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David Sayen: California’s PCIP — Health Insurance for People Who Can’t Get It

The Pre-Existing Condition Insurance Plan is available to children and adults previously denied coverage for medical reasons

If you’ve been turned down for health insurance because of a pre-existing condition, or offered coverage only at an unaffordable price, you may have another option: California’s Pre-Existing Condition Insurance Plan.

David Sayen
David Sayen

The Pre-Existing Condition Insurance Plan, or PCIP, is available to children and adults who’ve been locked out of the health insurance market because they have cancer, heart disease, diabetes, HIV/AIDS, asthma or some other pre-existing medical condition.

With PCIP, you’ll be insured for a wide range of benefits, including primary and specialty physicians’ services, hospital care and prescription drugs.

Like commercial insurance plans, PCIP requires you to pay a monthly premium, a deductible, and some cost-sharing expenses. But you won’t be charged a higher premium because of your medical condition, and your eligibility isn’t based on your income.

When you enroll in PCIP, you’ll have access to a provider network that includes 67,000 physicians, 5,906 pharmacies and 354 hospitals throughout the state.

A visit to the doctor will cost you $25. PCIP also covers emergency and ambulance services, surgery and anesthesia, organ transplants, X-ray and lab services, pregnancy and maternity care, skilled nursing care, home health services, orthotics and prosthetics, durable medical equipment, and inpatient and outpatient mental health, alcohol, and substance abuse care.

PCIP is already changing the lives of Americans who don’t have health coverage and need medical care. James H., who lives in Texas, was diagnosed with brain cancer in 2010. Shortly after his diagnosis, his insurance company rescinded his insurance coverage, claiming that his cancer was a pre-existing condition. James knew that his lack of coverage was a death sentence. Fortunately, he was able to join PCIP in Texas and is now receiving the treatment he needs.

To qualify for PCIP, you must have been denied health insurance within the past 12 months. You also have to live in California and be a U.S. citizen or legal resident. In addition, you must have been uninsured for at least six months before applying for PCIP.

Your premiums will be based on where you live and the amount you would pay if you had no pre-existing condition and were able to purchase individual insurance in the open market.

For example, a Central Valley resident age 50 to 54 would pay $481 per month for PCIP. A San Francisco Bay Area resident age 45 to 49 would pay $377 per month. Someone age 18 or younger living in Del Norte, Humboldt, Siskiyou or Shasta counties would pay $145 monthly.

You’ll pay a 15 percent coinsurance for most in-network services after meeting a $1,500 annual medical deductible. PCIP also has a $500 annual deductible for brand-name drugs. There are no out-of-pocket costs for preventive care, including regular physical exams, cancer screenings, immunizations and well-child care.

As a PCIP subscriber, you’ll pay no more than $2,500 a year out-of-pocket. When you reach this $2,500 cap, PCIP pays all costs for covered services received within the PCIP network for the remainder of the calendar year (although you have to keep paying your monthly premium to stay enrolled.)

And this is important: PCIP has no cap on annual or lifetime benefits.

The Pre-Existing Condition Insurance Plan was created under the Patient Protection and Affordable Care Act. It’s a transitional program until 2014, when all Americans — regardless of health status — will have access to affordable health insurance as the nation shifts to a new marketplace.

For more information, click here or call 877.428.5060 8 a.m. to 8 p.m. Monday through Friday or 8 a.m. to 5 p.m. Saturday.

— David Sayen is the regional administrator for Arizona, California, Hawaii, Nevada and the Pacific Trust Territories for the U.S. Centers for Medicare & Medicaid Services. For answers to Medicare questions 24/7, call 800.MEDICARE.


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