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Pre-Existing Condition Insurance Plan PCIP 101

Pre-Existing Condition Insurance Plan PCIP 101. Key Learning Points. By the end of this course we will have discussed: Affordable Care Act of 2010 Summary Pre-Existing Condition Insurance Plan (PCIP) Major Risk Medical Insurance Program (MRMIP) Eligibility Criteria

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Pre-Existing Condition Insurance Plan PCIP 101

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  1. Pre-Existing Condition Insurance PlanPCIP 101

  2. Key Learning Points • By the end of this course we will have discussed: • Affordable Care Act of 2010 Summary • Pre-Existing Condition Insurance Plan (PCIP) • Major Risk Medical Insurance Program (MRMIP) • Eligibility Criteria • Other PCIP Eligibility Rules • PCIP Application Requirements • Premium Rates • Payment Information • PCIP Benefits Overview and Providers Information • Application Completion

  3. Affordable Care Act of 2010 Summary • As a result of the federal Affordable Care Act of 2010, California has a contract with the Federal Department of Health and Human Services to establish and administer a federally-funded high risk pool program to provide health coverage for eligible individuals • The federally-funded program is called the California Pre-Existing Condition Insurance Plan (PCIP)

  4. PCIP & MRMIP Overview • Major Risk Medical Insurance Program(MRMIP) A separate program that provides health insurance for Californians unable to obtain coverage in the individual health insurance market because of their pre-existing condition Funded by the State • Administered by the Managed Risk Medical Insurance Board (MRMIB) Pre-Existing Condition Insurance Plan (PCIP) A temporary high risk pool program designed to provide coverage to uninsured individuals who have been denied health insurance OR been offered only unaffordable options because of a pre-existing condition Funded by the Federal Government Administered by the Managed Risk Medical Insurance Board (MRMIB) - managed at state level

  5. PCIP Eligibility Requirements • Resident of California • Must be a U.S. Citizen, National, or lawfully present in the U.S. • Social Security Number (required for U.S. Citizen/National) • The applicant must not have had any creditable health coverage in the previous 6 continuous months • Must provide proof of a pre-existing condition as shown by: • Denial of individual coverage by an insurance carrier dated within the last 12 months: OR • An offer of coverage with premium level above the MRMIP Preferred Provider Organization (PPO) rate within the last 12 months: OR • A letter or form dated and signed within the last 12 months, from a doctor, physician assistant, or nurse practitioner (who is licensed to practice), stating the individual has or used to have a medical condition, disability, or illness • If an applicant has moved from another state and was enrolled in PCIP in their former state, they may be automatically eligible for California’s PCIP. They must apply for PCIP within six (6) months of disenrollment from their former state’s PCIP and provide validation from the other state’s program. • Dependent coverage is NOT available – each individual must apply for themselves

  6. Creditable Coverage • Individual or job-based health plan, including COBRA or Cal-COBRA • Medicare (Part A and/or Part B) • Medicaid • Medi-Cal • Children’s Health Insurance Program (CHIP)- Healthy Families • A state high risk pool • TRICARE- military health insurance

  7. Creditable Coverage (continued) • Health coverage provided by a public health plan established by the U.S. government such as: • Coverage provided to Veterans enrolled in VA health care, or a foreign country • Federal Employees (or retirees) Health Benefits Plan, including Temporary Continuation of Coverage (TCC) • Health benefit plan provided to Peace Corps workers • Health benefit plan provided to Peace Corps workers • Services provided by the Indian Health Service or by a Tribal organization for treating medical conditions

  8. Other PCIP Eligibility Issues • If applicant has moved from another state and was enrolled in the PCIP in the other state, the applicant may be automatically eligible for California PCIP. The applicant must apply for the PCIP within six (6) months of disenrollment from the other state’s PCIP and provide validation from the other state’s PCIP • If the applicant has moved from another state and was enrolled in PCIP in the other state, the applicant must not have had other non-PCIP coverage since disenrollment from the other state's PCIP in order to qualify for California’s PCIP • If the applicant has qualified for the MRMIP and has not started coverage and is PCIP eligible, applicant may provide a Withdrawal Letter from the MRMIP to be enrolled in PCIP

  9. MRMIP Eligibility Requirements • Resident of California • Will not be considered California resident if absent for more than 210 consecutive days • SSN is NOT required • Must not be eligible for: • Medicare (except for end stage renal disease) • COBRA or Cal-COBRA benefits • Must provide proof of: • Denial of individual coverage by an insurance carrier dated within the last 12 months OR • An offer of coverage with premium level above the first plan choice rate within the last 12 months OR • Termination by an insurance carrier for reasons other than fraud or non-payment of premiums, ineligibility within the last 12 months • Dependent coverage is available

  10. Who Can Apply? • Person 18 years old and above • Person under the age of 18 years may apply for themselves, if emancipated • The following persons may apply on behalf of an individual under the age of 18 • Parents (natural or adoptive) • Legal Guardians • Step-parents • Foster Parents • Caretaker Relatives

  11. How to Apply • To apply for PCIP, applicants must complete the four-page PCIP/MRMIPApplication • Applications can be obtained by: • Downloading from pcip.ca.gov • Calling customer service at 1-877-428-5060 and request applications to be mailed • Submit an e-mail request to PCIP@maximus.com, including • First and Last Name • Address • Telephone number • E-mail Address

  12. PCIP/MRMIP Application Requirements • The PCIP/MRMIP Application requires the following information: • First and Last Name • Date of Birth • Address • Social Security Number (required for U.S. Citizens/Nationals for PCIP Only) • Signature • Declaration of no other creditable coverage in the past 6 months • First full month’s premium payment • Valid proof of Citizenship/Immigration documents • Proof of a pre-existing condition

  13. Authorized Representatives (AR) • An Authorized Representative (AR) is any person who has been designated, in writing, by the applicant to act on their behalf. • PCIP requires a separate complete Permission to Share Information Form for each person the applicant designates as an AR. This includes agents/brokers, CAAs, spouses, and others the applicant may designate. • A complete Permission to Share Form includes: • Applicant's Signature and Date are required on each Permission to Share Information Form. • Agents/Brokers’ California license number required, if applicable. • EE/CAA number required, if applicable • PCIP must receive the signed complete Permission to Share Information Form before PCIP can release any information to the AR.

  14. Authorized Representatives (AR) (continued) • The signed Permission to Share Information Form allows PCIP to give the designated AR, information over the telephone about the applicant’s initial application status. • PCIP will only release information on the outcome or resolution of a specific issue and is not for ongoing case management. • For ongoing assistance to the applicant, PCIP requires a new signed and complete Permission to Share Information Form (i.e., Non-payment Research requests, Appeals). • The Permission to Share Information Form is located on the PCIP/MRMIP Application. Additional forms can be downloaded from the PCIP website, www.pcip.ca.gov or requested from the PCIP Customer Service toll-free line, 1-877-428-5060.

  15. Permission to Share PCIP/MRMIP Information Permission to Share PCIP Information Form must include: • Applicant’s name, and Member Number • Insurance Agent/Broker Name • and CA license number • EE/CAA Name and number • What type of information • may be shared • Applicants Signature and Date Permission to Share PCIP Information Form can be downloaded from the PCIP website at www.pcip.ca.gov

  16. Insurance Agent/Broker and Enrollment Entity (EE) Application Assistance Payment Information • Insurance agents/brokers and EEs may receive a payment for each person they assist who is successfully enrolled into PCIP • To qualify for the application assistance payment, the Insurance Agent/Broker–EE/CAA section of the PCIP/MRMIP application must be filled out completely and legibly with the following information: • Agent/Broker Name or CAA Name • Agent/Broker Signature or CAA Signature • Agent/Broker CA license number or EE and CAA Number • Tax ID/SSN (Agent/Broker Only) • Full address (street address, city, state, and zip code) required for both Agent/Broker and CAA • Phone number required for both Agent/Broker and CAA • Payments are made in arrears each month based on the subscriber’s successful enrollment into PCIP

  17. Insurance Agent/Broker and Enrollment Entity (EE) Information (continued) • There is no contract or registration required in order to sell the PCIP product • There is no renewal process for PCIP, no renewal payment to EEs or insurance agents/brokers • If an agent/broker or EE would like to follow the application process the Permission to Share PCIP Information section of the application must be filled out • In addition, a separate Permission to Share PCIP Information Form must be filled out and signed by the applicant for each party that the applicant wishes PCIP to share information • Any further questions call PCIP’s toll-free line at 1-877-428-5060

  18. Required Documents

  19. Citizenship/Immigration Documents • All eligible U.S. Citizens and Nationals must provide acceptable citizenship documentation to be enrolled in PCIP. • The acceptable documentation for a Citizen/National of the United States is listed below: • U.S. Passport (even if expired) • Birth Certificate (including hospital birth verification) • Naturalization/Citizenship Certificate • American Indian/Alaskan Native Documentation • All lawfully residing individuals’ documentation must be valid/unexpired at the time of enrollment. • Permanent Residence • Conditional Entry • Asylum/Refugee, etc. • If documentation expires, valid/unexpired documentation will be required to remain in PCIP.

  20. Proof of Pre-Existing Condition • The applicant must provide one of the following as proof of their pre-existing condition: • Individual coverage Denial Letter or e-mail from an insurance company that is dated within the past 12 months (i.e. 365 days) from the date the application is received • A letter or email offering higher rates than the MRMIP PPO rates dated within the past 12 months from the date the application is received • A letter or form signed and dated within the last 12 months, from a doctor, physician assistant, or nurse practitioner (who is licensed to practice), stating the individual has or used to have a medical condition, disability, or illness

  21. Proof of Pre-Existing Condition(continued) • If an applicant is currently enrolled in creditable health coverage and receives a letter from their health plan stating that their premium will be increasing to an amount above the MRMIP PPO rates, they are not PCIP eligible • If an applicant has moved from another state and was enrolled in PCIP in their former state, they may be automatically eligible for California’s PCIP. They must apply for PCIP within six (6) months of disenrollment from their former state’s PCIP and provide validation from the other state’s program

  22. Letter/Form/E-mail Requirements • To be considered valid proof, the letter, form or e-mail must meet the following criteria information: • Denial Letter/E-mail • Dated within the last 12 months • Name of person being denied • Must specify that health coverage was denied, but reason is not required • Sent by health insurance plan carrier not an agent or broker • High Premium Offer Letter/E-mail • Must identify the amount being offered • Premium amount must be higher than the MRMIP PPO Rates • Dated within the last 12 months • Name of person being offered the high premium • Sent by health insurance plan carrier not an agent or broker • Physician’s Letter/Form • From a licensed doctor, physician assistant, or nurse practitioner, which includes the license number • Signed and dated within the last 12 months • Stating that the individual has or used to have a medical condition, disability, or illness

  23. Invalid Denial Letters • The letters listed below are NOT acceptable as proof: • Letters from Medi-Cal are NOT acceptable proof of pre-existing condition • A letter stating that the applicant is denied due to currently enrolled in Medi-Cal • A letter from an insurance company stating that the application was deferred because the insurance company could not request medical information • Forms completed by Insurance Agents/Brokers requesting coverage from insurance carrier

  24. So, What Happens Next?

  25. Application Process • Complete applications will be processed within 10 calendar days and PCIP will determine one of the following: • Applicant is eligible for PCIP or; potentially eligible for MRMIP • Applicant is denied for PCIP and/or potentially not eligible for MRMIP • Application has Missing Information (MI)

  26. Complete Application Process • If determined eligible, subscribers will be eligible for continuous enrollment through the life of the program • If the application isCompleteby the 10th of the month and determined eligible, the subscriber will have an effective date of the 1st of the following month • If the application is Completeafter the 10th of the month and determined eligible, the subscriber will have an effective date of the 1st of the second month January 1st 10th February 1st Complete application received and eligible Effective Date February 1st 10th March 1st 11th January 1st Effective Date Complete application received and eligible

  27. What happens when the applicant is determined Eligible? • When an applicant is determined eligible the following will occur • Welcome Letter will be sent • Welcome Call will be made • Subscriber will receive a Benefits Card, a Summary of Benefits and a Summary Plan Description booklet

  28. Incomplete Applications • If an application is determined incomplete: • A Missing Information (MI) letter will be sent • A phone call will be made • Applicant will have 40 calendar days from the application receipt date to submit the Missing Information or the applicant will be denied • Denial letter will be sent • If the initial premium payment was sent, payment will be refunded within 6 to 8 weeks from denial date • Upon denial, a new application will be requiredif applicant is still interested in enrolling in the program

  29. Forwarding Applications to MRMIP • Complete PCIP/MRMIP applications will be forwarded to MRMIP if any of the following occurs: • Applicant is screened eligible for MRMIP • Request to be enrolled in MRMIP • Denial of coverage for the PCIP

  30. Premiums and Payment Methods

  31. PCIP and MRMIP Monthly Premium Rates • Premium amounts will vary based upon subscriber’s age and region • Please visit the PCIP website www.pcip.ca.gov and/or handbook for the most accurate premium rates

  32. Premium Facts • Premiums will be calculated using the subscriber’s age and region at the time the application was received • Premiums may change upon a residential change into another region OR if a subscriber ages into another age range bracket If there is a premium change as a result of: • Address change • Once notification of an address change is received from the subscriber, PCIP will notify the subscriber if a premium change will occur • New age bracket • Effective date of the new premium will be the 1st of the month following the birth date • Letter notifications will be sent to subscribers prior to new premium effective date

  33. Payment Information • A first full month’s premium is required when submitting the application • Monthly payments are due on the 15th of every month for the following month’s coverage • i.e. coverage 12/1- 12/31, December’s premium is due by 11/15/10 • If payment is not received by the due date: • Non-Payment Letter will be mailed • Premium Reminder Call will be made • If FULL payment is not received, subscriber will be disenrolled and must wait 6 months to re-apply for PCIP coverage Note: Payments may be ‘overnighted’ to our office at: PCIP, 625 Coolidge Drive Suite 100, Folsom, CA 95630

  34. Payment Methods • Payments can be made to PCIP by: • Personal Check • Money Order • Cashier’s Check • Electronic Funds Transfer (EFT) • To enroll in EFT, the subscriber must submit: • Complete EFT Authorization form • Voided Check/Withdrawal Slip • Funds for current premium will be withdrawn from the subscriber’s bank account on the 4th of each month and posted on the 5th • Non-Sufficient Funds (NSF) must be paid by money order or cashier’s check for NSF including following month’s premium Note: (1) PCIP does NOT offer payment discounts (2) Any overpayment will be credited toward future payments

  35. PCIP Medical Benefits The Summary Plan Description (SPD) booklet summarizes the benefits, policies and coverage under PCIP. This document can be viewed and downloaded from the PCIP website at www.pcip.ca.gov

  36. Medical Benefits (continued)

  37. Medical Benefits (continued)

  38. Medical Benefits (end)

  39. Provider Search To find a PCIP PPO Network Provider • Go to www.pcip.ca.gov under the Providers Tab to search for a Provider in your area:

  40. Prescription Drug Benefits

  41. Additional Resources • The PCIP website is a great tool that provides useful information such as: • Cost of the program • Health Care providers • Services Covered • Download PCIP forms • Claim status, PCIP Benefits, and disenrollments • Important resources for insurance agents/brokers, EEs/CAAs health-related organizations and community-based organizations

  42. PCIP/MRMIP Application

  43. PCIP/MRMIP Enrollment Application Checklist • The PCIP/MRMIP Enrollment Application Checklist provides: • Instructions on filling out the application • List of required documentation • P.O. Box - all applications should be sent to PCIP P.O. Box to be screened to appropriate program • Reminder for Insurance Agents/Brokers and CAAs to complete bottom section of the application to request payment • Reminder to include payment for one month’s premium for chosen program

  44. Worksheet: Find Out Which Program Is Right For You

  45. PCIP Is Generally The Best Health Coverage For All Who Qualify!

  46. Application Questions 1-3 Question 1: • Identify if this is a NEW Enrollment or Adding a Dependent • Applicant’s First and Last Name • Mailing address • Phone Number • Date of Birth • Identify if applicant is a California resident • Identify if applicant is a US Citizen or US National • Optional Household Information Question 2: • If the applicant qualifies for both PCIP and MRMIP – identify program preference • If no choice is made and the applicant qualifies for both programs- they will be enrolled in PCIP Question 3: • Tell us how you learned about PCIP or MRMIP

  47. Application Question 4 Information for MRMIP Coverage Question 4: • Enter Choice of Health Plan • Identify if applicant was covered by a similar MRMIP program in another state within the last 12 months • Is applicant applying for deferred enrollment? • If Yes, provide current insurance company, health plan or health program • Date coverage began and when it will end • Reason for termination • Has applicant met requirements to avoid all (or part) of MRMIP exclusion/waiting period? • If Yes, include name of prior insurance company, health plan, or health program • Date coverage started • Date coverage will end

  48. Question 5 Information for MRMIP Coverage Family Information • List family members to be enrolled • Identify relationship and marital status • If dependent is over the age of 23, include a doctor’s note stating that the dependent may not work due to a continuous physical or mental disability that started before age 23. The dependent child cannot be married • Identify if disable dependent is receiving Medicare benefits • Identify if any dependents have met the requirements to avoid all (or part) of the exclusion/waiting period PCIP does not provide coverage for dependents. Each person interested in PCIP must qualify and complete a separate application.

  49. Question 6 Recent Health Insurance • Has the applicant received a denial letter from a health insurance company within the past 12 months? If yes, provide a copy of the denial letter • For PCIP and MRMIP, has the applicant received an offer of individual (not group) coverage at higher rates than the MRMIP PPO product? Or, at higher rates than your selected MRMIP health plan? If yes, provide a copy of the offer letter • For MRMIP – has the applicant been involuntary terminated from health insurance coverage for reasons other than fraud or nonpayment of premium? If yes, provide a copy of the termination letter • For PCIP – has the applicant received a letter from a doctor, physician assistant, or nurse practitioner (who is licensed to practice), stating the individual has or use to have a medical condition, disability or illness within the past 12 months? If yes, provide a copy of the provider letter

  50. Question 6Recent Health Insurance (continued) • Identify what health insurance the applicant has had – (if any) within the past 6 months • If applicant has had health insurance within the past 6 months, identify why the coverage ended. • Has an employer, insurance company or insurance Agent/Broker discouraged the applicant from getting health insurance coverage that he/she was qualified for? If yes, include contact information below

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