Pre-Existing Conditions Insurance Plans

UPDATE: For those enrolled in the pre-existing conditions insurance plan (PCIP); you will have to re-enroll through the health insurance marketplace when it opens on October 1, 2013. For those who do not want a gap in their coverage, make sure to enroll on or before DECEMBER 7, 2013!

For additional information, enrollment help, and inquiries, you can call a 24/7 toll free hotline: (800) 318-2596, or visit www.heathcare.gov.

They are basic health coverage for people who have been turned down for health insurance because of a pre-existing condition. The new Pre-Existing Condition Insurance Plan (PCIP) is a bridge program to make health coverage available to those who have a pre-existing condition and who have gone without coverage for at least six months.  The PCIP offers transitional coverage until 2014 when health insurance exchanges become available and pre-existing condition exclusions are prohibited.

What is a pre-existing condition exclusion?

It is a limitation or exclusion of a benefit based on the fact that a condition was present before the date of enrollment in coverage (or a denial of enrollment), whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date. For example, persons who are denied coverage because they already had a heart defect or seizure disorder when they applied.

Is there a plan in every state?

Yes. Each state has a plan. Some states have requested that the federal government run their PCIP. Other states have requested that they run the program themselves. In twenty-four states the federal government is operating the plan. Learn more and see how many people are enrolled in PCIPs in each state.

Who is eligible?

People with pre-existing conditions who were uninsured 6 months prior to applying for coverage in the plan are eligible. They need to be a citizen and a resident of the state in which the PCIP operates. They must also document that they have been turned down or have good reason to believe they would have been turned down for insurance based on their pre-existing condition.  Or the person must show that they were offered coverage but the policy excluded coverage of treatment for pre-existing conditions such as diabetes, seizures, or heart defects.

Are the plans really expensive?

The premiums vary depending on the age of the person and geographic location.  States determine the premiums and cost sharing.  However, the ACA does set some limits to ensure that they are roughly comparable to each states individual market rates. PCIP premiums won't cost more because of medical conditions and they are not based on income eligibility like Medicaid.

What is the out-of-pocket limit?

In 2010, the limit for the federal plans was $5,950. This includes the deductibles, co-pays and other costs (excluding premiums) that an individual would pay. To view more information about the state plans, see: http://www.healthcare.gov/law/provisions/preexisting/index.html

What benefits does the PCIP provide?

PCIP covers major medical and prescription drug expenses.  It will cover at least the following categories:

  1. Hospital inpatient services
  2. Hospital outpatient services
  3. Mental health and substance abuse services
  4. Professional services for the diagnosis or treatment of injury, illness, or condition
  5. Non-custodial skilled nursing services
  6. Home health services
  7. Durable medical equipment and supplies
  8. Diagnostic x-rays and laboratory tests
  9. Physical therapy services (occupational therapy, physical therapy, speech therapy)
  10. Hospice
  11. Emergency services and ambulance services
  12. Prescription drugs
  13. Preventive care
  14. Maternity care

Can you see any doctor that you want?

No. The plans may establish a list of providers. However, they must demonstrate that they have a sufficient number and range of providers to ensure that all covered services are reasonably available and accessible to people.

How can I apply?

You can apply on-line at https://www.pcip.gov/hrip/