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.
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, he said. The average person who has enrolled has annual medical costs of $20,000 a year, he said.
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 couldn't comment on the waiting period.
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 went with a federally run PCIP program, which is essentially the same as Blue Cross/Blue Shield's plan for federal employees. Twenty-seven states run their own programs.
Patients can apply at the federal government's website (www.pcip.gov
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.
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, in April 2010, Mr. Eddie complained of chest pain and was taken 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. 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.