12/2011 Application and Handbook 2012 PCIP California Pre-Existing Condition Insurance Plan MRMIP California Major Risk Medical Insurance Program Inside this booklet: 2 Glossary of Definitions 3 Health Insurance for Californians 4 Are You Eligible for PCIP or MRMIP? 4 PCIP and MRMIP Benefits 5 Worksheet: Find Out Which Program Is Right for You 6 Application Checklist: Important! A1 PCIP and MRMIP Application Form 7 Important Notices and Declarations 8 PCIP and MRMIP Monthly Premiums Comparison Charts 14 PCIP and MRMIP Costs and Benefits Comparison Charts 20 PCIP and MRMIP Frequently Asked Questions We’ve got you covered! Get the coverage you need, even if you have been denied before.
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Transcript
12/2011
Application and Handbook 2012PCIP California Pre-Existing Condition Insurance Plan
MRMIP California Major Risk Medical Insurance Program
In PCIP,therearenoannualorlifetimebenefitmaximums.MRMIPhasannualandlifetimebenefitmaximumsthatcanresultinyourbeingresponsibleforallcostsabovethemaximums,orbeingunabletoobtainmedicalcare.
In PCIP,thereisnowaitingperiodforimmediatetreatmentforyourpre-existingmedicalcondition.Note:MRMIPhasa3-monthpostenrollmentwaitingperiod(HMOs)orpre-existingconditionexclusion(PPO).Thesemaybewaivedundercertaincircumstances(see page 22).
n Anofferofindividual(notgroup)healthcoverageathigherpremiumsthantheMRMIPpreferredproviderorganization(PPO)ratewhereyoulive.Theofferlettermustbedatedwithinthelast12months(see pages 8 – 13 for MRMIP’s PPO monthly premiums.),or
n AcertificateofcreditablecoverageletterissuedbyanotherstateorFederallyadministeredPCIPprogramshowingpreviousenrollmentwithinthepast6months(see page 20).
premiumsthatarehigherthanyourfirstMRMIPplanchoice.Theofferlettermustbedatedwithinthelast12months(see pages 8 – 13 for MRMIP’s monthly premiums),or
n Proofofinvoluntaryterminationfromahealthplan,healthinsurancecompanyoremployerplanforreasonsotherthanfraudornon-paymentofpremiums.Theinvoluntaryterminationlettermustbedatedwithinthelast12months.
If you answered Yes to all the questions above, you probably qualify for PCIP.
If you answered Yes to all the questions above, you probably qualify for MRMIP.
Worksheet: Find Out Which Program Is Right for You
The PCIP is generally the best health coverage program for everyone who qualifies! ThePCIPpremiumsaremoreaffordableandPCIPhasnoannualorlifetimebenefitmaximum.Reviewtheprogramdifferencesbelow.
YouhavereviewedthePCIPandMRMIPcomparisoncharts,whichprovideinformationabouteligibility,benefits,andcosts. Youhaveansweredallquestionsontheapplication.(For PCIP, youmustprovideyour Social Security Number ifyouareaU.S.Citizenor
For PCIP,includeacopyofoneofthese: Adenialletterfromindividual(notgroup)healthcoveragereceivedinthelast12months Aletterdatedwithinthelast12monthsfromalicenseddoctor,physicianassistantornursepractitioner statingtheindividualhasorhadamedicalcondition,disability,orillness Anofferletterofindividual(notgroup)healthcoveragewithpremiumsthatarehigher than the MRMIP PPO rate basedontheareawhereyoulive ACertificateofCreditableCoverageletterissuedbyPCIPfromanotherstateorFederallyadministeredPCIPprogram, (responseonpageA3ofapplication)
For PCIP,includeacopyofoneofthese: CertificateofU.S.Citizenship CertificateofU.S.Naturalization U.S.birthcertificate U.S.passport Otherproofofcitizenship Proofofimmigrationstatus(Senddocumentsthatarenotexpired.Includecopiesofbothfrontandback.) Foralistofacceptableimmigrationdocuments,gotowww.pcip.ca.gov.Thenclickonthe“FrequentlyAskedQuestions”link onthewebsite.Or,callusifyouneedassistance!
If you choose MRMIP,includeacopyofoneofthese: Adenialletterfromindividual(notgroup)healthcoveragereceivedinthelast12months Anofferletterofindividual(notgroup)healthcoveragewithpremiumsthatarehigher than your first MRMIP plan choice receivedinthelast12months Aterminationletterfromahealthplan,healthinsurancecompanyoremployerplanforreasonsotherthanfraudornon-payment ofpremiumsreceivedinthelast12months
If you choose MRMIP and: you are applying for deferred enrollmentbecauseyoubelieveyouqualifybutcurrentlyhavehealthcoverage.Includeacopy ofaletterfromtheemployerorinsurancecompanyyouhavenow,tellinguswhentheinsurancecoveragewillend. youcurrently have Medicare Part A and Part B because of end-stage renal disease.Includeacopyoftheapprovalletter fromMedicare. youwanttowaive part or all of the waiting or exclusion period.Includeacopyofproofofanyinsurancecoveragethatyou hadbefore. youhaveadependent child who is over 23 years old.Sendadoctor’sletterwiththeapplicationforeachchildover23statingthatthe personcannotworkbecauseofacontinuousphysicalormentaldisabilitythatstartedbeforeage23.Thedependentchildcannotbemarried.
Signtheapplication.
Writeacheckforonemonth’spremiumfortheprogramyouareinterestedin.MakethecheckpayabletotheManaged Risk Medical Insurance Board (MRMIB).Seepages8–13fortheprograms’monthlypremiumsbyregion.
Mailtheapplicationwithyourcheckandallrequireddocumentsto: CaliforniaPre-ExistingConditionInsurancePlan,P.O.Box537032,Sacramento,CA95853-7032 Insurance Agents/Brokers or Certified Application Assistants: Completeall applicableboxesatthebottomoftheapplication
Wereyoucoveredbyasimilarhigh-riskinsuranceprograminanotherstatewithinthelast12months? Yes No
IfyoudonotqualifyforMRMIPrightnowbutexpecttoqualifysoon,areyouapplyingfordeferredenrollment?(see page 21) Yes NoIf Yes, please provide the following information:
Haveyoumettherequirementstoavoidall(orpart)oftheMRMIPexclusion/waitingperiod?(see page 22) Yes NoIf Yes, please fill in the information below:
If you are applying for MRMIP and want coverage for dependents, list the dependents here. PCIP does not provide coverage for dependents. Each person interested in PCIP must complete a separate application. He or she must qualify to be enrolled.
5
Name of dependent Gender Date of birth Married? Relationship to applicantLast,First,MiddleInitial,andSSN(optional) FemaleorMale Month/Day/Year YesorNo Checkone:
If you have more dependents,photocopypageA2andfillitout.Sendtheadditionalpageswithyourapplication. Subscriberdependentsage18andunderarenotsubjecttothepre-existingconditionexclusionperiodorthepost-enrollmentwaitingperiod.
Ifadependentchildisover23yearsold,sendadoctor’sletterwiththeapplicationforeachchildover23statingthatthepersoncannotworkbecauseofacontinuousphysicalormentaldisabilitythatstartedbeforeage23.Thedependentchildcannotbemarried.Isthedependentchild(whoisover23yearsold)coveredbyMedicare? Yes No
Haveanyofyourdependentsmettherequirementstoavoidall(orpart)oftheexclusion/waitingperiod?(see page 21) Yes NoIf Yes, list their names below:
A2
A3
Tell us about your recent health insurance experience that qualifies you for PCIP or MRMIP.
Hasyouremployer,aninsurancecompanyorinsuranceAgent/Brokerdiscouragedyoufromgetting Yes Nohealthcoveragethatyouqualifiedfor?If Yes, provide more information below.
Nameofemployerorhealthinsurancecompany:
Address:
City: State: ZIPcode:
6
For PCIP: Withinthepast6months,haveyouhadanyofthefollowingtypesofhealthcoverage? Yes NoIf Yes, please indicate by checking the boxes below, and indicate date your health coverage ended _____ /_____ /_____.
Haveyoureceivedadenialletterfromahealthinsurancecompanyorhealthplanwithinthepast12months? Yes No If Yes, provide a copy of the denial letter.
For PCIP: Withinthepast12months,haveyoureceivedanofferofindividual(notgroup)healthcoverageathigher Yes No ratesthantheMRMIPPPOproduct?If Yes, provide a copy of the offer letter.For MRMIP: Withinthepast12months,haveyoureceivedanofferofindividual(notgroup)healthcoverageathigher Yes No
ratesthanyourselectedMRMIPhealthplan?If Yes, provide a copy of the offer letter.
For PCIP: Haveyoureceivedaletterfromalicenseddoctor,physicianassistant,ornursepractitionerwithinthe Yes No past12months,statingtheindividualhasorhadamedicalcondition,disabilityorillness? IfYes, provide a copy of the provider letter.
For MRMIP: Haveyoubeeninvoluntarilyterminatedfromhealthinsurancecoverageforreasonsotherthanfraud Yes No ornonpaymentofpremium?IfYes, provide a copy of the termination letter.
mo day yr
MRMIP health plan dispute resolution and PCIP dispute resolution7InMRMIP,eachplanhasitsownrulesforresolvingdisputesaboutdelivery,services,andothermatters.Someplanssayyoumustusebindingarbitrationfordisputes(notincludingdisputeswiththeprogramaboutwhichbenefitsarecovered);othersdonot.Someplanssaythatclaimsformalpracticemustbedecidedbybindingarbitration;othersdonot.Iftheplanyouchooserequiresbindingarbitration,youaregivingupyourrighttoajurytrialandcannothaveadisputedecidedincourt.Tofindouthowaplanresolvesdisputes,youcancalltheplanandrequestanEvidenceofCoveragebooklet.ToseewhichMRMIPplansrequirebindingarbitration,seepage7.
In PCIP,therearerulesforresolvingdisputesaboutdelivery,services,andothermatters.TofindouthowPCIPresolvesdisputes,youcancallPCIPat1-877-428-5060,orrefertotheSummaryPlanDescriptionbookletonourwebsiteatwww.pcip.ca.gov.
A4
Important notices and declarations, and understandings and responsibilities 8
Agent/Broker or CAA signature: ____________________________________________________________________________________ Date:__________________________________________
Agent/Brokername:
Streetaddress:
TaxI.D./SocialSecurityNumber(Agent/Brokeronly):
City:
State: ZIPcode: Phone: Emailaddress:
For Insurance Agents/Brokers or Certified Application Assistants (CAAs) only:
Ifyouassistedanapplicantincompletingthisapplication,pleasecompletethissection.Youmustcompleteallapplicableboxes.Youwillnotbepaidifyoudonotcompletethissectionpriortosendingtheapplication.Missinginformationcannotbesubmittedatalaterdateforpayment.(Please see page 20.)IftheapplicantwantsPCIPorMRMIPtoprovideyouwiththestatusofthisapplicationandfinaleligibilitydecision,makesuretheapplicantsignsSection9above.
n IunderstandthatitismyresponsibilitytoinformPCIPofanyhealthcoverageIgetinthefutureorifImoveoutofCalifornia,sothatIcanbedisenrolled.
n Iunderstandthat,ifIvoluntarilydisenrollfromPCIPorifIamdisenrolledinvoluntarily(forexample,forfailuretopaymypremiumsontime),Imaynotre-qualifyforenrollmentuntilatleast6monthsaftermycoverageends.
n IunderstandthatmyapplicationandenrollmentinformationmaybesharedwithotherFederalandStategovernmentagenciesforpurposesofestablishingPCIPeligibility.
n IunderstandthatmyapplicationmustbereviewedtodeterminewhetherornotIqualifyforcoverage.
n Iunderstandthat,ifmyapplicationisapproved,theeffectivedateofcoveragewillbedeterminedaccordingtoapplicablelawsandregulationsandIwillbeinformedinwritingoftheeffectivedateofcoverage.
n IunderstandthattheMRMIPhealthplandisputeresolutionprocessmayincludebindingarbitration,ratherthanacourttrialtoresolveanyclaim.Thisincludesaclaimformalpracticeassertedbyme,myenrolleddependents,heirs,personalrepresentatives,orsomeonewitharelationtousagainsttheparticipatinghealthplanoragainsttheemployees,partnersoragentsoftheparticipatinghealthplan.
n IunderstandthatMRMIP’sContraCostaHealthPlanDOESNOTrequirebindingarbitration.
n IunderstandthatMRMIP’sAnthemBlueCrossandKaiserPermanenteHealthPlansDOrequirebindingarbitrationofdisputesINCLUDINGmalpractice,solongasthedisputesarebeyondthejurisdictionallimitofthesmallclaimscourt.Thisdoesnotincludedisputeswiththeprogramaboutwhichbenefitsarecovered.
n IunderstandthatifIdonotprovideallthenecessaryinformationrequestedtoprocesstheapplication,theapplicationwillbedeniedorreturnedasincomplete.
n Ideclarethat,withinthelast6months,IhavenothadhealthcoveragepriortothedateIamaskingforcoverageinthePCIP.
n IdeclarethatallindividualslistedonthisapplicationareresidentsoftheStateofCalifornia.
n IdeclareandunderstandthatmakingamonthlypremiumpaymentdoesnotmeanthatIamacceptedby,or,ifaccepted,immediatelyenrolledinto,theprograms.
n IdeclarethatnopersonlistedonthisapplicationandapplyingforMRMIPiseligibleforbothMedicarePartsAandPartB,unlesstheyaresolelyeligiblebecauseofend-stagerenaldisease.
n IdeclarethatnopersonlistedonthisapplicationandapplyingforPCIPisenrolledinMedicarePartsAandB.
n Ideclarethatallindividualslistedonthisapplicationwillabidebyallrulesofprogramparticipation.
n IdeclarethatnopersonlistedonthisapplicationandapplyingforcurrentordeferredenrollmentintoMRMIPiscurrentlyeligibletopurchaseanycontinuationofemployerhealthbenefitsundertheprovisionsof29U.S.Code1161etseq.(COBRA),orundertheprovisionsofInsuranceCodeSections10128.50etseq.andHealthandSafetyCodeSections1366.20etseq.(Cal-COBRA).Thesearelawswhichallowpeopletobuyintotheiremployer’shealthinsuranceforupto36consecutivemonthsaftertheyleavetheiremployment.
n IdeclarethatnopersonlistedonthisapplicationandapplyingforPCIPisenrolledinCOBRAorCal-COBRA.
n Ideclarethatnopersonlistedonthisapplication,andapplyingforcoveragethroughtheMRMIP,wasterminatedwithinthelast12monthsfroma“Post-MRMIPGuaranteedIssuePilotProgram”asaresultofnon-paymentofpremiums,arequesttodisenrollvoluntarily,orfraud.A“PostMRMIPGuaranteedIssuePilotProgram”isahealthplaninwhichanindividualhadanopportunitytoenrollbetweenSeptember1,2003andDecember31,2007asaresultofbeingdisenrolledfromMRMIPafter36consecutivemonthsofenrollment.
n IdeclarethatIhavereadandunderstandtheinformationonthisApplicationandagreetotheseNoticesandDeclarations.
PCIP and MRMIP Monthly Premiums | Area 1Usethischarttocomparepremiumsbasedonyourageandwhereyoulive.
Premiums for people who live in:Alpine,Amador,Butte,Calaveras,Colusa,DelNorte,ElDorado,Glenn,Humboldt,Inyo,Kings,Lake,Lassen,Mendocino,Modoc,Mono,Monterey,Nevada,Placer,Plumas,SanBenito,Shasta,Sierra,Siskiyou,Sutter,Tehama,Trinity,Tulare,Tuolumne,Yolo,andYubacounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.
PCIP
Subscriber only
Age
PCIP
0 – 14 $119.00
15 – 18 $119.00
19 – 29 $164.00
30 – 34 $237.00
35 – 39 $264.00
40 – 44 $292.00
45 – 49 $332.00
50 – 54 $411.00
55 – 59 $492.00
60 – 64 $535.00
65 – 69 $535.00
70 – 74 $535.00
> 74 $535.00
Subscriber and 1 dependent
Anthem Blue Cross
PPO
Kaiser Permanente
N. California 1
$741.00 $561.88
$999.00 $747.59
$999.00 $747.59
$1,185.00 $850.48
$1,290.00 $937.91
$1,409.00 $1,208.78
$1,701.00 $1,078.53
$2,151.00 $1,285.99
$2,614.00 $1,424.89
$3,182.00 $1,622.08
$3,564.00 $2,402.18
$3,755.00 $2,534.53
$3,978.00 $2,680.48
Subscriber and 2 or more dependents
Anthem Blue Cross
PPO
Kaiser Permanente
N. California 1
$1,165.00 $974.04
$1,645.00 $1,224.26
$1,645.00 $1,224.26
$1,955.00 $1,481.46
$2,121.00 $1,481.46
$2,179.00 $1,503.75
$2,436.00 $1,503.75
$2,817.00 $1,663.21
$3,243.00 $1,663.21
$3,833.00 $1,879.28
$4,293.00 $3,121.43
$4,523.00 $3,299.8
$4,791.00 $3,490.98
Subscriber only
Anthem Blue Cross
PPO
Kaiser Permanente
N. California 1
$374.00 $281.50
$488.00 $354.06
$488.00 $354.06
$674.00 $418.36
$768.00 $449.24
$810.00 $504.10
$860.00 $553.86
$1,101.00 $639.58
$1,324.00 $732.16
$1,670.00 $811.03
$1,870.00 $1,354.51
$1,971.00 $1,429.93
$2,087.00 $1,517.08
1. Kaiser Permanente Northern California servestheseZIPcodesinthesecounties:Amador 95640and95669 | El Dorado 95613-14,95619,95623,95633-35,95651,95664,95667,95672,95682,and95762 | Kings
PCIP and MRMIP Monthly Premiums | Area 2 Usethischarttocomparepremiumsbasedonyourageandwhereyoulive.
Premiums for people who live in: Fresno,Imperial,Kern,Madera,Mariposa,Merced,Napa,Sacramento,SanJoaquin,SanLuisObispo,SantaCruz,Solano,Sonoma,andStanislauscounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.
2. Kaiser Permanente Northern California servesallZIPcodesinSacramento,
San Joaquin, and SolanocountiesandtheseZIPcodesinthesecounties:Fresno93242,93602,93606-07,93609,93611-13,93616,93619,93624-27,93630-31,93646,93648-52,93654,93656-57,93660,93662,93667-68,93675,93701-12,93714-18,93720-30,93737,93741,93744-45,93747,93750,93755,93760-61,93764-65,93771-79,93786,93790-94,93844,and93888| Madera 93601-02,93604,93614,93636-39,93643-45,93653,and93669| Mariposa 93623 |
PCIP and MRMIP Monthly Premiums | Area 3 Usethischarttocomparepremiumsbasedonyourageandwhereyoulive.
Premiums for people who live in: Alameda,ContraCosta,Marin,SanFrancisco,SanMateo,andSantaClaracounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.
Subscriber only
Anthem Blue Cross
PPO
Contra Costa Health Plan 4
Kaiser Permanente
N. California 5
$396.00 $268.35 $281.50
$518.00 $341.28 $354.06
$518.00 $341.28 $354.06
$715.00 $495.84 $418.36
$815.00 $495.84 $449.24
$859.00 $571.16 $504.10
$912.00 $571.16 $553.86
$1,168.00 $762.59 $639.58
$1,404.00 $762.59 $732.16
$1,771.00 $963.45 $811.03
$1,984.00 $1,292.97 $1,354.51
$2,090.00 $1,292.97 $1,429.93
$2,214.00 $1,292.97 $1,517.08
PCIP
Subscriber only
Age
PCIP
0 – 14 $124.00
15 – 18 $124.00
19 – 29 $171.00
30 – 34 $247.00
35 – 39 $275.00
40 – 44 $305.00
45 – 49 $346.00
50 – 54 $428.00
55 – 59 $514.00
60 – 64 $557.00
65 – 69 $557.00
70 – 74 $557.00
> 74 $557.00
Subscriber and 1 dependent
Anthem Blue Cross
PPO
Contra Costa Health Plan 4
Kaiser Permanente
N. California 5
$785.00 $662.17 $561.88
$1,060.00 $662.17 $747.59
$1,060.00 $662.17 $747.59
$1,257.00 $878.70 $850.48
$1,368.00 $878.70 $937.91
$1,494.00 $1,085.82 $1,028.78
$1,804.00 $1,085.82 $1,078.53
$2,281.00 $1,487.56 $1,285.99
$2,773.00 $1,487.56 $1,424.89
$3,375.00 $1,920.65 $1,622.08
$3,780.00 $2,520.04 $2,402.18
$3,983.00 $2,520.04 $2,534.53
$4,219.00 $2,520.04 $2,680.48
Subscriber and 2 or more dependents
Anthem Blue Cross
PPO
Contra Costa Health Plan 4
Kaiser Permanente
N. California 5
$1,235.00 $1,220.80 $974.04
$1,745.00 $1,220.80 $1,224.26
$1,745.00 $1,220.80 $1,224.26
$2,073.00 $1,349.45 $1,481.46
$2,250.00 $1,349.45 $1,481.46
$2,311.00 $1,606.81 $1,503.75
$2,584.00 $1,606.81 $1,503.75
$2,987.00 $1,839.03 $1,663.21
$3,439.00 $1,839.03 $1,663.21
$4,065.00 $2,231.32 $1,879.28
$4,553.00 $2,988.48 $3,121.43
$4,797.00 $2,988.48 $3,299.80
$5,082.00 $2,988.48 $3,490.98
4. Contra Costa Health Plan isavailableonlyinContra Costa County.
5. Kaiser Permanente Northern California servesallZIPcodesinAlameda, Contra Costa, Marin, San Francisco, and San Mateo countiesandtheseZIPcodesinthiscounty:Santa Clara 94022-24,94035,94039-43,94085-89,
PCIP and MRMIP Monthly Premiums | Area 6 Usethischarttocomparepremiumsbasedonyourageandwhereyoulive.
Premiums for people who live in: Riverside,SanBernardino,andSanDiegocounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.
Subscriber and 1 dependent
Anthem Blue Cross
PPO
Kaiser Permanente
S. California 8
$683.00 $515.68
$922.00 $697.13
$922.00 $697.13
$1,093.00 $792.53
$1,190.00 $875.75
$1,299.00 $960.73
$1,569.00 $1,005.79
$1,984.00 $1,200.04
$2,412.00 $1,330.11
$2,936.00 $1,513.91
$3,288.00 $2,305.54
$3,464.00 $2,432.19
$3,670.00 $2,584.93
Subscriber and 2 or more dependents
Anthem Blue Cross
PPO
Kaiser Permanente
S. California 8
$1,074.00 $894.15
$1,518.00 $1,238.20
$1,518.00 $1,238.20
$1,804.00 $1,382.11
$1,956.00 $1,382.11
$2,010.00 $1,404.66
$2,247.00 $1,404.66
$2,598.00 $1,552.08
$2,991.00 $1,552.08
$3,536.00 $1,754.98
$3,960.00 $2,919.93
$4,173.00 $3,081.30
$4,420.00 $3,274.44
Subscriber only
Anthem Blue Cross
PPO
Kaiser Permanente
S. California 8
$345.00 $258.41
$450.00 $330.34
$450.00 $330.34
$622.00 $390.19
$708.00 $419.66
$748.00 $471.68
$793.00 $516.79
$1,016.00 $596.56
$1,221.00 $683.25
$1,540.00 $757.83
$1,725.00 $1,295.81
$1,818.00 $1,365.71
$1,925.00 $1,446.86
PCIP
Subscriber only
Age
PCIP
0 – 14 $108.00
15 – 18 $108.00
19 – 29 $149.00
30 – 34 $214.00
35 – 39 $240.00
40 – 44 $265.00
45 – 49 $301.00
50 – 54 $375.00
55 – 59 $447.00
60 – 64 $485.00
65 – 69 $485.00
70 – 74 $485.00
> 74 $485.00
8. Kaiser Permanente Southern California servesZIPcodesinthesecounties:Riverside 91752,92220,92223,92320,92501-09,92513-19,92521-22,92530-32,92543-46,92548,92551-57,92562-64,92567,92570-72,92581-87,92589-93,92595-96,92599,92860,and92877-83|San Bernardino 91701,91708-10,91729-30,91737,91739,91743,91758,91761-64,91784-86,92252,92256,92268,92277-78,92284-86,92305,92307-08,92313-18,92321-22,92324-26,92329,92331,92333-37,92339-41,92344-46,92350,92352,92354,
92357-59,92369,92371-78,92382,92385-86,92391-95,92397,92399,92401-08,92410-15,92418,92423-24,and92427|San Diego 91901-03,91908-17,91921,91931-33,91935,91941-47,91950-51,91962-63,91976-80,91987,92007-92011,92013-14,92018-27,92029-30,92033,92037-40,92046,92049,92051-52,92054-58,92064-65,92067-69,92071-72,92074-75,92078-79,92081-85,92091-93,92096,92101-24,92126-32,92134-40,92142-43,92145,92147,92149-50,92152-55,92158-79,92182,92184,92186-87,and92190-99.
PremiumseffectivethroughDecember31,2012
14
PCIP MRMIP Health Plan Options
Plan areaYoucanchoosethePCIPPPONetworkifyouliveinany countyinCalifornia(statewide).
Plan areaYoucanchoosethisplanifyouliveinany countyinCalifornia(statewide).
Plan areaYoucanchoosethisplanifyouliveinContra CostaCounty.
Plan areaNorthern CA counties:Alameda,Amador,ContraCosta,ElDorado,Fresno,Kings,Madera,Marin,Mariposa,Napa,Placer,Sacramento,SanFrancisco,SanJoaquin,SanMateo,SantaClara,Solano,Sonoma,Sutter,Tulare,Yolo,Yuba
Southern CA counties:Kern,LosAngeles,Orange,Riverside,SanBernardino,SanDiego,Ventura
Annual deductibleDoes not apply to in-network preventive care.$1,500persubscriber(in-networkproviders)$3,000persubscriber(out-of-networkproviders)Thereareseparatedeductiblesforin-networkandout-of-networkservices.
Annual deductibleDoes not apply to preventive care.
Annual deductibleDoes not apply to in-network preventive care.$500perhouseholdTheannualdeductibleappliesonlytoinpatienthospitalservices.Allotherservicesarenotsubjecttothedeductible.
Annual deductibleDoes not apply to in-network preventive care.
Ifyourcompleteapplicationisreceivedwithalltherequireddocumentationby the 15thofthemonth,coveragewillbeginthe1stdayofthefollowingmonth.Forexample,wereceiveacompleteapplicationbyOctober15ththestartdateofcoveragewillbeonNovember1st.
However,ifyourcompleteapplicationisreceivedwithallrequireddocumentationafter the 15thofthemonth,coveragewillbeginonthe1stdayofthesecondmonthfollowingyourapplication.Forexample,wereceiveacompleteapplicationafterOctober15ththestartdateofcoveragewillbeonDecember1st.Incompleteapplicationswillresultindelayedordeniedcoverage.WewillsendyoualetterinformingyouifyouareenrolledinPCIP.
Can Insurance Agents/Brokers assist people in applying for PCIP and MRMIP?
If I had health coverage in the last 6 months, why don’t I qualify for PCIP? I have a pre-existing condition and I cannot be without health coverage for 6 months.
I am a U.S. Citizen or U.S. National. Why do I have to provide my Social Security Number?
PCIPisafederalprogramadministeredinCaliforniaandthefederallawrequiresthatU.S.CitizensorU.S.NationalsprovidetheirSocialSecurityNumber. If you do not provide your Social Security Number,yourapplicationwillbeconsideredincomplete.Wewillsendyoualetterinformingyouthatyourapplicationisincomplete.Ifyoudonotsendustheinformationbytheduedate,youwillbedeniedPCIPcoverageandwewilldetermineyoureligibilityfortheMRMIP.
What is the difference in how Dependents are covered in MRMIP and PCIP?
I was previously enrolled in another state or federally administered PCIP program. I moved and want to enroll in California’s PCIP program. Can I transfer my eligibility?n Yes.Ifyouweredisenrolledbecauseyounolongerresideinthat
PCIP and MRMIP Frequently Asked Questions (continued)
Provide a copyofaCertificateofCreditableCoverageLetterissuedbythePCIPprogramfromtheotherstate.MakesuretheCertificateofCreditableCoverageLetteridentifiesyourstartdateandenddateofcoveragewiththeotherPCIPprogram.
Can I transfer my eligibility from another state’s high-risk pool?
What if I do not qualify for MRMIP right now, but will be eligible for MRMIP coverage soon? Can I apply for deferred enrollment?
Yes.IfyoucurrentlydonotqualifyforMRMIP,butwillbeeligibleinthenearfuture,youmayapplyfor“deferredenrollment.”Deferredenrollmentisappropriatewhenyoucurrentlyhavehealthcoverage(i.e.COBRA,Cal-COBRA,oremployercoverage),butyourhealthcoveragewillbeendingsometimeinthefuture.Ifyouwanttoapplyfordeferredenrollment,completetheinformationontheApplication(pageA2,section4).Youmustprovideacopyofaletter,showingthatyourcurrenthealthcoveragewillterminate.Thelettermustbeissuedfromahealthinsurancecarrier,healthplan,healthmaintenanceorganization,oranemployerplan.Thelettermust specifytheexact datewhenyourcurrentcoveragewillend.Deferred enrollment is not allowed for temporary health insurance policies.
Duringthefirst3months,no benefits or services related to a pre-existing condition are covered.However,othertypesofbenefitsandservicesmaybecoveredduringthisperiod.Subscribersarerequiredtopaymonthlypremiumsduringthepre-existingconditionexclusion.
What is a MRMIP post-enrollment waiting period?
MRMIPsubscribersenrolledinaHealthMaintenanceOrganization(HMO)havetowait 3 months beforetheybeginreceivinganyhealthcarebenefits(includinganypre-existingconditiontreatment).No benefits or services are provided to subscribers during the post-enrollment period and no premiums are paid for this period.MRMIPwillinformsubscriberswhenthepost-enrollmentperiodbeginsandends.ThepremiumpaymentincludedwiththeapplicationwillbeappliedtowardsyourfirstmonthofMRMIPcoverage,afterthepost-enrollmentwaitingperiodends.
I previously had other health coverage or was on the MRMIP waiting list. Can I waive all (or part) of the MRMIP pre-existing condition exclusion or post enrollment waiting period?
n YouareontheMRMIPwaitinglistfor180daysorlonger.Theexclusion/waitingperiodwillbecompletelywaived.
n Youpreviouslyhadhealthcoverage(includingMedicareandMedi-Cal)andyouapplyfortheMRMIPwithin 63 daysfromthedateyourinsuranceended.
n Youpreviouslyhadhealthcoverageanditendedbecauseofoneofthefollowing: Lossofemployment, Employerstoppedofferinghealthcoverage,or Employerstoppedmakingcontributionstowardsthehealth
Ifthefirstlevelappealisdenied,youwillbenotifiedofyourrighttorequesta second level appealtotheExecutiveDirectoroftheManagedRiskMedicalInsuranceBoard(MRMIB).TheMRMIBisthestateagencythatadministersandoverseesthePCIP.Thesecondlevelappealmustbefiledinwritingwithinthirty(30)days
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PCIP and MRMIP Frequently Asked Questions (continued)