
- Children’s Health Insurance Program (Healthy Families Program);
- A state high risk pool (Major Risk Medical Insurance Program);
- Health coverage provided by a public health plan established by the state (i.e. CalPERS), the U.S. government such as coverage provided to veterans enrolled in VA health care or a foreign country;
- FEHBP (health insurance for Federal employees or retirees), including Temporary Continuation of Coverage (TCC);
- Health benefit plan provided to Peace Corps workers; or
- Services provided by the Indian Health Service or by a Tribe or Tribal organization for treating your medical condition.
If you have any questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.
If I had health coverage in the last 6 months, why don’t I qualify for PCIP? I have a pre-existing condition and I cannot be without health coverage for 6 months.
The federal health care reform law requires that a person be without individual or public health coverage for at least 6 months prior to applying for PCIP. This rule is based on federal requirements. Since California is administering and overseeing the PCIP program for the federal government, we must follow their rules. If you have concerns about the 6 month requirement, we encourage you to contact your Congressional Representatives (Senate and House) in your area.
To find out who is your Congressional Representative, go to www.house.gov.
If you have questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.
Why do I have to fill out a MRMIP Application if I want to apply for PCIP?
You must fill out both the PCIP Supplemental Application and MRMIP Application because the PCIP Supplemental Application does not ask all of the questions required for the PCIP program. Therfore, you also need to complete the MRMIP Application too. You must complete both the PCIP Supplemental Application and MRMIP Application to apply for PCIP.
What are the different eligibility rules for the PCIP and MRMIP programs?
The PCIP and MRMIP have different eligibility rules and requirements. The differences between the 2 programs are:
PCIP and MRMIP Eligibility Rules
Pre-Existing Condition Insurance Plan (Federal) Major Risk Medical Insurance Program (State) - Resident of California.
- A pre-existing condition as shown by:
- Rejection letter from a health insurance company in the last 12 months, or
- Offered coverage with premiums higher than those of the MRMIP preferred provider organization (PPO) in the geographic region where the individual is seeking coverage.
- U.S. Citizen, U.S. National or lawfully present individual.
- No health insurance coverage in the last six months prior to application.
- Not enrolled in Medicare Part A & Part B; or COBRA or Cal-COBRA benefits.
- Not enrolled in No Cost Medi-Cal/No-Cost Medicaid
- Social Security Number required.
- Dependent coverage not available.
- Resident of California.
- A pre-existing condition as shown by:
- Rejection letter from a health insurance company in the last 12 months, or
- Offer of premiums equal to or higher than those of the individual’s first MRMIP plan choice, or
- Termination by an insurance carrier for reasons other than fraud or non-payment of premiums, ineligibility.
- Not eligible for Medicare Part A or Part B (except for end stage renal disease), or COBRA or Cal-COBRA benefits.
- Social Security Number not required.
- Dependent coverage available.
If you have any questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.
For more information about the MRMIP program, please visit the website at www.mrmib.ca.gov.
How do I show that I am medically-uninsurable for the PCIP program?
You must provide one of the following as documentation showing that you are medically-uninsurable:
- Rejection Letter – You must have been denied individual insurance coverage within the past 12 months, or
- Offer Letter – You were offered individual coverage in excess of the Major Risk Medical Insurance Program (MRMIP) PPO product within the past 12 months.
If you have any questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.
I am currently enrolled in MRMIP program, may I apply for PCIP?
If you are currently enrolled in the MRMIP, you do not qualify for the PCIP program. The PCIP requires that an individual not have health insurance coverage for at least 6 months. Because you currently have health coverage through the MRMIP, you do not qualify for the PCIP.
If you have any questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. or, on Saturday, from 8 a.m. to 5 p.m.
I am currently enrolled in MRMIP. MRMIP has an annual benefit cap of $75,000 per calendar year and a $750,000 lifetime cap. Can I apply for PCIP, when I reach the MRMIP benefit or lifetime cap limit?
No, the PCIP requires that an individual be without health insurance for at least 6 months. To qualify for PCIP, you cannot have health coverage 6 months prior to applying. Because you are currently enrolled in the MRMIP, you do not qualify for PCIP.
If you have questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.
If I qualify for both programs, which program will I be enrolled?
If you qualify for both the PCIP and MRMIP programs, you will be enrolled in the program that you indicated on question #13 of the PCIP Supplemental Application. It is important that you let us know which program you prefer on the PCIP Supplemental Application. If you do not let us know which program you prefer, we will enroll you into the PCIP program.
If you qualify for both programs and you are enrolled in the MRMIP, you will no longer qualify for the PCIP. This is because the PCIP program requires that an individual not have health insurance coverage for at least 6 months.
If you have any questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.
I want to know if there is a waiting list for the Major Risk Medical Insurance Program (MRMIP)?
The MRMIP has an enrollment cap which limits the number of individuals that can be enrolled. MRMIP may have a waiting list due to available funding.
For more information about the MRMIP waiting list, please call 1-800-289-6574, Monday – Friday from 8:30 a.m. – 7:00 p.m. The call is toll free!
If I am disenrolled from the PCIP, when am I eligible to re-enroll?
If you were disenrolled from the PCIP program for any reason, you must wait 6 months before you may be eligible again. The PCIP program requires that an individual not have health coverage for at least 6 months when they apply. You will have to fill out the again and you must also meet all of the program rules and requirements in order to re-enroll in the program again.
If you have questions, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.
