Simply stated health care

The elimination of exclusions for pre-existing health conditions was one of the most heralded provisions of the Patient Protection and Affordability Care Act.

The U.S. Department of Health and Human Services (HHS) got a step closer to enacting this provision on July 30, 2010 with the release of the interim final regulations on the Pre-existing Condition Insurance Plan (PCIP) program.

Background

As with many of the provisions of the health reform law, enforcement of the pre-existing provision occurs in stages.

Here are some of the most significant stages.

• Temporary High Risk Insurance Pool – HHS establishes a temporary high risk health insurance pool program, providing affordable insurance to uninsured individuals with pre-existing health conditions- The interim regulations initiate implementation of this requirement.
• Prohibit Pre-existing Condition Exclusions for Children- the health reform law bans exclusions on pre-existing health conditions for children – effective with health plans starting on or after September 23, 2010.
  
• Prohibit Pre-existing Condition Exclusions for All- the health reform law bans exclusions on pre-existing health conditions for all health plans – effective in 2014.

The PCIP is a temporary band-aid until the full enactment in 2014 of the provisions for pre-existing health conditions.

What the PCIP Provides

The PCIP provides health insurance coverage to uninsured individuals with pre-existing health conditions, who are unable to secure coverage because of that condition.

Eligibility

The following are some of the rules for eligibility:

• Individual must be a U.S. citizen
• Individual has a pre-existing health condition
• Individual had no health insurance or public health coverage for at least six months

Pre-existing Criteria

The following is the criteria used by the PCIP program in defining pre-existing health conditon:

• Denial of Coverage – Documentation from an insurer of denial for coverage, based on individual’s health status
• Offer for Partial Coverage – Documentation from an insurer for limited coverage, excluding coverage of benefits for treatment of pre-existing health condition
• Evidence of Health Condition – Documentation supporting existence of health condition specified by the state and approved by HHS

Of course, there is the proverbial “other criteria” as defined by the PCIP program and approved by HHS.

What PCIP Means for State High-Risk Pools

Currently, there are 35 states with existing high-risk pools. Those programs will continue as a separate operation from the PCIP program.

The PCIP program has similar benefits, but also some differences from the state high-risk pools.

One significant difference is the PCIP without any benefit limitations on pre-existing health conditions or waiting period.  Most of the state programs contain provisions limiting benefits or establishing a waiting perior for pre-existing health conditions.

No Dumping Allowed

To protect individuals from group health plans dumping high-risk individuals from their plans, the PCIP program must establish procedures for identifying and reporting that activity.

Suspected health plans may be responsible for expenses incurred by the PCIP program, as well as receiving some form of enforcement, from HHS.

More Information

Individuals can obtain more information at the new HealthCare.gov website at the section titled, New Pre-Existing Condition Insurance Plan (PCIP).

If you have other information to share, please do so in comments.

i-Stock Photo Credit: mstahlphoto

Notice of Disclaimer –Cathy Miller is not an attorney and cannot provide legal advice. The information provided is for your general background only, and is not intended to constitute legal advice as to your specific circumstances. We recommend you review legislation with legal counsel.

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