The following questions were asked during AARP’s webinar series about the new health care law. Additional information about the Pre-existing Condition Insurance Plan, including instructions on how you can apply, is available at Healthcare.gov.
Q: What is a pre-existing condition?
A: A pre-existing condition is a disability or illness (either physical or mental) that you have before you enrolled in a health plan. A wide variety of health conditions have been used by insurance companies as a reason to deny coverage. Different states may use different methods of determining whether you have a pre-existing condition, and whether you have been denied insurance coverage due to that condition. If you live in a state that guarantees insurance coverage, you may be considered to have been denied coverage if you were offered insurance at an unreasonable price.
Q: What is the Pre-existing Condition Insurance Plan?
A: The Pre-existing Condition Insurance Plan (PCIP) was created as part of the nation's new health insurance law, the Affordable Care Act. The PCIP program was designed to make health insurance available to you if you have been denied coverage by private insurance companies because of a pre-existing condition. PCIP provides a new health coverage option if you are a U.S. citizen, or are residing here legally, and have been uninsured for at least six months, have a pre-existing condition and have been denied health coverage because of your health condition. PCIP is a transitional program until 2014.
Q: What happens when the PCIPs end in 2014?
A: PCIP is a "transitional" program because on Jan. 1, 2014, health insurance companies will be prohibited from denying coverage due to a pre-existing condition. PCIP is a bridge until 2014 for people who have been denied coverage by health insurance companies. In 2014, PCIP enrollees will be able to acquire health care coverage through new state-based health care exchanges.
Q: Is PCIP available now?
A: PCIP is available in most states now. Whether the state or the federal government runs the program depends on the state. Also, the program name and design may vary depending on which state you live in. To learn more about eligibility, how to apply and what benefits are available in your state, visit the provisions page at Healthcare.gov.
Q: Who is eligible for coverage through PCIP?
A: Eligible individuals must:
- Be a U.S. citizen or a legal resident
- Have a pre-existing medical condition
- Not have been covered under creditable health coverage — as defined by Section 201(c)(1) of the Public Health Service Act — for the previous six months before applying for coverage
People now covered by a health plan, including employer plans, COBRA, TRICARE, Medicare, Medicaid and existing high-risk pool programs, are not eligible for PCIP. Even if you have a pre-existing condition, and your COBRA or other continuation of coverage is about to run out, you won't meet the requirement to be uninsured for the last six months. More about eligibility here.
If you are uninsured and have been told that you may be eligible for coverage through programs such as Medicaid and the Children’s Health Insurance Program, you should check out those programs first, as they may better meet your needs. If you have job-based coverage, or individual insurance coverage, you aren’t eligible to apply.
Enrolling in the PCIP
Q: How do I enroll in the PCIP?
A: If the PCIP in your state is run by the federal government, it's simple. Download an application at Healthcare.gov. If your state is running its own program, check with the State Health Insurance Assistance Program at SHIPtalk.org.
Q: What if someone calls me or sends a letter asking me to enroll in a PCIP?
A: You can enroll only in a plan by applying for coverage using the methods described at Healthcare.gov. Do not respond to phony calls or letters asking you to enroll and pay a fee.
Premiums and Other Costs
Q: How much do I have to pay for insurance through PCIP?
A: Premiums and other cost sharing will vary depending on the state you live in. For information, visit Healthcare.gov. After you pay your monthly premiums for the year, the out-of-pocket costs for care in the plan's network cannot exceed $5,950 annually.
Q: What if I can’t afford the premiums for PCIP?
A: If you have limited income and resources (assets), you may be eligible for the Medicaid program in your state. If you're seeking insurance coverage for your child, go to InsureKidsNow.gov to learn more about children’s health insurance in your state.
Q: Why must a person have no health coverage for six months before applying for PCIP?
A: It's just something that’s required by federal law, which stipulates that an individual must be uninsured for at least six months and meet other criteria before applying for PCIP.
Q: What happens to people who are already enrolled in existing state high-risk pools?
A: The new national program will not affect individuals already covered by a state high-risk pool; those individuals will maintain their current coverage.
Q: If I obtain coverage under PCIP and then obtain group coverage through a new employer, but then lose that coverage, must I go through the six-month waiting period a second time?
A: Yes, if you had but then lost health coverage, you must still meet the requirement to be uninsured for at least the last six months. You also need to meet the criteria for having a pre-existing condition and be a U.S. citizen or an individual legally residing in the United States.
Q: I am unemployed and had COBRA, which just ran out. I applied for private insurance but was denied due to pre-existing conditions, as was my 19-year-old son. Do I have to be uninsured for six months to qualify for the federal plan? My existing state high-risk pool is too expensive. What are our options for obtaining insurance coverage?
A: To qualify for the new PCIP, you need to be without health insurance for at least six months. Meanwhile, to learn about your current options for insurance, contact your State Health Insurance Assistance Program (SHIP). Counselors for SHIP can answer your question about obtaining insurance in your state.
Q: Can a husband and wife enroll in a PCIP if only one has been without insurance for six months or more?
A: PCIP is available only for individuals. Family plans are unavailable in this program. If both you and your wife meet the eligibility requirements, you would each have to apply individually for the program.
Q: Can my children be covered under my PCIP insurance?
A: Coverage is available to only an eligible individual. There are no family plans or premium levels in PCIP.
PCIP Coverage and Services
Q: If I'm eligible for PCIP, when will my coverage start?
A: Enrollment began July 1, 2010, in states where the U.S. Department of Health and Human Services is running the program. Generally, a completed application received on or before the 15th of the month will go into effect on the first day of the next month. A completed application received after the 15th of the month will go into effect on the first day of the following month. Once you are approved and enrolled in PCIP, there is no waiting period to receive covered health services.
Q: What types of health care providers are in the PCIP network?
A: PCIP has provider networks that include a full range of services and specialists.
Q: What benefits are included?
A: Coverage includes doctor visits, hospitalizations and prescription drugs. Enrollees will get better benefits when they use in-network providers. There are no waiting periods, and pre-existing conditions are covered.
Other Options for the Uninsured
Q: I understand that state insurance exchanges will offer coverage for the uninsured in 2014. What about those of us who need insurance now?
A: To learn about your current insurance options, contact your State Health Insurance Assistance Program. SHIP counselors can answer your question about obtaining insurance in your state. You can find your area SHIP office at SHIPtalk.org.
Q: I heard that low-income people would get some help on their premiums starting this year. Is that true? I can no longer afford my premiums, which just increased $80 a month after my income dropped drastically.
A: If you earn less than about $43,000 a year, you will get tax credits or subsidies to help you pay the premiums for insurance you buy through an exchange. But this help won’t be available until the exchanges begin offering insurance in 2014.
For more information about PCIP and the new health care law, go to Healthcare.gov.