PCIP has been a godsend for East Coast Health Insurance and its clients. The Pre-Existing Condition Insurance Plan makes health insurance available to people who have had a problem getting insurance due to a preexisting condition. To find out more about this plan, call us right now at 888 803 5917 or apply online for PCIP now!
The PCIP plan is available right here on our website and you can quote it and apply for it by going through our health insurance quote engine.
The Pre-Existing Condition Insurance Plan, PCIP, was established in June 2010 by the Patient Protection and Affordable Care Act, in order to provide medical coverage to individuals who normally would be rejected by health insurance companies due to their health. Pre-existing conditions are viewed as an extraneous expense for insurers to deliberately avoid, and therefore the ACA brought this new option into the open for those who were stuck with an illness and no way to pay for treatment.
PCIP is operated through federal government, by the Department of Health and Human Services (HHS), or by an individual state. There are 27 state-run and 24 HHS-run PCIPs. This temporary high-risk pool program was created to give coverage to people who have been uninsured for at least six months and have a qualifying condition, or have been denied a plan as a result of their illness. As every state and the HHS operate differently, each state PCIP program has its own set of premium rates, deductibles, and out-of-pocket limits, Specific region also dictates rate variability.
PCIP closely resembles a basic individual health plan, like a PPO, for a healthy beneficiary than like Medicaid or a discount program. If you have a pre-existing condition in addition to very low income, it is important you find out if you are eligible for your state’s Medical Assistance program. Rates are going to be affordable and similar to a low-cost private policy in most cases, though in some areas, premiums can be rather steep.
With PCIP monthly premiums and an annual deductible comes coverage for major medical (hospital, physician) and prescription medication costs. There is also cost sharing like a private plan, as services are available for set copayments and percentages of coinsurance, though there are set limits for out-of-pocket expenses. The good news is that the plans do not charge individuals more based on their health, as an insurance company would.
Hospital services are covered at 80% after deductible, and preventive care is covered in full with in-network providers with all three types of PCIP. Primary care and specialist office visits with an in-network physician are available for a $25 copay per visit.
Individuals who have preexisting health conditions of any income level, and have been uninsured for a minimum of six months can apply for the Pre-Existing Condition Insurance Plan in their state. As it is a government plan, applicants must be U.S. citizens or legal residents to be considered.
Proof of your preexisting condition must be provided through at least one document from a health care professional or health insurer. Documents accepted to prove a preexisting condition include:
- A letter of denial from a health insurer for individual coverage (not a group plan through an employer) dated within the past year. An alternative is a letter dated in the past year from an agent or broker licensed in your state that indicates you are ineligible for an individual plan from one or more companies due to your health.
- An offer of individual insurance coverage (not group) that you turned down because it did not cover your condition, dated within the past year. The offer must include a statement making note that the medical condition will not be covered if you agree to accept.
- A letter from a doctor, physician assistant, or nurse practitioner for persons under age 19 or living in Massachusetts or Vermont, dated within the past year. The letter must give your name and a current or past medical condition, disability, or illness, as well as the health care professional’s name, license number, state of licensure, and signature.
- An offer for individual insurance for persons under age 19 or living in Massachusetts or Vermont, dated within the past year, that you did not accept because the premium was too high. The offer of coverage must show a premium rate that is at least double the cost of you state PCIP’s Standard Option.
Application & Approval
Within 2-3 weeks after applying, individuals should receive a letter acknowledging whether or not their application has been approved for a PCIP. If you do receive approval, the letter will indicate your monthly premium rate, the start date of your coverage, and how to pay your first premium. In order for your coverage to become effective, you are required to send the first premium payment within 30 calendar days after receiving the approval notice. Your application will be cancelled if the premium is not sent or received within that range.
Once your coverage begins, all covered benefits are available immediately. Even the treatment of a preexisting condition does not require a waiting period. If your application is received between the 1st and the 15th of the month, your plan will start on the 1st of the following month. If your application arrives between the 15th and 31st, your coverage will begin the first day of the second month, though you also have the option of choosing an earlier start date.
If your application is denied, a letter explaining why you were not approved. You have 45 days after receiving the notice to file an appeal if you feel a mistake was made in the evaluation process. You are also able to re-apply for PCIP if you meet the criteria for eligibility. To file an appeal, you write a letter detailing your reasoning for the appeal and include any additional documents to prove you qualify for PCIP. Once that letter is received, PCIP will send you a final decision regarding your eligibility. They give you 45 days to file another appeal for the denial letter, after which all rights to appeal are lost.
The federally operated PCIP currently provides three different plans:
- Standard Plan
- Extended Plan
- Health Savings Account (HSA) Plan
Every plan type has different premium levels, annual deductibles, separate pharmacy deductibles, and prescription copayments. HSA plans allow members the option of opening a health savings account for tax-advantaged funds used specifically for medical costs – as you can find with an individual health plan.
Once the deductible is reached, PCIP covers 80% of in-network services, and you pay 20% coinsurance. All covered services for network and non-network care add up to your out-of-pocket maximum, which is $7,000 in 2012. When using network providers, the maximum is even less. PCIPs have no lifetime maximum limit on how much the plan pays for your care.
If you have any questions regarding these plans, feel free to call us, and we will be happy to help clarify details, run a quote on your behalf, or lead you towards the right plan. Call 888 803 5917 to speak with a licensed agent.