Uncle Sam slashes PCIP health plan premiums

By Michele Lerner Posted : 07/21/2011

PCIP health insuranceIf you have a pre-existing health condition, your insurance costs now may be less expensive, courtesy of Uncle Sam.

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On July 1, premiums for federally administered pre-existing condition insurance plans (PCIPs) were reduced by between 2 percent and 40 percent in 17 states (plus the District of Columbia) where the program is administered by the federal government.

Created under 2010's Affordable Care Act, PCIPs provide federally administered insurance coverage to people who previously have been denied insurance because of a pre-existing condition.

The federal government is in charge of PCIPs in 23 states and the District of Columbia. The remaining states manage their own PCIP programs while using federal funds provided by the Affordable Care Act.

States where PCIP rates have decreased







District of Columbia



South Carolina








West Virginia

The premium decreases are designed to bring the PCIP health insurance rates in line with rates in individual markets.

Rates remained unchanged in six of the 23 states – Hawaii, Idaho, Massachusetts, North Dakota, Vermont and Wyoming – where premiums were deemed already in line with standard health plan costs.

The latest changes are part of several tweaks made to the health insurance policies since they were introduced, says Richard Popper, director of insurance programs at the Center for Consumer Information and Insurance Oversight (CCIIO).

"The feedback we were getting from the states where we operate the program and from our state partners was that we needed to get our premiums in line with more affordable insurance products," says Popper. "We also needed to make it easier to apply for the coverage."

PCIP insurance provides comprehensive health coverage, including:

  • Primary and specialty care
  • Hospital care
  • Prescription drugs
  • Home health and hospice care
  • Skilled nursing care
  • Preventive health and maternity care

As of the end of April, 21,454 people had enrolled in the PCIP plans run by either the federal government or individual states, according to the Department of Health and Human Services (HHS).

Easier to prove eligibility for health insurance

In addition to lowering premium costs, the July 1 change included a provision that makes it easier to prove eligibility for federally administered PCIP programs.

Previously, you had to wait until receiving a denial of coverage letter from an insurance company before you could get PCIP coverage. Now, you will be allowed to simply submit a letter from a doctor, a physician assistant or a nurse practitioner dated within the previous 12 months, stating that you have or have had a medical condition, disability or illness.

"The benefit of this change is that it saves people weeks if not months of time before they can get insurance coverage," says Popper, who adds that the new provision "cuts down the wait time to a day or two after the doctor's letter."

Forget about trying to pull a fast on the government and trying to claim a previous denial of coverage that never occurred. The application form states that anyone who makes material misstatements or omissions can have their policy canceled "as though it were never effective" and will be subject to "any other action available by law."

To apply for a PCIP, you still must meet the other criteria established by the federal government:

  • You must be an American citizen or residing legally in the U.S.
  • You must have been without health insurance coverage for six months or longer.

Applying for PCIP insurance

If you lack health insurance because of a pre-existing condition or have been offered insurance that excludes treatment for your condition, visit the government's Pre-existing Condition Insurance Plan website to find out about eligibility, plan benefits, rates and how to apply for PCIP coverage. Or, call 1-866-717-5826.

In some states, you may also be eligible for a PCIP plan if you have been offered insurance at twice the cost of PCIP because of your health condition, Popper says. However, keep in mind that you cannot have purchased this more expensive health insurance – to qualify for PCIP, you must be uninsured for six months or longer.

"Once approved, the coverage begins on the first day of the following month without any waiting period," says Popper.

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