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Jim Guidry Commentaries Bay Area Houston Guidry News Gazette
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Nov 4 Election 160 X 50
Health Insurance for People with Pre-existing Conditions
By Rachel Neycheril, Ramya Krothapally, Nik Nikam, M.D.
Monday, October 17, 2011

Three years ago Mr. Khatani came to the hospital with a severe chest pain. He had an emergency cardiac catheterization and coronary artery bypass surgery. His hospital bill was well over $100,000. He had to mortgage his house to pay his hospital bills. He could not get health insurance because of his pre-existing condition. At least, not until now.  Thanks to the United States Health and Human services and the State of Texas sponsored, "Pre-existing Condition Insurance Plan, (PCIP)” today, Mr. Khatani has health insurance despite having  heart disease, diabetes, and hypertension.

Mr. Khatani is not alone. There are 47 million people without health insurance. Eighty percent of them have at least one family member who has a stable job. In the past, many of them could not get insurance, even if they could afford the premium, because of pre-existing medical conditions. However, today, with the government sponsored PCIP insurance, they have hope.

PCIP: The Pre-Existing Condition Insurance Plan or PCIP was introduced last year by United States Health and Human services for the multitude of people who have been denied health coverage due to a medical condition. It provides many health benefits, including treatment for pre-existing conditions, and doesn’t charge extra because of a medical condition or decide eligibility on income.

The U.S. Department of Health and Human Services, with the help of the U.S. Office of Personnel Management and the U.S. Department of Agriculture’s National Finance Center, runs PCIP Plan in 23 states and the District of Columbia. The federal government contracts with a national insurance plan to administer benefits in those states. In the other 27 states, there are state-based programs.

Premiums:  The premiums are very reasonable. Here are some quotes for Texas residents based on the type of plan. For example, an individual with a pre-existing condition at age 60 would have a premium ranging from $426 to $572 per month, which is considerably less than the premiums they would be charged if they even managed to get coverage from any other insurance program.

AGE

STD-PL

EXT-PL

HSA-PL

19-34

$199

$268

$207

35-44

$239

$323

$248

45-54

$306

$412

$318

55-65

$426

$572

$442

PCIP offers three different programs: Standard Plan, Extended Plan, and Health Savings Account Plan. The maximum out-of-pocket expense for services in a twelve month period is $5,950 if you are in network and $7,000 if you get out-of-network services. The deductibles vary by plan and on whether the care is in-network or out-of network. For more information on co-pay, deductibles, and maximum costs, please visit www.pcip.gov.

Deductible

STD-

PLAN

EXT-

PLAN

HSA-

PLAN

In- Network

$2000

$1000

$2500

Out- Network

$3000

$1500

$3000


Coverage: PCIP covers a wide variety of health benefits, which include primary and specialty care, prescription drugs, hospital care, and most importantly, any treatment for pre-existing conditions.

All PCIP plans provide preventive care, paid at 100% without a deductible, when you see an in-network doctor. Full coverage also includes annual physicals, flu shots, routine mammograms, cancer screenings, maternity, durable medical equipment, skilled nursing services ($700/day) and Hospice (Max $15,000), mental illness, emergency services,­­ and outpoint diagnostic studies.

For any additional care, you will need to pay a deductible before PCIP can pay for your health care and prescriptions. After paying the deductible, you will need to pay 20% of medical costs in-network. To top it off, there is no lifetime maximum on the amount of money the plan can pay for your health care.

Eligibility: To be eligible for this program, you must meet certain requirements:

  • You must be an American citizen or reside in America legally.
  • You must have been without health coverage for at least the last 6 months. This includes any insurance that doesn’t cover your medical condition.
  • You must have a pre-existing condition or a health problem that has been denied health coverage.

For more information on eligibility, refer to the PCIP contact information provided.

How to Apply: The application is simple and hassle-free. There are three options of applying: online, on the phone, or by mail.

To apply online, go to the website www.pcip.gov and click on “APPLY NOW” near the bottom of the home page. It will provide more information through the rest of the process.

 To apply through the phone, there is a phone number available on the website www.pcip.gov that will allow you to reach the PCIP facility. The number is also available below in the Contact Information.

To apply by mail, go to the website www.pcip.gov and click on the tab “HOW TO APPLY.”  The instructions are available. It requires printing and filling out an Application, in English or Spanish.

An additional document is required that must be copied and included in each application process to verify your medical condition and denial of health coverage. It can be a letter from your doctor, physician assistant, or nurse practitioner, dated within the past 12 months, that verifies your medical condition, illness, or disability.

  • A denial letter from an insurance company for individual insurance (disregard health insurance from your company) within the past 12 months
  • A letter within the past 12 months from your insurance agent or broker licensed in your state that you have been denied health coverage due to medical conditions
  • An offer from an insurance company licensed in your state that you have denied in the past 12 months which has a rider saying that it shall not cover your medical condition if you should accept.

Additional information about enrolling into the PCIP program is available on http://www.pcip.gov.

Contact Information: For more detailed information on the Pre-Existing Condition Insurance Plan (PCIP), visit www.pcip.gov or call the numbers 1-866-717-5826: (TTY: 1-866-561-1604). Their regular operational hours are Monday - Friday, 8 a.m. to11 p.m., Eastern.

This community awareness project was organized by Rachel Neycheril and Ramya Krothapally, of High Tower High School--Medical Academy and sponsored by SUGAR LAND HEART CENTER, TEXAS.

We would like to visit your business, civic, social, or religious gathering and make a 5-minute presentation. If we can help one person with a pre-existing medical condition, we would have accomplished our mission of making a giant leap in that person's life.

Please contact Rachel Neycheril at (832)-338-6040 or Ramya Krothapally at (281)-902-6343 for more information or for addressing your group.




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