Pre-existing conditions and the Affordable Care Act: what you need to know

Robin Wulffson MD's picture
Affordable Care Act, pre-existing condition, PCIP, health insurance
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One popular feature of the Affordable Care Act is the provision for health insurance coverage of individuals with pre-existing conditions. In the past, many insurance plans turned down individuals with pre-existing conditions, such as cancer, cystic fibrosis, or multiple sclerosis, or offered insurance at significantly higher rates. Dixie Swanson, MD offers invaluable information regarding pre-existing conditions and the Affordable Care Act.

Although significant opposition to the Affordable Care Act still exists, now that the 2012 presidential election is behind us, its future is assured. It is likely that some modifications will occur; however, one popular feature is the provision for health insurance coverage of individuals with pre-existing conditions. In the past, many insurance plans turned down individuals with pre-existing conditions, such as cancer, cystic fibrosis, or multiple sclerosis, or offered insurance at significantly higher rates.

Dixie Swanson, MD is a former television health reporter and a lupus patient. She offers invaluable information regarding pre-existing conditions and the Affordable Care Act.

Dr. Swanson says, “Care is available in every state” as a result of the Affordable Care Act. She explains, “People can apply for the Pre-existing Condition Insurance Plan [PCIP], which will not deny you coverage because you have asthma, diabetes, or some other condition, and will not charge you more simply because of it… In Washington D.C. and 23 states, including Florida, Massachusetts, and Texas, it’s run by the federal government. Twenty-seven states run their own PCIP program.” She notes that policies vary from state to state and premiums may vary; however, coverage can cost less than $200 a month. However, shockingly low number of people know about the coverage. As of July 31, there were 82,000 people enrolled. Maine had only 42 enrollees; California had the most: 11,118. She stresses, “Getting and keeping health insurance is Job One for many patients with chronic illness. This is a real step forward.”

Dr. Swanson describes the important points related to PCIP:

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You are eligible for PCIP coverage ONLY if you have been without insurance coverage for the past six months. If you have coverage––even if it does not cover your condition–– you are not eligible, and if you are in a state high-risk pool, you’re not eligible.

Rules vary depending on who administers the plan. In states with the federally administered program, you must submit one of the following with your application: (1) An insurance company’s letter denying you coverage from within the past 12 months; ( 2) An offer of insurance with a rider disallowing your condition, provided you did not accept a policy; (3) If you are under 19 or you live in Vermont or Massachusetts, a letter from a doctor, physician’s assistant or nurse practitioner stating your condition; and (4) If you are under 19 or you live in Vermont or Massachusetts, an offer of insurance that you did not accept because the premium was too high (provided it is at least double the cost of a standard option PCIP premium).

In states with the federally administered program, if your application is accepted, you will receive a letter within two to three weeks. If you submitted your application and all documentation before the 15th of the month, your coverage can start by the 1st of the following month (i.e. by November 15, coverage starts December 1). If you apply after the 15th, it will start by the first of the month after that (i.e. January 1).

PCIP is designed to be temporary. The Affordable Health Care Act calls for private insurance companies to cover pre-existing conditions beginning in 2014, at which time PCIP will not be necessary.

To find out more about PCIP, visit the plan’s official website.

About Dixie Swanson
Dixie Swanson was a pediatrician for 10 years and the Family Health Reporter for NBC’s Houston affiliate. She also spent time working for a Washington lobbyist with access to the White House. Dixie is the author of “The Accidental President Trilogy – a Political Fable for Our Time.”

Reference: Dr. Dixie Swanson

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