“The comprehensive plan covers primary and specialty care, hospital stays, skilled nursing care, home health care, and prescription drugs. And there’s no waiting period for new enrollees.”
before obtaining coverage under PCIP. Now, patients can submit a letter from a physician, physician assistant, or nurse practitioner dated within the preceding 12 months stating that they have or had a medical condition, disability, or illness, or they can submit proof that they had been offered a health insurance policy with a rider excluding coverage for their preexisting condition. The letter must include the patient’s name and medical condition, disability, or illness, and the name, license number, state of licensure, and signature of the physician, physician assistant, or nurse practitioner. Richard Popper, director of the Office of Insurance Programs at CMS’s Center for Consumer Information and Insurance Oversight, says there is no specific list of conditions that a person must have to be eligible for PCIP, but some of the condi- tions that could qualify include cancer, heart disease, diabetes, and asthma. “A person must simply submit docu- mentation that she or he has or has had a medical condition, disability, or illness,” Mr. Popper said.
PCIP and other sources, is trying to raise awareness of the program and get the word out to physicians across the state that they can help their patients with preexisting conditions gain coverage. “Physicians now have the opportunity to help patients with pre-existing condi- tions obtain affordable and comprehen- sive health coverage,” Aelia Khan, CHAP director, said in a letter in June to at- tendees of Texas Medical Association’s TexMed 2011. Recent changes mean adults and children can now submit a letter from their doctor as proof of a pre- existing condition, Ms. Khan says.
Overcoming denial ACA created PCIP as a bridge to help people with preexisting conditions get coverage until 2014, when all group insurance plans and all new individual insurance plans will be required to cover preexisting conditions.
The federal Government Employee Health Association runs PCIP in Texas and 19 other states. Other states chose to run the program themselves. In a recent opinion article, Renard L.
40 TEXAS MEDICINE October 2011
Murray, DM, Southwest regional admin- istrator for the U.S. Centers for Medicare & Medicaid Services (CMS), said PCIP “has made health care coverage available to people who have been unable to buy or afford it because they have a preexist- ing condition. “The comprehensive plan covers pri-
mary and specialty care, hospital stays, skilled nursing care, home health care, and prescription drugs,” Dr. Murray added. “And there’s no waiting period for new enrollees; the insurance provides immediate coverage of their condition.” Texas already has its own high-risk pool for people with preexisting condi- tions, the Texas Health Insurance Pool (THIP). That pool has some 26,000 en- rollees, but Ms. Khan says PCIP monthly premiums are substantially lower. To be eligible for PCIP, a person must have been uninsured for at least the pre- vious six months, have a preexisting con- dition, and be a U.S. citizen or be legally present in the United States. Previously, patients had to submit a
letter from a private insurer denying cov- erage because of a preexisting condition
Getting subsidized PCIP premiums are lower than the Texas insurance pool because PCIP is subsi- dized with $5 billion in federal funds. “That funding was allocated as part of the Affordable Care Act and provides funding for the program through 2013,” Mr. Popper said. “The funding makes up the difference between the total costs of the program, including claims costs and the premiums collected from PCIP enrollees.” THIP, by statute, charges twice the
prevailing private market rate. PCIP premiums range from $133 to $572 per month based on which plan is chosen and the person’s age. PCIP has three plan options — the
standard plan, an extended plan, and a health savings account (HSA) option. The standard plan offers compre- hensive coverage with separate medical and prescription deductibles. The medi- cal deductible is $2,000 for in-network care and $3,000 for out-of-network care. There is also a 20-percent coinsurance for in-network services, 40 percent for out-of-network services, $25 in-network
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