Health Insurance In California For Those With Pre Existing Conditions

June 20th, 2011 by Craig Mullins

Did you know that you can now apply health insurance in California, and not have to worry about being turned down due to a pre existing condition?

It’s pretty damn cool!

As some of you may know I haven’t been the golden child of good health the past 4 years or so. I sprained an ankle a few years back and it created an autoimmune disease similar to Rheumatoid Arthritis in most of the joints throughout my body. I’m now taking a self-injection drug called Enbrel (Etanercept) once a week to keep it in check. The medication is working great and I feel almost like a normal person again, but without health insurance it costs thousands of dollars a month.

Although I think the Obama Administration took the health insurance overhaul a little further than they needed to, I’m thankful it was passed. Personally, I think all people really need is the assurance that they would not be denied coverage due to a pre existing condition.Not all the mumbo jumbo stuff they put into it, but lets not get into politics. :)

I’m not sure what the rates are for others, but I’ll tell you what I pay.

I rate as a 34 year old single male, who weighs 220lbs, is 5′ 10″ tall, does not smoke, and lives in the zip code 94588. That’s all they know about me and those are the only rating factors they used when approving me; as far as i know.

I pay $292.00 a month for my coverage.

That sounds great, but who is the coverage through, you ask?

Each state within the U.S. seems to have a different system, so be sure to check here for more info: https://www.pcip.gov/Default.html

I am in California so I’ll tell you how it works for me in this state.

First you need to find out if you are eligible.

Check this page for more information on Federal guidelines: https://www.pcip.gov/Eligibility.html

  • You must be a citizen or national of the United States or reside in the U.S. legally.
  • You must have been without health coverage for at least the last 6 months. Please note that if you currently have insurance coverage that doesn’t cover your medical condition or are enrolled in a state high risk pool, you are not eligible for the Pre-Existing Condition Insurance Plan.
  • You must have a pre-existing condition or have been denied health coverage because of your health condition. Information about what documents about your pre-existing condition you need  to provide with your application is available here.
  • If you are eligible, we will mail you a letter that includes the amount of your monthly premium and instructions for making your first premium payment to complete your enrollment. You must pay your monthly premium to maintain that coverage.

Below is information on guidelines that are specific to California. You can find out more information here: http://www.pcip.ca.gov/PCIP_Program/

The PCIP eligibility requirements are:

  • You must be California resident.
  • You must have no health insurance coverage for the past 6 months, prior to application being received. This means in the last 6 months you were not enrolled in an individual or job-based health plan, including COBRA or Cal-COBRA, or enrolled in Medicare Part A and/or Part B, or in No-Cost Medicaid/No-Cost Medi-Cal.
  • You must be a U.S. Citizen, U.S. National, or lawfully present individual.
  • U.S. Citizens or U.S. Nationals must provide their Social Security Number.
  • You must have been denied individual insurance coverage within the past 12 months, for a pre-existing condition as shown by:
    • Rejection letter from a health insurance company in the last 12 months, or
    • Offered coverage with premiums higher than those of the Major Risk Medical Insurance Program (MRMIP) preferred provider organization (PPO) in the geographic region where the individual is seeking coverage.

How do I apply for PCIP In California:

To apply for PCIP, you must complete both the PCIP Supplemental Application (PDF 149kb) and the Major Risk Medical Insurance Program (MRMIP) Application (PDF 474kb).

When you review the information, it is important that you carefully review the PCIP Supplemental Application Overview and the MRMIP Handbook, in order for you to make important decisions regarding your health care needs! The PCIP Supplemental Application Overview has information that compares the differences between the PCIP and MRMIP programs.

The PCIP Supplemental Application contains a Checklist. The Checklist is helpful for you to have when filling out your application. It tells you each step you need to complete. The Checklist explains the supporting documents and monthly premium you need to send with your application.

All questions on both forms must be answered. In addition, both applications along with a check for your first month’s premium and all necessary documents should be mailed to:

Pre-Existing Condition Insurance Plan
P.O. Box 537032
Sacramento, CA 95853-7032

If you have questions when you fill out the applications, please give us a call at 1-877-428-5060, Monday – Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.

Important Notice:

If you are currently or will be enrolled in the MRMIP, you will not qualify for the PCIP. The PCIP requires that an individual not have health insurance coverage for at least six (6) months, prior to receiving your application.

So what do I think of the coverage?

It’s actually quite good. It’s a PPO plan, so I can pretty much see any doctor I want; although if I see an in-network doctor, PCIP will pay a higher percentage of the bill. Here are a couple items/a summary of what is paid for in network care.

Copay to see a DR – $25
I have an annual deductible of $1,500 and a max out of pocket cost of $2,500.
No fee for preventative care
Emergency/inpatient services – 15%

Prescriptions:
Generics – $5
Preferred brand – $15
Non Preferred brand – $30
Deductible – $500

One thing to note. I kept going to dr’s and they had no idea when I told them I had the “pcip plan”. It’s actually thru the Blue Shield CA PPO network, so if your dr covers that one your fine.

While it’s not perfect plan, it certainly saves me a ton of money, and I am very thankful to have health insurance right now.

If you or your family can’t get anything it’s really something you should consider!

health insurance in california

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