PCIP California : Pre-Existing Condition Insurance Plan California
What Is The Pre-Existing Condition Insurance Plan?
The California Pre-Existing Insurance Plan (PCIP) was created as part of the Affordable Care Act of 2010, better known as Health Care Reform, to provide health insurance to medically uninsurable people living in California. The PCIP California is funded by the federal government and administered by California.
The benefits provided in state PCIP plans vary considerably from one state to the next because the Federal government set minimum benefit levels and allowed the states to define what benefits would be provided in each state’s plan. The PCIP plan in California is generally a richer benefit plan than those offered in almost all the other states (see below for the benefit detail description).
The PCIP will last until the end of 2013 when the health care reform laws will prevent insurance companies from denying health insurance because of existing medical conditions. At that point, the need for this insurance plan will no longer exist, and everybody in the PCIP will be able to get regular health insurance from any insurance company.
Who Is The Plan Good For?
The PCIP is a plan that few people know about, and that’s a shame because the plan can be a great solution for many situations.
The primary use is for people who have been declined for health insurance coverage by insurance companies, because of pre-existing conditions. It does not matter what the condition was that resulted in the “decline to offer” letter, as the PCIP plan will accept you as long as you meet the eligibility requirements outlined below.
The California PCIP is a great solution to provide Health Insurance for Pregnant Women.
For pregnant mothers-to-be that don’t have health insurance, this plan would be a good solution if you don’t qualify for the MediCAL or AIM programs (see the California Maternity Health Insurance page for more details about these programs). The PCIP provides coverage for your prenatal care and delivery costs, and when compared to all the maternity health insurance plans, the PCIP is the 3rd best maternity health insurance plan.
Who Can Qualify For PCIP?
In order to qualify for the PCIP you need to meet the following requirements:
- Residency in California.
- You are not on COBRA or Cal-COBRA.
- You are not enrolled in Medicare Part A and B.
- You are a U.S. Citizen or U.S. National – or you are legally allowed to be
in the U.S. (you must provide a Social Security Number if you are a U.S. Citizen or U.S. National).
- You have a medical pre-existing condition, documented by ONE of the following:
- A health insurance company denial letter no more than 12 months old
- If not declined for health insurance, then offered an insurance plan that is at a higher premium than the Major Risk Medical Insurance Program (MRMIP) preferred provider organization rate in your area. The offer letter must be dated within the last 12 months. The MRMIP rates are outlined in the MRMIP handbook, and are provided here PCIP MRMIB Premiums for your convenience.
- A letter from a licensed doctor saying that you have a medical condition or illness (or used to have one). Here is a sample letter your doctor can use to create this.
- If you have moved from another state and were on the PCIP plan in that state, then you need a certificate of creditable coverage letter issued by other state, showing that you were on that plan within the last 6 months.
- You have not had health coverage for at least 6 months.
The last item is a key one. You can not have had health insurance in the past 6 months, unless you were on a PCIP plan in another state.
What Are The Plan Benefits?
The California PCIP plan is a rich benefit plan that would cost significantly more if this plan were available in the health insurance marketplace. It is set up like a basic PPO plan with office copayments when you see the doctor, and a deductible that you are required to pay before the PCIP plan begins to pay for any non-copayment services. The overview of the benefits isoutlined below.
California Pre-Existing Condition Insurance Plan (PCIP)
|Type of service||Subscriber Costs||Limitations and Explanations|
|Annual Deductible||$1,500||$3,000||The deductibles for in-network and out-of-network are separate from each other|
|Coinsurance||15%||50%||Coinsurance is based on the Plan Allowance for services provided in-network. For services at out-of-network providers, the coinsurance is 50% of the Plan Allowance plus the additional provider charges.|
|Annual Out-Of-Pocket Maximum||$2,500||N/A||Includes payments towards in-network medical, brand name prescription drug deductibles, and any copayments and coinsurance. Once a Subscriber reaches the annual maximum, the PCIP pays 100% of all in-network covered services for the rest of the calendar year. There’s no out-of-pocket maximum for out-of-network services.|
|Preventive Care||0%||50%*||Preventive services include: routine physical examination and related laboratory services, routine gynecological examination, routine mammogram, routine Pap smear, Human Papillomavirus (HPV) screening, ovarian and cervical cancer screening, cytology examinations, family planning counseling services, health education services, prostate screening, routine colonoscopies, hearing and vision examinations for children, newborn blood tests, sexually transmitted infections tests, Human Immunodeficiency Virus (HIV) testing, well baby and well child care, certain immunizations for adults and children, and disease management programs. In-network preventive care services are free. For preventive care services from an out-of-network provider, you will pay any out-of-network deductible that you have not met, along with 50% of the Plan Allowance, and any additional provider charges.|
|Doctor Office Visit||$25||50%*||$25 copay for office visits in-network. In-network office visits aren’t subject to the annual deductible, but count towards the annual out-of-pocket maximum|
|Doctor Inpatient Visit||15%*||50%*||Doctor visits while you’re in a hospital.|
|Inpatient Hospital Services||15%*||50%*||You must contact PCIP within 48 hours of an emergency admission because Prior Authorization is required.|
|Inpatient Acute Rehabilitation||15%*||50%*||Prior authorization required.|
|Outpatient Hospital Services||15%*||50%*||Prior authorization required for some surgical procedures.|
|Emergency Services||15%*||15%*||Limited to treatment of a medical emergency. The in-network deductible and coinsurance apply to emergency services received from an in-network or out-of-network provider.|
|Ambulance||15%*||15%*||Limited to a transport during a medical emergency. The in-network deductible, coinsurance, and out-of-pocket maximum apply to emergency services received from an in-network or out-of-network provider.|
|Surgery & Anesthesia||15%*||50%*||Prior authorization required for some surgical procedures.|
|Organ Transplants||15%*||50%*||Some transplants must be performed in a Center of Expertise to receive the in-network benefit. Prior authorization required.|
|Blood & Blood Products||15%*||50%*|
|Cancer Clinical Trials||15%*||50%*||Prior authorization required.|
|Outpatient Diagnostic X-ray & Laboratory Services||15%*||50%*||Prior authorization required for some radiological procedures.|
|Family Planning Services||15%*||50%*||Certain birth control products covered under the prescription drug
|Pregnancy and Maternity Care||15%*||50%*||Includes prenatal care, delivery services and postpartum care.|
|Occupational Therapy||15%*||50%*||Prior authorization required.|
|Speech Therapy||15%*||50%*||Prior authorization required.|
|Skilled Nursing Facility||15%*||50%*||If determined to be a cost effective, medically appropriate alternative plan of treatment, then services are available. Prior authorization required.|
|Home Health Care||15%*||50%*||Prior authorization required.|
|Hospice Care||15%*||50%*||Prior authorization required.|
|Durable Medical Equipment||15%*||50%*||Prior authorization required for some durable medical equipment.|
|Orthotics and Prosthetics||15%*||50%*|
|Inpatient Mental Health Care Services||15%*||50%*||Inpatient treatment of Serious Emotional Disturbances (SED) of a child and Severe Mental Illness (SMI) has no day limits. All other inpatient mental health care is limited to 10 days each calendar year. Prior authorization required.|
|Outpatient Mental Health Care Services||15%*||50%*||Outpatient treatment of Serious Emotional Disturbances (SED) of a child and Severe Mental Illness (SMI) has no visit limits. All other outpatient mental health care is limited to 15 visits each calendar year.|
|Inpatient Alcohol and Substance Abuse Treatment||15%*||50%*||Services are covered to remove toxic substances from the system. Prior authorization required.|
|Outpatient Alcohol and Substance Abuse Treatment||15%*||50%*||Limited to 20 visits each calendar year. Extra visits may be possible with prior authorization.|
* Annual deductible applies.
Pre-Existing Condition Insurance Plan California (PCIP)
|The CVS Caremark Drug Plan allows you access to retail pharmacies and provides mail and on-line prescription drug services.
Refer to “Section 5. How to Get Prescription Drugs” of the Summary Plan Description Booklet to read more about the pharmacy benefit.
|Prescription Drug||Subscriber Costs||Limitations and Explanations|
|Generic Drug Co-pay||$5||$5||50%**||No annual deductible.|
|Annual Brand Name Drug Deductible||$500||$500||There are separate deductibles for in-network and out-of-network pharmacies.|
|Preferred Brand Name Drug Copayment||$15*||$15*||50%**||In-network: After you have met the annual brand name prescription drug deductible, if you choose a brand name drug for which a generic drug exists, you will pay the generic copayment plus the difference between the cost of the brand name drug and the cost of the generic drug, unless your doctor indicates medical necessity by writing “do not substitute” or “dispense as written” on the prescription order or by requesting and receiving prior authorization from PCIP California.
Out-of-network: See note below.
|Non-Preferred Brand Name Drug Copayment||$30*||$30*||50%**|
|Specialty Drugs||N/A||$30*||N/A||Specialty drugs require prior authorization..|
|Maximum Supply||30 days||90 days||30 days|
* The annual brand name prescription drug deductible applies.
** Subscribers pay the full cost of all drugs up front at an out-of-network pharmacy. The California PCIP reimburses the Subscriber 50% of the charges for the generic or brand name prescription drug after the Subscriber submits a claim and, for brand name drugs, has satisfied the out-of-network brand name drug deductible.
For a more detailed look at the benefits in the PCIP plan you can look at the Summary Plan Description.
What Does The Pre-Existing Condition Insurance Plan Cost In California?
The PCIP plan is a middle of the road plan from a pricing standpoint, and a BMW 325 from a features standpoint. In other words it provides higher benefit levels at a medium price point. The pricing for the California PCIP plan is contained in the PCIP MRMIB Premiums document.
As an example of this, if we look at a pricing example for a 30 year old woman in San Diego county, we see that the PCIP California plan costs $214, and if we look at other individual health insurance plans that offer similar benefits, we find that the pricing for the Anthem Blue Cross Premier 1500 plan costs $177 (the Blue Cross plan has slightly lower benefit levels than the PCIP), and the pricing for the Blue Shield Essential 1750 plan is $246 (the Essential plan has slightly better benefit levels than the PCIP).
No matter how you look at it, the PCIP is a good plan at a reasonable price!
How Do You Enroll?
To enroll in the PCIP, you need to fill out the PCIP California Application, collect the necessary support documentation, and mail everything along with a check for the first month’s premium to:
Pre-Existing Condition Insurance Plan
P.O. Box 537032
Sacramento, CA 95853-7032
OR, you can mail them to our office and we will submit your application, and follow up with the state for you. Our office address is:
SPF Insurance Services
17927 Sencillo Ct
San Diego, CA 92128
The California PCIP application is used for the PCIP and the Major Risk Medical Insurance Programs (MRMIP). This 4 page application needs to be filled out carefully because any errors or unanswered questions will delay the processing of the application. On QUESTION #2 be sure to check the box for PCIP! Remember to sign the application in SECTION 8 and 9.
Use this PCIP Checklist & Declarations to make sure you include all the required documents for your application package. You’ll need to provide proof of citizenship, and provide proof that you can’t get individual health coverage by showing a denial letter from an insurance company, a letter from a doctor stating that you have a medical condition, an offer letter from an individual health insurance company with premium costs higher than the MRMIP rates, or a certificate of creditable coverage from a PCIP plan in another state (if you recently moved to California).
Be sure your check is made payable to the “Managed Risk Medical Insurance Board (MRMIB)”.
Call our office if you have any questions or need help filling out the application package.
Pre-Existing Condition Insurance Plan California (PCIP California): When Will My Coverage Start?
The PCIP California program uses the 10th of each month as the cutoff date to get an effective start date at the beginning of the next month. Any complete applications (including the required support documents) received by the 10th, if approved, will get a start date of the beginning of the next month. For example, an application received on Aug 9th, and approved, will get a Sept 1st start date, or effective date. An application received on Aug 11th, and approved, will get an Oct 1st effective date.
Can I Still See My Regular Doctor?
The California PCIP uses a network of physicians and hospitals located throughout California. To determine if your doctor is in the network, use this link to search the PCIP PPO Network. The PCIP program uses the First Health Network. Within San Diego county there are almost 7000 doctors in the First Health Network.
For doctors within the PCIP PPO Network you will pay the In-Network costs. If the doctor you go to is not in the PCIP PPO Network, then you will pay the out-Of-Network costs. You will save money by using In-Network physicians and facilities.
If I get a job at a company that offers health benefits, how do I cancel my PCIP coverage?
The best way to cancel your PCIP coverage is to send a letter with your name, ID number, and the date you want PCIP to stop, to the PCIP office. You will probably know at least 1 month in advance that you are enrolling in a group plan, so a good idea is to send your letter along with your last month’s premium.
The second way to cancel your PCIP coverage is to simply not pay your monthly premium. If your payment is not received by the 15th of the month, you will be disenrolled from the program. If you are disenrolled or leave PCIP, you must wait 6 months before you can qualify to enroll again.
How do I pay my California PCIP premiums?
After you are signed up for the program, you will receive monthly bills. You must pay this bill by the 15th of the month. You can pay the bill by using a personal check, a money order, or a cashier’s check. Follow the instructions on the bill to ensure your payment is properly credited to your account.
You can also pay by submitting a Electronic Funds Transfer (EFT) payment authorization form. The instructions to set up an EFT payment are on the back of your monthly bill, or you can download the form from the California PCIP website at http://www.pcip.ca.gov/Publications/PCIP_FM_69_EN.pdf. After you submit the EFT form, it can take 6-8 weeks for the EFT to begin withdrawing your monthly payments. You will need to continue making monthly payments yourself, until you see that the EFT payments are taking place. EFT payments will happen on or around the 4th of each month.
I’m Pregnant Without Insurance What Can I Do?
You’re not alone. In the US, over 22% of all women in their child-bearing years are un-insured, so the number of women who are pregnant without health insurance is growing.
Here’s what you should do:
- Call your local state Medicaid office to see if you qualify for coverage under their programs (in California this is the MediCAL office)
- if you don’t qualify for MediCAL, then contact the California state AIM (Aid for Infants and Mothers) program office to determine if you can get into the AIM program (for more information about both the MediCAL and AIM programs, see the article “California Maternity Health Insurance for the Pregnant: Is it Possible?” on the California Maternity Health Insurance page.
- if neither of those options work, then apply for the California Pre-Existing Condition Insurance Plan discussed on this page.
For all women who are pregnant with no insurance in California, don’t despair. There is a pregnancy health insurance plan you can get. If you are uncertain about if you can qualify or how to proceed, then call our offices at 858-613-3628 and we’ll be happy to lead you through the steps.
How can I find health insurance for pregnant women?
That’s a great question! There really is only one insurance plan for pregnant women, because the other options provide coverage for maternity care, but are not actually maternity insurance plans.
Medicaid is a Federal and State program that provides free maternity coverage that is paid for by the government. The AIM program provides low-cost pregnancy coverage, but again, the benefits are paid for by the government. In both cases the government pays for the benefits without regard to whether they have the money to pay for the program or not.
The California PCIP has been funded by the government to set up a reserve pool of money. As people sign up for PCIP and pay premiums the funds in the reserve pool grow. As people receive medical services and the payments for those services happen, money is taken out of the reserve pool. This is how insurance companies work (a simple model of course).
So the only true health insurance plan for pregnant women is the PCIP California.
Lowest California Medical Insurance Prices Anywhere
The California Department of Insurance regulates California medical insurance premiums. It doesn’t matter if you go directly to the carrier or apply with SPF, you will get the same price wherever you go. Working with SPF you don’t have to visit multiple medical insurance websites, we have all the information you need right here, and can help you simplify the process to make it fast and easy.
So go ahead and get a quote today!