Frequently asked questions
What is the Pre-Existing Condition Insurance Plan?
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
has made health insurance available to people who have been denied coverage by private insurance companies because of a pre-existing condition. PCIP is a transitional program until 2014.
Why is PCIP enrollment being suspended?
PCIP is a temporary program for those locked out of the current insurance marketplace. The program has a limited amount of funding from Congress.
Based on program experience and trends since the start of the program, PCIP enrollees have serious and expensive illnesses with significant and immediate
health care needs. More information can be found in the Annual Report on the Implementation and Operation of the PCIP Program at
http://www.cciio.cms.gov/resources/files/pcip_annual_report_01312013.pdf.
This suspension will help ensure that funds are available through 2013 to continuously cover people currently enrolled in PCIP.
The Health Insurance Marketplace
Starting next year, the Affordable Care Act guarantees that all Americans – regardless of their health status or pre-existing conditions – will finally have access to quality,
affordable coverage. People will be able to apply for affordable health insurance coverage choices in Health Insurance Marketplaces when open enrollment begins on October 1. The
Health Insurance Marketplace will offer a choice of quality, affordable health plans. Coverage begins on January 1, 2014. Visit www.healthcare.gov to learn more about the Marketplace.
How is the PCIP funded?
The program is funded entirely by the federal government. The health reform law allocated $5 billion for the program nationwide. Funding will go toward health care claims and administrative costs that exceed the premiums collected for PCIP.
What benefits are included for enrollees?
The same benefits will be provided in all states in the federally administered PCIP. In these states, enrollees can access a health plan with both a deductible and an annual maximum amount of out-of-pocket expense. That means that they will be responsible for health care costs up to a specified dollar amount, then PCIP will begin paying benefits. After the out-of-pocket maximum has been met, the plan pays the expenses in full.
Coverage includes preventive care, doctor visits, hospitalizations and prescription drugs. Enrollees will get better benefits when they use in-network providers. There are no waiting periods. Pre-existing conditions are covered.
For more details, click on PCIP benefits.
What do current enrollees pay for premiums?
Premiums will vary depending on the state where you live. To see rate information for the PCIP states in the federally administered PCIP, click on premium rates.
What doctors and hospitals are included in the plan?
Enrollees will have access to the PCIP network of providers. Click to search online for providers.
The availability and unavailability of membership in the Pre-Existing Condition Insurance Plan (PCIP) and any benefits through the plan are at all times subject to federal law, regulations, and the contract between the PCIP Administrator and the United States Department of Health and Human Services, and is dependent on continued availability of federal funding. Any authorizations for treatment or service given by the PCIP Administrator simply confirms that the treatment or service is a covered benefit under the Plan and will be reimbursed, if funds are available, in an amount determined under the terms of the Plan. Actual reimbursement by the Plan for such treatment or service can only be made from the PCIP fund established by Congress and no payment can be made to any member or provider, even if prior authorization for the treatment or service was given, if federally-appropriated PCIP funds are exhausted.
