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Topic: Pre-Existing Condition Insurance Plan (PCIP)

Forum: Employment, Insurance, and Other Financial Issues —

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Posted on: Jul 2, 2010 05:52PM - edited Jul 2, 2010 05:52PM by MaryNY

MaryNY wrote:

Yesterday he U.S. Department of Health and Human Services (HHS) launched a new online tool that "will help consumers take control of their healthcare by connecting them to new information and resources that will help them access quality, affordable health care coverage. Called for by the Affordable Care Act, www.HealthCare.gov  is the first website to provide consumers with both public and private health coverage options tailored specifically for their needs in a single, easy-to-use tool."

Under the new law, people who have been denied coverage due to a pre-existing condition and who have been uninsured for at least six months may qualify to buy insurance. Read about the Pre-Existing Condition Insurance Plan (PCIP); then use the PCIP Map to learn more about how the program works in your state.Premiums will vary depending on the state you live in. (But as an example, if you live in a state where the U.S. Department of Health and Human Services provides coverage, the premium for an age 50 year old enrollee may range between $320 and $570, depending on state of residence. For an estimated premium range for your state, go to that state on the website map below.)

While you can apply for the U.S. Department of Health and Human Services run Pre-Existing Condition Insurance Plan today, the premium rates won't be officially available until July 15. If you apply before July 15, and are determined to be eligible for enrollment you will be notified by mail of the premium. Then, you'll send in your payment to finalize your enrollment in the Pre-Existing Condition Insurance Plan.

Mary ~~ lumpectomy 8/10/2009, Oncotype DX 18, Chemo 10/28/09--2/1/10 AC*4, CMF*4 Dx 5/19/2009, IDC, 1cm, Stage IIA, Grade 2, 2/6 nodes, ER+/PR+, HER2-
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Jul 2, 2010 09:09PM 2z54 wrote:

Fortunately, I don't need this yet as I am on COBRA and have just gotten a job.  BUT, when the health care reform was being voted on, I don't remember seeing anything about the requirement for a 6 month waiting period WITHOUT health insurance before joining the high risk pool for pre-existing conditions. I've been wondering when they slipped that in.  Did the 6-month non-insurance qualifier seem strange and unfair to any one else?  Did it seem like a new requirement, too? 

Dx 7/23/2008, IDC, 3cm, Stage II, Grade 3, 0/3 nodes, ER-/PR-, HER2-
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Jul 2, 2010 10:49PM MaryNY wrote:

Yes, it does seem unfair. Maybe it's there way of ensuring that applicants have exhausted all other options. But six months is a long time to wait if you have a serious condition that requires treatment.  I'm just wondering if the waiting period might be waived under certain circumstances.

My COBRA runs out at the end of this month. I've just submitted an application for Healthy NY, a low-cost plan here in NY state. One of the eligibility criteria for that is "You have not had health insurance for twelve months prior to your Healthy NY application or have lost that coverage due to a specific event." Included in the specific events is loss of coverage due to COBRA running out. Maybe the PCIP plan will have a similar waiver.

Mary ~~ lumpectomy 8/10/2009, Oncotype DX 18, Chemo 10/28/09--2/1/10 AC*4, CMF*4 Dx 5/19/2009, IDC, 1cm, Stage IIA, Grade 2, 2/6 nodes, ER+/PR+, HER2-
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Jul 2, 2010 10:55PM sewescape wrote:

All the high risk pool in Colorado requires is that you have a letter showing you have been turned down by an insurance company. I have been on it while my husband was between jobs and our Cobra had run out.

Sue
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Jul 2, 2010 11:07PM MaryNY wrote:

Sue, what was the premium for the CO ins? I got a quote for an individual plan with Oxford. Their HMO plan would be $1,139/mo, the POS plan would be $1,678. There is no way I could afford these premiums so I didn't even pursue it further. These are the standard rates even w/o mentioning my pre-existing condition.

Mary ~~ lumpectomy 8/10/2009, Oncotype DX 18, Chemo 10/28/09--2/1/10 AC*4, CMF*4 Dx 5/19/2009, IDC, 1cm, Stage IIA, Grade 2, 2/6 nodes, ER+/PR+, HER2-
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Jul 3, 2010 10:45PM karen333 wrote:

Mary, you surely are a invaluable resource!!!  Maybe it will have a clause like COBRA having run out, like HealthyNY had.  I already emailed for more information and an application, just in case. Karen

Dx 8/8/2009, 2cm, Stage IIA, Grade 1, 0/1 nodes, ER+, HER2+
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Jul 3, 2010 11:39PM - edited Jul 3, 2010 11:44PM by MaryNY

Hi Karen: yes, I wonder if we might be eligible for this. I think I will contact my congresswoman's office again as they might have more details than those on the website.

Oh, another thing ... I was in CVS today and they told me that they have the generic anastrozole in stock already. I was there trying to fill an Rx before my COBRA runs out. It was for naftin gel, which is used to treat athlete's foot. The pharmacist said my copay would be $50. I think the most I've ever paid for an Rx copay was $20. I walked away without the Rx. 

Mary ~~ lumpectomy 8/10/2009, Oncotype DX 18, Chemo 10/28/09--2/1/10 AC*4, CMF*4 Dx 5/19/2009, IDC, 1cm, Stage IIA, Grade 2, 2/6 nodes, ER+/PR+, HER2-
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Jul 3, 2010 11:55PM wyldblumusic wrote:

Hello, everyone.

The thought of waiting six months for a pre-existing condition bugged the heck out of me when I first read this.  So, I went to that website to check it out.  Here's a quote from that site...

The Pre-Existing Condition Insurance Plan (PCIP), which is administered by either your state or the U.S. Department of Health and Human Services, will provide a new health coverage option for you if you have been uninsured for at least six months, you have a pre-existing condition OR have been denied health coverage because of your health condition, and are a U.S. citizen or are residing here legally.  [Emphasis added]

I am fluent in crazy government speak.  This seems to imply that you can get coverage with a pre-existing condition without any wait.  I sure hope this is the way it really works.

Dx 2/2010, DCIS, ER+/PR+
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Jul 4, 2010 01:18AM gale1525 wrote:

I just sent for an application so we will see what happens, I keep you posted.

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Jul 4, 2010 01:31AM - edited Jul 4, 2010 01:33AM by gale1525

Hello: Thank you for your interest in California’s Pre-existing Conditions Insurance Plan (PCIP), also known as the temporary federal high risk pool. Currently, we do not have applications available for the PCIP. The Managed Risk Medical Insurance Board (MRMIB) continues discussions on the specific rules for developing, implementing and operating the PCIP. California’s goal for implementing the PCIP is to begin accepting applications in August 2010 with the first effective date of coverage beginning in September 2010. To be eligible for the new PCIP, federal law sets out three requirements: 1. Be a US Citizen, US National or lawfully present individual; 2. Have a pre-existing medical condition that meets the guidelines set by the federal government; and 3. Have not had health insurance or public health coverage for at least six (6) months. Applicants must have been uninsured for at least six months at the time they apply for the PCIP but the State high risk pool does not have such a requirement. You can access info on the CA Major Risk Medical Insurance Program at www.mrmib.ca.gov/MRMIB/MRMIP.s... If you have included your name, address, telephone number, and email address, we will place your name on the list for a PCIP application when they are available in the next month or so. If you have not included this information, please re-submit your request with that information. We will be posting updates on MRMIB’s website under "What's New" on the homepage at www.mrmib.ca.gov/. Also, if you know others who want a PCIP application ask them to send us an email with their name, address, telephone number and email address to FHRP@mrmib.ca.gov. Again, thank you for your interest in California’s PCIP I just got this reply.

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Jul 4, 2010 02:06AM wyldblumusic wrote:

Unbelievable.  I am speechless.  Off to do more research...

Dx 2/2010, DCIS, ER+/PR+
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Jul 4, 2010 11:29AM - edited Jul 4, 2010 11:30AM by MaryNY

I'm guessing that the conditions will vary depending on whether your state uses the federal program or has its own state-run program. The PCIP map shows which states will have their own programs. I'm looking at this statement that Iluistro got from State of CA:

    "Applicants must have been uninsured for at least six months at the time they apply for the PCIP but the State high risk pool does not have such a requirement."

This is at odds with the information on the CA requirements listed on the PCIP site, where it says:

    "You must have been uninsured for at least the last six months before you apply."

My guess (and hope) is that the above is just boilerplate text that they have added to each state's description, but that each state can set its own conditions. 

Mary ~~ lumpectomy 8/10/2009, Oncotype DX 18, Chemo 10/28/09--2/1/10 AC*4, CMF*4 Dx 5/19/2009, IDC, 1cm, Stage IIA, Grade 2, 2/6 nodes, ER+/PR+, HER2-
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Jul 4, 2010 03:16PM leaf wrote:

All this disappears in 2014, but between now and then things can be really hard:

Ralf Burgert had no idea how costly toenail fungus could be.

The San Rafael resident got rid of the common infection by treating it with the prescription medication Lamisil. It was the last thing on his mind when he applied for a health insurance policy on the individual market a short time later.
He could not believe the response: Because of the toenail fungus, an insurer informed him, he would be in a higher-risk insurance pool with a 50 percent jump in premiums. Burgert was flabbergasted.

"I'm in perfect health," said the 43-year-old nurse practitioner. "Except for the toenail thing, I haven't had any illnesses. Of all the diseases you can have, it's as close to a harmless one as you can get. All it does is make your toenails white and kind of thick-looking."

The insurers are "just doing it because they can," he said.

Consumer advocates say they are often perplexed by the minor health issues that can create serious problems for people seeking health insurance. Each company sets its own policies.

Common conditions such as asthma, sleep apnea, allergies, ear infections, mild depression, migraine headaches, and joint sprains can trigger denial of insurance or higher premiums, the state learned in 2006 when it required insurers to submit information on their underwriting policies.

"The things that people have been denied for raise the question if simply living is a pre-existing condition," said Anthony Wright, executive director of Health Access California, a consumer advocacy group.
<...>
People have been rejected for such common conditions as acne and high blood pressure, said Judy Dugan, research director for Consumer Watchdog.

"If you are pregnant, (insurers) will run the other way screaming," she added. "They don't want to insure a baby until they have looked it over to make sure it's absolutely healthy."
<...>
the insurance industry generally supported eliminating medical underwriting and guaranteeing coverage to applicants, as long as the change came with a government mandate that most people buy insurance.


www.mercurynews.com/ci_15401885
Classic LCIS.If knowledge can create problems, it is not through ignorance that we can solve them- Isaac Asimov Dx 12/8/2005, LCIS, ER+/PR- Surgery 1/24/2006 Lumpectomy: Left Hormonal Therapy 7/15/2006 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Jul 4, 2010 05:20PM LisaAlissa wrote:

MaryNY, the PCIP (as it will exist in California) is a different insurance plan than California's Major Risk Medical Insurance Program ("MRMIP"), which is a creature of California law, which has (since 1991) been providing a high risk pool for medically uninsurable CA residents.  Note that the availability of MRMIP is limited by the state-allocated funds.  That is, applicants who otherwise meet the requirements for the program may not be accepted based on the available funding for the program.

There's a note at the top of this pagesaying "Important Notice  If you enroll in the MRMIP, it will prevent you from qualifying for the new Federal high risk pool.  For more information click here."   That link takes you to a pdf that describes that. 

HTH,

LisaAlissa 

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Jul 7, 2010 12:44PM crabbiepattie wrote:

Well, my insurance company has denied some of my claims citing my "fibrocystic breast disease" exclusion. I specifically asked about breast cancer when I applied, and was assured I would have coverage for breast cancer, but I didn't get that in writing.

I've already had a lumpectomy that probably isn't covered; I expect to start chemo this month. It may be that I can switch to CoverColorado and get some of the chemo covered.  The premiums are about 75% more than the usual. For me (nonsmoker age 57), a $2000 deductible HSA will be about $565 a month.

MaryNY, CoverColorado has a quote link on their web site, www.covercolorado.org.

Dx 6/8/2010, IDC, 5cm, Stage IIIA, Grade 3, 1/11 nodes, ER-/PR-, HER2-
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Jul 7, 2010 01:04PM MaryNY wrote:

Hi crabbiepattie: were you uninsured prior to getting your current coverage? I'm still unclear on whether (1) and insurance company can deny coverage because of a pre-existing condition and (2) once you have coverag whether they can still deny claims because they determine that it's a pre-existing condition. And then state and federal laws don't seem to be in sync on these matters.

Mary ~~ lumpectomy 8/10/2009, Oncotype DX 18, Chemo 10/28/09--2/1/10 AC*4, CMF*4 Dx 5/19/2009, IDC, 1cm, Stage IIA, Grade 2, 2/6 nodes, ER+/PR+, HER2-
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Jul 7, 2010 02:37PM crabbiepattie wrote:

Hi MaryNY - I was insured before getting my current coverage, but it and my current coverage are individaul insurance, which has little protection under the law. You're right - federal and state laws are not in sync - for example, some states explicitly say that exclusions must be limited in scope.

Until 2014, unless it is prohibited by your state, an insurance company can deny coverage because of a pre-existing condition.

Right now, if you have coverage, I don't think an insurance company can deny claims for a pre-existing condition unless there is an exclusion or rider or a 6-month waiting period. However, they can interpret exclusions and riders broadly. And they can cancel your insurance if you forgot to include some minor doctor's appointment 8 years ago on your application. (My last application required 10 years of medical info.) If they do cancel your insurance due to missing info, it might be considered fraud on your part and might prevent you from joining a state high-risk pool.

In 2003, I was denied coverage because I had high blood pressure although it was well controlled by inexpensive meds. I'm sure no company in Colorado would agree to insure me now.

My state high-risk pool is starting to change over to the federal plan. Using the old rules, I might be able to slip through a loophole and avoid the 6 month no-insurance period.

Dx 6/8/2010, IDC, 5cm, Stage IIIA, Grade 3, 1/11 nodes, ER-/PR-, HER2-
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Jul 12, 2010 02:03AM crabbiepattie wrote:

I googled a bit on health insurance in NY and found some indication that claims for pre-existing conditions can be denied for something like 24 months even if the 6-month waiting period is met. Maybe not, but that's what the info seemed to say.  Good grief!

Dx 6/8/2010, IDC, 5cm, Stage IIIA, Grade 3, 1/11 nodes, ER-/PR-, HER2-
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Jul 12, 2010 10:38AM lvtwoqlt wrote:

I am going to be laid-off next month due to 'consolidation' of several smaller divisions of the corporate offices. I have carried insurance on myself and my husband for the past 10 yrs. My husband has a group policy that will prevent me from qualifing for COBRA, but his policy is more of a major medical plan (no copay for doctor's visits and $5000 deductible per person before insurance starts paying their 80%) and high weekly premiums (almost all of my unemployment benefits). I tried picking up a private policy (that was cheaper per week and had copay) to cover us until we can get other insurance. The private policy was with the insurance company that we have been covered under for the past 10 years, they denied me coverage because of my BC. I will go with the bad group plan as soon as I am laid-off so I won't have a lapse in coverage.

Sheila

Women are like tea bags, we don't know how strong we are until we were thrown into hot water. Eleanore Roosevelt Diagnosed ADH Feb 2005, ADH Sept 2006 Surgery 2/12/2005 Lumpectomy: Left Surgery 9/10/2006 Lumpectomy: Right Hormonal Therapy 10/12/2006 Dx 4/27/2007, DCIS, Stage 0, Grade 1, 0/7 nodes Surgery 6/1/2007 Mastectomy: Left, Right
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Jul 12, 2010 02:53PM crabbiepattie wrote:

Sheila,

That sucks, kiddo - not even COBRA. If you can tolerate being uninsured for six months, you'll be eligible for your state pre-existing condition plan. It's probably better than your husband's plan but might not be any cheaper.

Hugs,

crabbie

 

Dx 6/8/2010, IDC, 5cm, Stage IIIA, Grade 3, 1/11 nodes, ER-/PR-, HER2-
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Jul 12, 2010 04:42PM AnneW wrote:

Sheila, I am so sorry to hear you're losing your job and good coverage. Fortunately, you're at a point where you don't need as much follow-up. Best of luck to you in the job search. I know times are especially tough in Western NC.

Best wishes,

Anne

2002 IDC stage 1, grade 1, rads & AI Dx 9/18/2007, ILC, <1cm, Stage I, Grade 1, 0/1 nodes, ER+/PR+, HER2-
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Jul 12, 2010 05:38PM lvtwoqlt wrote:

Crabbie, The agent I checked with last week about the private policy said that I could get on the state plan now but it cost more per week than my husband's policy (closeer to all of my unemployment per week). Like Anne said, I am not in active treatment, just follow-up appointments with my doctors every 6 months and not even on tamox or AI so my hubby's plan wouldn't be a 'bad' option. He is actually on more meds than I am (diabetic, high blood pressure, high cholesterol) but 2 of the 4 meds he takes are generic we can get at Walmart cheap without insurance coverage.

Sheila

Women are like tea bags, we don't know how strong we are until we were thrown into hot water. Eleanore Roosevelt Diagnosed ADH Feb 2005, ADH Sept 2006 Surgery 2/12/2005 Lumpectomy: Left Surgery 9/10/2006 Lumpectomy: Right Hormonal Therapy 10/12/2006 Dx 4/27/2007, DCIS, Stage 0, Grade 1, 0/7 nodes Surgery 6/1/2007 Mastectomy: Left, Right
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Jul 13, 2010 11:03PM crabbiepattie wrote:

Hi Sheila,

Well, a major-medical group plan is better than an individual plan anyway.  Sending good luck thoughts your way on the job hunt.

Hugs,
crabbie

Dx 6/8/2010, IDC, 5cm, Stage IIIA, Grade 3, 1/11 nodes, ER-/PR-, HER2-
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Jul 29, 2010 11:44AM lago wrote:

I'm currenlty doing research on this myself.  Some Employer (cobra) plans allow you to transfer. Check it your employer offers a TCA wire transfer. 

 I just found out that my cobra ends this december instead of April of 2011 (like 5 minutes ago). I was just diagnosed and still don't have a surgery date. I know that I will not be able to get insured unless I get  into the state high risk pool. I've been healthy all my life paying insurance and now when I need it they basically say F-you.

 Here are some other links you might want to check out, especially the first on: 

http://www.cobrahealth.com/statehighriskpools.html
http://articles.latimes.com/2009/jun/17/business/fi-rescind17
http://www.hcvadvocate.org/hepatitis/hepC/cobra-2.html

DONE!! goo.gl/IoaN6U • Tattoos 2.7.2012 • Nipples 10.6.2011 • Exchange 6.24.2011 • Chemo 1.18. 2011 • BMX 8.31.2010 Dx 7/13/2010, IDC, 5cm, Stage IIB, Grade 3, 0/14 nodes, ER+/PR+, HER2+
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Jul 30, 2010 06:28PM - edited Jul 30, 2010 06:29PM by browneyedgurl

Also check into the BCCTP PLAN -- The Breast Cancer and Cervical Treatment Plan. Every state has it and is managed through Medicaide...In my state, AZ, it is managed through ACHHS, and from what I hear, the coverage is very good.

I applied to the PCIP....Does anyone know who is underwriting the PCIP?  I need to go see a surgeon, but can't because I dont know who the Insurance Company is and if they take it. I did an application on CIGNA.COM .... got a decline letter within 5 days ...that is all I needed to apply ...  

Also, if you are unemployed...your COBRA payments are less..

Colleen 

Dx 7/20/2010, IDC, 1cm, Stage II, Grade 3
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Jul 30, 2010 08:30PM Dovehome wrote:

Hi, read this thread just because I wanted to gain some information about coverage if I am to change jobs.  Thanks for the links posted as they are good references.

Right after reading this I went to my facebook page and found a new post from a friend about wanting to meet a courageous lady? and it had a link to her web page:  www.theinsurancewarrior.com.  Wasn't sure what it was all about but watched her 2 videos about her battle in fighting appeals to insurance companies for coverage of treatment.  I'm not advocating this site or know this lady...just wanted to share.  There may be someone here that might need to obtain some direction in getting help in fighting for health insurance coverage and possibly this could help.  I'd suggest to do your research on her as you would normally do when buying something on the internet.  She had some good tips I thought.

Surgery 3/3/2009 Lumpectomy: Right; Lymph node removal: Right, Underarm/Axillary Dx 3/4/2009, IDC, Right, 2cm, Stage IIA, Grade 3, 2/18 nodes, ER+/PR+, HER2- Chemotherapy 4/29/2009 AC + T (Taxol) Radiation Therapy 10/18/2009 Breast, Lymph nodes Hormonal Therapy 2/9/2010 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 10/11/2012 Mastectomy: Left, Right Surgery 1/1/2013 Reconstruction (left): DIEP flap; Reconstruction (right): DIEP flap Surgery 4/30/2013 Reconstruction (left): Nipple reconstruction; Reconstruction (right): Nipple reconstruction

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