Enrollment Lags for Federal Pre-Existing Insurance Plan

A federal program to help people with pre-existing conditions obtain health insurance has lagged in terms of the government’s projected enrollment, which may be partly because it has largely gone unnoticed as one of the benefits of the health reform law.

The Pre-Existing Condition Insurance Plan (PCIP) was launched in July 2010 with $5 billion in funding from the Affordable Care Act. The goal is to provide an insurance option to people who may be barred from coverage or who have to pay huge surcharges because of a pre-existing condition such as hypercholesterolemia or cancer. The program will be in force until 2014, when the new insurance exchanges go into effect and insurers are prohibited from denying coverage to adults with pre-existing conditions. (They are already barred from doing so for children.)

Although the Department of Health and Human Services initially estimated that several hundred thousand people might benefit from the PCIP, as of early May only about 18,000 people had enrolled, according to the government’s statistics.

In an interview, Richard Popper, director of insurance programs at the federal Center for Consumer Information and Insurance Oversight, would not comment on the number of enrollees. But he said that enrollment had been strongest in states with higher populations, such as Texas, California, Pennsylvania, and Illinois.

A "significant number" of patients with cancer, coronary artery disease, chronic obstructive pulmonary disease, and digestive system problems have accessed the program, said Mr. Popper, whose office is a division within the Centers for Medicare and Medicaid Services. The average person who has enrolled has annual medical costs of $20,000 a year, he said.

Enrollment, Eligibility How-Tos

To be eligible for the PCIP, an individual must have been without insurance for 6 months before enrollment. Mr. Popper said that because he was not working for DHHS at the time the Affordable Care Act was developed, he can’t comment on why this waiting period was made an essential part of the eligibility.

After that, the program varies according to whether it is administered by a state or the federal government, although there are minimum coverage criteria. Twenty-three states and the District of Columbia elected to have their PCIP program have a federally-run program, which is essentially the same as the plan offered by Blue Cross/Blue Shield to federal employees.

Twenty-seven states run their own programs.

Patients can apply at the PCIP website. They must prove that they have been denied insurance and have a pre-existing condition. That can be accomplished through a letter of denial from an insurer. In some states, an individual can qualify with a letter from a physician noting the pre-existing conditions and stating that the person has been diagnosed or treated for the conditions within the previous 6 months, said Mr. Popper.

In all cases, the patient gets coverage immediately. There is no waiting period, and premiums will be the same as for a healthy person in the same age range. There are no surcharges for health conditions.

At a meeting of the Association of Community Cancer Centers in March, Mr. Popper cited figures for the plan in Texas, which has a program that is operated by the federal government. For standard coverage, individuals could expect to pay from $174 to $557 monthly, depending on age, with a $2,000 deductible for medical care and a $500 deductible for medications. Higher benefit plans run $234-$749 for premiums, with $1,000 and $250 deductibles, respectively. There is also a health savings account option, with premiums of $181-$578 and a $2,500 deductible.

The out-of-pocket maximum that patients would pay under all plans is $5,950. There is no lifetime limit and no limit on physician visits or prescription drugs.

Relief in Rhode Island

At least one couple – Don and Renee Eddie of Rhode Island – has been thrilled to have stumbled upon the PCIP. The couple had been trying to stay insured over the last 6 years or so, through a patchwork of plans. They also have a son who is disabled.

Initially, they had family coverage through her teaching job, but after a series of back surgeries left her unable to work in 2004, she lost the coverage along with the job. Mr. Eddie had coverage through his workplace, Electric Boat, and when he retired in 2006, the Eddies elected a family plan through the company. But the premiums were $1,299 a month. "We did that for 18 months, and it was draining us," said Ms. Eddie in an interview.

They found a discount insurance program; the premiums were cheap at $300 a month, but the coverage was paltry. After being left with a $587 bill for a blood test, the family decided to drop the plan. And then, a few months later, in April 2010, trouble set in. One day, after doing some work at home, Mr. Eddie complained of chest pain. When he became sweaty, Ms. Eddie drove him down the road to a nearby fire department. They packed him up in an ambulance and took him to the emergency department.

Shortly thereafter he had two stents inserted and spent 4 days in intensive care. The bill came to $92,000.

Ms. Eddie went back to trying to find an affordable insurance plan for Mr. Eddie. They settled on one that would cost $700 a month, but at the last minute decided they couldn’t stand the financial burden and backed out. A few months later, she read about the PCIP in an article in the Providence Journal.

Ms. Eddie applied, and in October her husband got coverage for $519 a month through Blue Cross of Rhode Island. The state runs its own plan, which has a $1,000 deductible. Mr. Eddie’s premiums have risen this year, as he just turned 60, but they are still a relatively affordable $567, said Ms. Eddie.

His prescriptions, which include Plavix, simvastatin, and Crestor, are relatively affordable also, she said. The best part of the plan, according to Ms. Eddie, is the monthly call from a Blue Cross nurse coordinator to offer tips and to monitor his care. "It’s the first time we’ve had anything like that, so that’s a very nice component," said Ms. Eddie, who added that the "personal connection" made them feel as if they were getting better care.

"I’ve been very, very pleased with this program," said Ms. Eddie. She was able to resume coverage for herself through the retirement plan offered through her teaching position, and her son is receiving Medicaid benefits.

In the meantime, DHHS is trying to get the word out about the PCIP. Mr. Popper said that when people apply for disability under the Social Security program, they receive notification about the PCIP. Many insurance companies have also been advising patients who are rejected for coverage that the PCIP is a potential alternative, said Mr. Popper.

Finally, his office has been reaching out to hospitals and to physicians and provider organizations to educate them about the program, he said.

A federal program to help people with pre-existing conditions obtain health insurance has lagged in terms of the government’s projected enrollment, which may be partly because it has largely gone unnoticed as one of the benefits of the health reform law.

The Pre-Existing Condition Insurance Plan (PCIP) was launched in July 2010 with $5 billion in funding from the Affordable Care Act. The goal is to provide an insurance option to people who may be barred from coverage or who have to pay huge surcharges because of a pre-existing condition such as hypercholesterolemia or cancer. The program will be in force until 2014, when the new insurance exchanges go into effect and insurers are prohibited from denying coverage to adults with pre-existing conditions. (They are already barred from doing so for children.)

Although the Department of Health and Human Services initially estimated that several hundred thousand people might benefit from the PCIP, as of early May only about 18,000 people had enrolled, according to the government’s statistics.

In an interview, Richard Popper, director of insurance programs at the federal Center for Consumer Information and Insurance Oversight, would not comment on the number of enrollees. But he said that enrollment had been strongest in states with higher populations, such as Texas, California, Pennsylvania, and Illinois.

A "significant number" of patients with cancer, coronary artery disease, chronic obstructive pulmonary disease, and digestive system problems have accessed the program, said Mr. Popper, whose office is a division within the Centers for Medicare and Medicaid Services. The average person who has enrolled has annual medical costs of $20,000 a year, he said.

Enrollment, Eligibility How-Tos

To be eligible for the PCIP, an individual must have been without insurance for 6 months before enrollment. Mr. Popper said that because he was not working for DHHS at the time the Affordable Care Act was developed, he can’t comment on why this waiting period was made an essential part of the eligibility.

After that, the program varies according to whether it is administered by a state or the federal government, although there are minimum coverage criteria. Twenty-three states and the District of Columbia elected to have their PCIP program have a federally-run program, which is essentially the same as the plan offered by Blue Cross/Blue Shield to federal employees.

Twenty-seven states run their own programs.

Patients can apply at the PCIP website. They must prove that they have been denied insurance and have a pre-existing condition. That can be accomplished through a letter of denial from an insurer. In some states, an individual can qualify with a letter from a physician noting the pre-existing conditions and stating that the person has been diagnosed or treated for the conditions within the previous 6 months, said Mr. Popper.

In all cases, the patient gets coverage immediately. There is no waiting period, and premiums will be the same as for a healthy person in the same age range. There are no surcharges for health conditions.

At a meeting of the Association of Community Cancer Centers in March, Mr. Popper cited figures for the plan in Texas, which has a program that is operated by the federal government. For standard coverage, individuals could expect to pay from $174 to $557 monthly, depending on age, with a $2,000 deductible for medical care and a $500 deductible for medications. Higher benefit plans run $234-$749 for premiums, with $1,000 and $250 deductibles, respectively. There is also a health savings account option, with premiums of $181-$578 and a $2,500 deductible.

The out-of-pocket maximum that patients would pay under all plans is $5,950. There is no lifetime limit and no limit on physician visits or prescription drugs.

Relief in Rhode Island

At least one couple – Don and Renee Eddie of Rhode Island – has been thrilled to have stumbled upon the PCIP. The couple had been trying to stay insured over the last 6 years or so, through a patchwork of plans. They also have a son who is disabled.

Initially, they had family coverage through her teaching job, but after a series of back surgeries left her unable to work in 2004, she lost the coverage along with the job. Mr. Eddie had coverage through his workplace, Electric Boat, and when he retired in 2006, the Eddies elected a family plan through the company. But the premiums were $1,299 a month. "We did that for 18 months, and it was draining us," said Ms. Eddie in an interview.

They found a discount insurance program; the premiums were cheap at $300 a month, but the coverage was paltry. After being left with a $587 bill for a blood test, the family decided to drop the plan. And then, a few months later, in April 2010, trouble set in. One day, after doing some work at home, Mr. Eddie complained of chest pain. When he became sweaty, Ms. Eddie drove him down the road to a nearby fire department. They packed him up in an ambulance and took him to the emergency department.

Shortly thereafter he had two stents inserted and spent 4 days in intensive care. The bill came to $92,000.

Ms. Eddie went back to trying to find an affordable insurance plan for Mr. Eddie. They settled on one that would cost $700 a month, but at the last minute decided they couldn’t stand the financial burden and backed out. A few months later, she read about the PCIP in an article in the Providence Journal.

Ms. Eddie applied, and in October her husband got coverage for $519 a month through Blue Cross of Rhode Island. The state runs its own plan, which has a $1,000 deductible. Mr. Eddie’s premiums have risen this year, as he just turned 60, but they are still a relatively affordable $567, said Ms. Eddie.

His prescriptions, which include Plavix, simvastatin, and Crestor, are relatively affordable also, she said. The best part of the plan, according to Ms. Eddie, is the monthly call from a Blue Cross nurse coordinator to offer tips and to monitor his care. "It’s the first time we’ve had anything like that, so that’s a very nice component," said Ms. Eddie, who added that the "personal connection" made them feel as if they were getting better care.

"I’ve been very, very pleased with this program," said Ms. Eddie. She was able to resume coverage for herself through the retirement plan offered through her teaching position, and her son is receiving Medicaid benefits.

In the meantime, DHHS is trying to get the word out about the PCIP. Mr. Popper said that when people apply for disability under the Social Security program, they receive notification about the PCIP. Many insurance companies have also been advising patients who are rejected for coverage that the PCIP is a potential alternative, said Mr. Popper.

Finally, his office has been reaching out to hospitals and to physicians and provider organizations to educate them about the program, he said.

A federal program to help people with pre-existing conditions obtain health insurance has lagged in terms of the government’s projected enrollment, which may be partly because it has largely gone unnoticed as one of the benefits of the health reform law.

The Pre-Existing Condition Insurance Plan (PCIP) was launched in July 2010 with $5 billion in funding from the Affordable Care Act. The goal is to provide an insurance option to people who may be barred from coverage or who have to pay huge surcharges because of a pre-existing condition such as hypercholesterolemia or cancer. The program will be in force until 2014, when the new insurance exchanges go into effect and insurers are prohibited from denying coverage to adults with pre-existing conditions. (They are already barred from doing so for children.)

Although the Department of Health and Human Services initially estimated that several hundred thousand people might benefit from the PCIP, as of early May only about 18,000 people had enrolled, according to the government’s statistics.

In an interview, Richard Popper, director of insurance programs at the federal Center for Consumer Information and Insurance Oversight, would not comment on the number of enrollees. But he said that enrollment had been strongest in states with higher populations, such as Texas, California, Pennsylvania, and Illinois.

A "significant number" of patients with cancer, coronary artery disease, chronic obstructive pulmonary disease, and digestive system problems have accessed the program, said Mr. Popper, whose office is a division within the Centers for Medicare and Medicaid Services. The average person who has enrolled has annual medical costs of $20,000 a year, he said.

Enrollment, Eligibility How-Tos

To be eligible for the PCIP, an individual must have been without insurance for 6 months before enrollment. Mr. Popper said that because he was not working for DHHS at the time the Affordable Care Act was developed, he can’t comment on why this waiting period was made an essential part of the eligibility.

After that, the program varies according to whether it is administered by a state or the federal government, although there are minimum coverage criteria. Twenty-three states and the District of Columbia elected to have their PCIP program have a federally-run program, which is essentially the same as the plan offered by Blue Cross/Blue Shield to federal employees.

Twenty-seven states run their own programs.

Patients can apply at the PCIP website. They must prove that they have been denied insurance and have a pre-existing condition. That can be accomplished through a letter of denial from an insurer. In some states, an individual can qualify with a letter from a physician noting the pre-existing conditions and stating that the person has been diagnosed or treated for the conditions within the previous 6 months, said Mr. Popper.

In all cases, the patient gets coverage immediately. There is no waiting period, and premiums will be the same as for a healthy person in the same age range. There are no surcharges for health conditions.

At a meeting of the Association of Community Cancer Centers in March, Mr. Popper cited figures for the plan in Texas, which has a program that is operated by the federal government. For standard coverage, individuals could expect to pay from $174 to $557 monthly, depending on age, with a $2,000 deductible for medical care and a $500 deductible for medications. Higher benefit plans run $234-$749 for premiums, with $1,000 and $250 deductibles, respectively. There is also a health savings account option, with premiums of $181-$578 and a $2,500 deductible.

The out-of-pocket maximum that patients would pay under all plans is $5,950. There is no lifetime limit and no limit on physician visits or prescription drugs.

Relief in Rhode Island

At least one couple – Don and Renee Eddie of Rhode Island – has been thrilled to have stumbled upon the PCIP. The couple had been trying to stay insured over the last 6 years or so, through a patchwork of plans. They also have a son who is disabled.

Initially, they had family coverage through her teaching job, but after a series of back surgeries left her unable to work in 2004, she lost the coverage along with the job. Mr. Eddie had coverage through his workplace, Electric Boat, and when he retired in 2006, the Eddies elected a family plan through the company. But the premiums were $1,299 a month. "We did that for 18 months, and it was draining us," said Ms. Eddie in an interview.

They found a discount insurance program; the premiums were cheap at $300 a month, but the coverage was paltry. After being left with a $587 bill for a blood test, the family decided to drop the plan. And then, a few months later, in April 2010, trouble set in. One day, after doing some work at home, Mr. Eddie complained of chest pain. When he became sweaty, Ms. Eddie drove him down the road to a nearby fire department. They packed him up in an ambulance and took him to the emergency department.

Shortly thereafter he had two stents inserted and spent 4 days in intensive care. The bill came to $92,000.

Ms. Eddie went back to trying to find an affordable insurance plan for Mr. Eddie. They settled on one that would cost $700 a month, but at the last minute decided they couldn’t stand the financial burden and backed out. A few months later, she read about the PCIP in an article in the Providence Journal.

Ms. Eddie applied, and in October her husband got coverage for $519 a month through Blue Cross of Rhode Island. The state runs its own plan, which has a $1,000 deductible. Mr. Eddie’s premiums have risen this year, as he just turned 60, but they are still a relatively affordable $567, said Ms. Eddie.

His prescriptions, which include Plavix, simvastatin, and Crestor, are relatively affordable also, she said. The best part of the plan, according to Ms. Eddie, is the monthly call from a Blue Cross nurse coordinator to offer tips and to monitor his care. "It’s the first time we’ve had anything like that, so that’s a very nice component," said Ms. Eddie, who added that the "personal connection" made them feel as if they were getting better care.

"I’ve been very, very pleased with this program," said Ms. Eddie. She was able to resume coverage for herself through the retirement plan offered through her teaching position, and her son is receiving Medicaid benefits.

In the meantime, DHHS is trying to get the word out about the PCIP. Mr. Popper said that when people apply for disability under the Social Security program, they receive notification about the PCIP. Many insurance companies have also been advising patients who are rejected for coverage that the PCIP is a potential alternative, said Mr. Popper.

Finally, his office has been reaching out to hospitals and to physicians and provider organizations to educate them about the program, he said.