The Affordable Care Act created the Pre-Existing Condition Insurance Plan (PCIP) to make health insurance available to those that have been denied coverage by private insurance companies because of a pre-existing condition.
PCIP runs until 2014. In 2014, everyone will have access to affordable health insurance choices through a new competitive marketplace called an Exchange, which prohibits discrimination based on a pre-existing condition.
PCIP provides health coverage options for people who:
- Have been uninsured for at least six months
- Have a pre-existing condition or have been denied health coverage because of a health condition
- Are a U.S. citizen or are residing here legally
PCIP Program Basics:
- PCIP covers a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs.
- The program will not charge you a higher premium just because of your medical condition.
- PCIP does not base eligibility on income.
State Programs
Previously, many states have run “high-risk pools” or other programs that offer insurance to people with pre-existing conditions. Now, PCIP is available in every state, but the program may vary between states.
The Department of Health and Human Services (HHS), the Office of Personnel Management, and the Department of Agriculture’s National Finance Center, are running PCIP in some states. The federal government is contracting with a national insurance plan to administer benefits in those states. States have the option to build on their current programs, choose to run the new program, or elect to rely on HHS to provide coverage.
To learn more about PCIP, including eligibility, how to apply, and benefits, please visit www.HealthCare.gov or call 1-866-717-5826.
Funding for PCIP
The law appropriates $5 billion of federal funds to support PCIP, beginning on July 1, 2010 until January 1, 2014.
HHS proposed allocating funds for the program by using a formula almost identical to the formula used for the Children’s Health Insurance Program (CHIP). Specifically, funds are allotted to states using a combination of factors including nonelderly population, nonelderly uninsured, and geographic cost as a guide.
As under CHIP, HHS intends to reallocate allotments after a period of not more than two years, based on an assessment of state actual enrollment and expenditure experiences. This proposed reallocation aims to ensure that the capped amount of federal funding is allocated to states based on both the initial formula and performance.
Proposed Allocations by State
The table below presents the estimated state allotments over the four years based on the above methodology.
Potential Allocation of High-Risk Pool Funds Dollars in Millions*
| State | Funds |
|---|
| Alabama | 69 |
| Alaska | 13 |
| Arizona | 129 |
| Arkansas | 46 |
| California | 761 |
| Colorado | 90 |
| Connecticut | 50 |
| Delaware | 13 |
| Dist of Columbia | 9 |
| Florida | 351 |
| Georgia | 177 |
| Hawaii | 16 |
| Idaho | 24 |
| Illinois | 196 |
| Indiana | 93 |
| Iowa | 35 |
| Kansas | 36 |
| Kentucky | 63 |
| Louisiana | 71 |
| Maine | 17 |
| Maryland | 85 |
| Massachusetts | 77 |
| Michigan | 141 |
| Minnesota | 68 |
| Mississippi | 47 |
| Missouri | 81 |
| Montana | 16 |
| Nebraska | 23 |
| Nevada | 61 |
| New Hampshire | 20 |
| New Jersey | 141 |
| New Mexico | 37 |
| New York | 297 |
| North Carolina | 145 |
| North Dakota | 8 |
| Ohio | 152 |
| Oklahoma | 60 |
| Oregon | 66 |
| Pennsylvania | 160 |
| Rhode Island | 13 |
| South Carolina | 74 |
| South Dakota | 11 |
| Tennessee | 97 |
| Texas | 493 |
| Utah | 40 |
| Vermont | 8 |
| Virginia | 113 |
| Washington | 102 |
| West Virginia | 27 |
| Wisconsin | 73 |
| Wyoming | 8 |
| United States | 5 Billion |
* Preliminary: Final allotments may increase or decrease by +/- 1%.
Data sources: ACS State Population 2008; BLS Wage Data 2008.
Additional Resources
FAQs
Under the Affordable Care Act, health insurance companies can't refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts.
How do insurers find out about pre-existing conditions? ›
If you claim that you suffered injuries in a crash resulting of someone else's negligence, the insurance company may dig into your medical history. Your medical records will show what injuries or conditions you have endured in the past and compare them with your current claim.
Do insurance companies still consider pre-existing conditions? ›
Is there health insurance for pre-existing conditions? Choosing a health plan is no longer based on the concept of a pre-existing condition. A health insurer cannot deny you coverage or raise rates for plans if you have a medical condition at the time of enrollment.
How do you explain pre-existing conditions? ›
A health problem, like asthma, diabetes, or cancer, you had before the date that new health coverage starts.
What counts as a pre-existing condition? ›
A pre-existing medical condition (PEMC) is an illness or injury you had before your policy began or was renewed. Examples of pre-existing medical conditions include, diabetes, asthma, high cholesterol or a long-term back condition.
What is the exclusion period for pre-existing conditions? ›
The time period during which a health plan won't pay for care relating to a pre-existing condition. Under a job-based plan, this cannot exceed 12 months for a regular enrollee or 18 months for a late-enrollee.
What happens if you don t disclose pre-existing condition life insurance? ›
Pre-existing conditions don't automatically disqualify you from life insurance. Specialized life insurance policies cater to individuals with health concerns. Honesty about your health history in the application process is crucial. The severity of your condition significantly impacts policy options and costs.
Is high blood pressure a pre-existing condition? ›
Pre-existing diseases or PED is a kind of chronic or long-term medical condition which already exists at the time when one buys a health insurance. The most common examples of pre-existing diseases are: High blood pressure.
Is a broken bone a pre-existing condition? ›
So what do health insurance companies mean by “pre-existing condition”? A pre-existing condition can refer to the following: A past injury or illness that you have already recovered from (such as a broken ankle from your youth)
What if pre-existing conditions are not declared? ›
Failure to disclose pre-existing conditions not only jeopardizes the chances of successful claims but may also lead to the cancellation of the policy in extreme cases.
The Affordable Care Act (ACA or “Obamacare”) prohibited pre-existing condition exclusions for all plans beginning January 2014, which was great news for all insurance beneficiaries with pre-existing conditions.
Is high cholesterol a pre-existing condition? ›
In the health insurance world, a pre-existing condition is any injury, sickness or condition that exists before the date an insurance policy takes effect. Examples include asthma, diabetes, anxiety, depression, high blood pressure, high cholesterol and so on.
Can I be denied health insurance because of a pre-existing condition? ›
Health insurers can no longer charge more or deny coverage to you or your child because of a pre-existing health condition like asthma, diabetes, or cancer, as well as pregnancy. They cannot limit benefits for that condition either.
Which is an example of a pre-existing condition? ›
An illness or injury experienced before enrollment in a health insurance plan may be considered a pre-existing condition. Pre-existing conditions can include health issues such as cancer, diabetes, lupus, depression, acne, pregnancy, or just about any other health condition you can imagine.
What is the new definition of pre-existing disease? ›
Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and I or were diagnosed, and I or for which medical advice I treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter.
Can an insurer exclude coverage for a preexisting? ›
A pre-existing condition is any health problem, like diabetes, or cancer, that you had before the date you applied for insurance. Insurers cannot refuse to cover treatment for your pre-existing condition or charge you more under the ACA.
What is the denial code for pre-existing conditions? ›
Denial code 51 is used to indicate that the services being billed for are not covered by the insurance provider because they are related to a pre-existing condition.
Can UnitedHealthcare deny coverage for pre-existing conditions? ›
You cannot be denied coverage based on preexisting conditions.
