New health plan covers pre-existing conditions
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. You may be eligible for the Pre-Existing Condition Insurance Plan, a new program created under the Affordable Care Act.
California's Pre-Existing Condition Insurance Plan, or PCIP, opened for business last October. This transitional program is available to children and adults who have been locked out of the health insurance market because they have cancer, heart disease, diabetes, HIV/AIDS, asthma, or some other pre-existing condition. In 2014, all Americans - regardless of health status - will have access to affordable health insurance when the nation shifts to a new marketplace.
Under PCIP, you'll be insured for a wide range of benefits including physician's services, hospital care, and prescription drugs. You won't be charged a higher premium because of your medical condition and your eligibility isn't based on your income.
Like standard health insurance plans, you'll be required to pay a monthly premium, a deductible, and some cost-sharing expenses.
Californians enrolled in PCIP have access to a provider network that includes 67,000 physicians, 5,906 pharmacies and 354 hospitals throughout the state.
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 Shortly after his diagnosis, James' insurance company rescinded his insurance coverage, claiming that his cancer was a pre-existing condition.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, applicants must have been either denied health coverage because of a pre-existing condition or offered coverage with unaffordable premiums. Subscribers must also be U.S. citizens or legal residents and have been uninsured for at least six months before applying for PCIP.
Premiums are based on the amount a subscriber would pay if he or she had no pre-existing condition and was able to purchase individual insurance in the open market. For example, a Sonoma County resident aged 45-49 would pay $364 per month for PCIP.
Subscribers 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.
The plan caps subscribers' out-of-pocket expenses at $2,500 each year. When a subscriber reaches this $2,500 maximum, PCIP pays all the costs for covered services received within the PCIP network for the remainder of the calendar year, although subscribers must continue to pay their monthly premiums to remain enrolled. Subscribers pay no out-of-pocket costs for preventive care, including regular physical exams, immunizations, and well-child care.
PCIP has no cap on annual or lifetime benefits.
For more information, visit www.pcip.ca.gov or call 877-428-5060 Monday through Friday from 8 a.m. to 8 p.m., or Saturday from 8 a.m. to 5 p.m.
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David Sayen is Medicare's regional administrator for California.