There may be an answer for significantly disabled people who have been, up until now, unable to purchase private health insurance.  Due to recent health care legislation passed by Congress, as of August 1, 2010, the new high-risk pool of individuals who have pre-existing conditions can purchase health insurance.  


In 2014, the main program kicks in, entitled the Health Insurance Exchange – in which these people will participate with all healthy people. 


However, as a stopgap for persons with disabilities or other pre-existing conditions, the legislation provided that by April 30th, 2010 the state governors had to elect to either run a no-pre-existing condition health insurance program themselves, or elect to have the federal government do it via the U.S. Department of Health and Human Services.  Governor Charlie Crist advised that Florida would opt for the federal plan, and not administer this by the state-run Department of Children and Families. 

 

The program set to begin on August 1, 2010 is called the “Pre-existing Condition Insurance Program” (PCIP).  It requires that the person have pre-existing conditions that caused him or her to be rejected by at least one insurance company, and have been without health insurance for 6 months. 

 

To be eligible for this coverage:

  1. You must be a citizen or national of the United States or lawfully present in the United States. You must provide a copy of a document that confirms your citizenship, such as a copy of your U.S. Passport, a copy of your birth certificate, a copy of your certificate of citizenship, or a copy of your naturalization certificate. By August 15th, 2010, we will have a system in place to match your information with the records of another Federal agency and will no longer require you to document your citizenship. We thank you for your patience.
  2. You must have been uninsured for at least the last six months.
  3. You must have had a problem getting insurance due to a pre-existing condition. For more details, download the Application Form to the right.
  4. For children under age 19 or persons who live in Massachusetts only: You must have been quoted a premium of 200% or more of the Pre-Existing Condition Insurance Plan premium for your state. To find out if the premium you were offered is twice as much as the Pre-Existing Condition Insurance Plan premium go to “Find Your State”. Premium rates will not be available until July 15, so if you send an application before rates are available, that determination will be made for you.

 

 

The application form is available ONLINE, and after August 1st, a person can actually apply online and not have to download and submit the form by mail.

 

The cost in Florida for someone over age 55 would be $773 per month.  It may seem high, but when compared to private health insurance for healthy individuals of the same age, it is actually comparable or lower.    And, of course, uninsured people can use up most of their resources paying fee-for-service rates if their medical costs are high.  Medical debt is the number one reason for bankruptcy in the United States.

 

Here’s some more info from the PCIP website:

 

Pre-Existing Condition Insurance Plan (PCIP): Florida


PCIP will cover a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs. All covered benefits are available for you, beginning on your coverage effective date, even if it’s to treat a pre-existing condition – there are no waiting periods.

The monthly premiums for your state are:

Age

00-34

35-44

45-54

55+

 

$363

$435

$556

$773

In addition to your monthly premium, you will pay other costs. Covered in-network services are subject to a $2,500 annual deductible (except for preventive services) before the plan starts to pay benefits. Once you’ve met the deductible, you will pay a $25 copayment for doctor visits, $4 to $30 for most drugs at a retail pharmacy for the first two prescriptions and 50% of the cost of the prescriptions after that. If you use mail order, you will pay $10 for generic drugs or $75 for brand drugs on the plan formulary for a 90 day supply. You will pay 20% of the cost of any other covered benefits received from a network provider. Your out-of-pocket costs cannot be more than $5,950 per year. However, your out-of-pocket costs may be higher if you go outside the plan’s network. See below for a benefits summary.

If you apply for PCIP coverage, you will be billed for the premium once your application is approved. You will need to send in your payment in order for your coverage to be effective. Please do not send in the premium before you are billed.

 

 

Here’s some more from the website – Questions and Answers:

 

Questions and Answers

What is a pre-existing condition?

A pre-existing condition is a condition, disability or illness (either physical or mental) that you have before you enrolled in a health plan.

 

Will the Pre-Existing Condition Insurance Plan (PCIP) be available in every state?

Yes, every state will have a plan that offers comprehensive health coverage for uninsured Americans with pre-existing conditions. The program name, start date, and other plan details may vary depending on which state you live in and whether the program is run by the state or the Department of Health and Human Services. Check out the State Plans page to learn more about how the Pre-Existing Condition Insurance Plan works in your state.

 

When will my coverage be effective?

If you live in a state where the U.S. Department of Health and Human Services is running the program, you can apply and enroll starting July 1, 2010. Coverage will begin August 1 if you apply and are approved for enrollment by July 15th. Generally, a completed application received on or before the 15th of the month will go into effect on the first day of the next month. A completed application received after the 15th of the month will go into effect on the first day of the following month. 

In all other states, coverage should be available by the end of the summer but the exact start date will vary by state. Check out the State Plans page to learn more about when the Pre-Existing Condition Insurance Plan begins in your state.

 

May I apply for the Pre-Existing Condition Insurance Plan if I have existing health coverage?

You are not eligible unless you have been without health coverage for at least the last six months. For example, if you have Medicare or TRICARE, you shouldn’t apply. If you are uninsured and have been told that you may be eligible for other coverage programs like Medicaid and the Children’s Health Insurance Program, you should check out those programs first, as they may better meet your needs. If you have job-based coverage, or individual insurance coverage, you aren’t eligible to apply.

 

May I apply for the Pre-Existing Condition Insurance Plan if I have COBRA or other continuation of coverage?

No, even if your COBRA or other continuation of coverage is about to run out, you won’t be eligible until you have been uninsured for at least the last six months, and meet other eligibility criteria.

 

What health care providers are in the network?

The Pre-Existing Condition Insurance Plan will have provider networks that include a full range of services and specialists.

 

What do I do if I can’t afford these premiums?

If you have limited income and resources, you may be eligible for the Medicaid program in your state. If you are seeking insurance coverage for your child, go to www.insurekidsnow.gov to learn more about children’s health insurance in your state.

 

 

Finally, we noted that Florida rates are around 40% higher than comparable programs in other states.  This may benefit disabled persons considering a move to another state.

The organizers of the Florida State Guardianship Annual Convention asked me to prepare some comments on Social Security, Medicare and Medicaid – It Just Keeps Changing.  The ten page paper highlights changes in how  attorneys and guardians of disabled individuals will have to change the way they interact with SSA, video hearings, “paperless” medical and legal files at SSA, as well as the 2008 changes in Medicare, and changes we are expecting in the SSI POMS that relate to Special Needs Trust administration: new rules on employment by the trustee of parents to care for minor disabled children, support of dependent spouses and minor children using the disabled parent’s trust funds (see our previous post on July 11th), and structured settlement annuity problems, particularly with deeming of healthy parents’ annuities against the disabled child’s continued eligibility for SSI and Medicaid.

If you want more information on guardianship, or the Florida State Guardianship Association and an application for membership, click here.