Pre-Existing Condition Insurance Plan (PCIP) Banner

Frequently Asked Questions

UPDATE Effective March 3, 2013: Following federal direction, received on February 15, 2013, California PCIP has suspended new enrollments for applications received after March 2, 2013. Applications received after March 2, 2013, will be screened for California's high risk pool, Major Risk Medical Insurance Plan (MRMIP) eligibility. Read More...

What is a Pre-Existing Condition Insurance Plan (PCIP)?

The Pre-Existing Condition Insurance Plan (PCIP) was created as part of the national health care reform law, Patient Protection and Affordable Care Act (ACA) of 2010. PCIP is a federally-funded temporary transitional program for those unable to secure coverage in the current insurance marketplace that ends on December 31, 2013. In California, PCIP is run by the Managed Risk Medical Insurance Board (MRMIB). Starting on January 1, 2014, there will no longer be a need for PCIP because the ACA does not allow insurers to deny individuals with pre-existing conditions or charge them higher rates than those without such conditions.

The ACA also includes provisions for individuals to have access to affordable health insurance choices through a new competitive marketplace called an Exchange. The Exchange will provide a transparent insurance marketplace where individuals and small businesses can buy affordable health benefit plans. In California, the new Exchange program is called, "Covered California".

What is the PCIP Enrollment Suspension?

On February 15, 2013, the Federal Center for Consumer Information & Insurance Oversight at the Centers for Medicare and Medicaid Services directed state-administered PCIP programs to suspend new PCIP enrollments for applications received after March 2, 2013.

California PCIP is closed to new enrollment as of March 3, 2013. The change does not impact subscribers currently enrolled in California’s PCIP program. We encourage you to visit www.mrmib.ca.gov/MRMIB/MRMIP.shtml to review California’s state-funded high risk pool, Major Risk Medical Insurance Program (MRMIP). MRMIP is still open for new enrollment for individuals with a pre-existing condition.

Why is PCIP suspending enrollment?

PCIP helps uninsured individuals with pre-existing conditions get affordable health insurance. The program has a limited amount of funding from Congress. Based on national experience and trends since the program began, PCIP subscribers have serious and expensive illnesses with significant and immediate health care needs. This enrollment suspension will help ensure that funds are available for existing PCIP subscribers.

Are current PCIP subscribers affected by the PCIP Enrollment Suspension?

Current PCIP subscribers are not affected by this change. However, subscribers need to pay their monthly PCIP premiums by the due date and continue to meet all eligibility requirements. Subscribers who are disenrolled cannot be re-enrolled.

If PCIP is closed to new enrollment, can I still apply for MRMIP?

Yes, the Major Risk Medical Insurance Plan (MRMIP), California's high risk pool, is still open for new enrollment and available for individuals with pre-existing conditions. The application is for both programs.

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I submitted my application before March 2, 2013, but it wasn't received until afterwards and I do not want MRMIP. What happens to the initial premium payment that I submitted with my application?

If your PCIP application was received after March 2, 2013, and you do not want to enroll in MRMIP, your initial premium payment will be refunded. Refunds may take up to 8 weeks to process from the date the application was received. Please contact PCIP toll free at 1-877-428-5060, Monday through Friday, 8:00 am to 8:00 pm and Saturday, 8:00 am to 5:00 pm.

I submitted my application before March 2, 2013, but it wasn't received until afterwards and I do want to be considered for MRMIP. What happens if the initial premium payment that I submitted with my application is less than the MRMIP premium amount?

If your application was received after March 2nd, 2013, and you want to be considered for MRMIP, then you will be notified to submit the additional premium for the MRMIP Health Plan that you select by a specific due date.

How Can I Apply for PCIP?

To apply for PCIP, you must complete the four-page PCIP/MRMIP Application (PDF 122kb).

Find out which program is right for you. The PCIP/MRMIP Worksheet (PDF 44kb) will help you understand if you could qualify and which program is better for you.

When you review the application, it is important that you carefully review the PCIP/MRMIP Handbook (PDF 1,600kb) which contains a Checklist (PDF 59kb). The Checklist explains the supporting documents and monthly premium you need to send with your application.

Mail the application, first month's premium and all necessary documents to:

Pre-Existing Condition Insurance Plan
P.O. Box 537032
Sacramento, CA 95853-7032

If you have questions when you fill out the applications, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.

Who Can Apply for PCIP?

  • Any person 18 years of age or older. These individuals must apply for coverage for themselves;
  • Parents (natural or adoptive) or stepparents applying for children who are under 18 years old. Parents or stepparents cannot apply for children 18 years of age or older.
  • Legal guardians, foster parents, or caretaker relatives applying for a child who is under 18 years old, living in their home;
  • An emancipated minor.  This is a person who is under 18 years old who does not live with their parent, legal guardian, stepparent, or caretaker relative.  Emancipated minors must apply for themselves.

If you have questions when you fill out the applications, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.

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Does PCIP have a waiting list?

No, PCIP does not have a waiting list. If you apply and qualify for PCIP, you will be enrolled into the program.

Does PCIP offer dependent coverage?

No, PCIP does not offer dependent coverage. PCIP requires that each individual applying for the PCIP program must complete his or her own application.

If you have questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.

How much will the monthly premium cost for PCIP?

The PCIP monthly premium costs are based on your age and where you live in California. Refer to the monthly premium table (PDF 68kb) for specific rates.

You must include a full month's premium payment with your application. This payment is required for PCIP to process your application. If you do not send the full premium amount, it will delay the processing of your application. Send a check, money order, or cashier's check made payable to the Managed Risk Medical Insurance Board (or MRMIB).

Mail your payments to:
Pre-Existing Condition Insurance Plan
P.O. Box 537031
Sacramento, CA 95853-7032

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How do I make sure that my application is complete?

Carefully review the Application Checklist (PDF 59kb). This Checklist helps you make sure your application is complete. It explains the required supporting documents and monthly premium you must send with your application.

What if the name I used to apply for PCIP does not match the name on my citizenship or immigration documents?

Your legal name on your citizenship/immigration documents is used for enrollment into PCIP. PCIP can enroll you with a name other than the name on your citizenship/immigration documents only if one of the following documents is also submitted as proof of the name on the application:

  • Unexpired California Driver’s License or California Identification Card.
  • Marriage License or Marriage Certificate issued from local or state Office of Vital Statistics.
  • Legal Name Change document that contains the legal name both before and after the name change.
  • Adoption document that contains the legal name as a result of the adoption.
  • Dissolution of Marriage document that contains the legal name as a result of court action.
  • Domestic Partnership Certificate, Declaration, or Registration document verifying formation of a domestic partnership.

How do I know if I am eligible for PCIP?

You are eligible for PCIP if the following requirements are met:

  • Be a California resident.
  • Have no health insurance coverage for the past 6 months. This means in the last 6 months you were not enrolled in an individual or job-based health plan, including COBRA or Cal-COBRA, or enrolled in Medicare Part A and/or Part B, or in Medicaid/Medi-Cal.
  • Be a U.S. Citizen, U.S. National, or lawfully present individual in the United States.
  • U.S. Citizens or U.S. Nationals must provide their Social Security Number.
  • A denial letter from a health insurance company or health plan dated within the last 12 months, or
    • An offer of individual (not group) health coverage with higher premiums than the Major Risk Medical Insurance Program (MRMIP) preferred provider organization (PPO) rate in the area where you live. The offer letter must be dated within the last 12 months, or
    • Letter (PDF 22kb) from a licensed doctor, physician assistant, or nurse practitioner dated within the past twelve (12) months, stating that the individual has or, at any time in the past, had a medical condition, disability, or illness.

If you have questions on PCIP eligibility requirements, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.

Will I qualify for the PCIP if I currently have Share of Cost (SOC) Medi-Cal?

No, you do not qualify for PCIP if you currently have Share of Cost (SOC) Medi-Cal. To qualify for the PCIP, you can not have had creditable health insurance coverage in the last 6 months. Share of Cost and No Cost Medi-Cal are considered creditable coverage.

To learn more about Medi-Cal with a share of cost, click on link below and contact a County Medi-Cal office near you:

http://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx

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What are acceptable U.S. Citizenship and U.S. National documents for PCIP?

Proof of U.S. Citizen/U.S. National as shown by one of these:

  • U.S. Passport;
  • Birth certificate;
  • Naturalization/Citizenship certificate;
  • American Indian or Alaska Native enrollment document from a federally recognized tribe;
  • A Certificate of Degree of Indian Blood (CDIB) from the Bureau of Indian Affairs; or
  • A letter of Indian Heritage from a California Indian Health Service Clinic.

If you are not a U.S. Citizen or U.S. National, please send acceptable immigration documents which show that you are lawfully present in the U.S. We need immigration documents that show the expiration date. The documents cannot be expired. Send copies of the front and back sides of the immigration documents. Click here for a list of acceptable immigration documents.

What are acceptable immigration documents for PCIP?

We accept immigration documents or immigration cards that have been approved by either, the U.S. Citizenship and Immigration Services (USCIS), formerly known as the Immigration and Naturalization Service (INS) or the U.S. Department of State Bureau of Consular Affairs.

  • Send your unexpired immigration documents or immigration card to show PCIP that you are lawfully present in the U.S. Please make sure the immigration documents or immigration card show the expiration date. The immigration documents and immigration cards cannot be expired at the time you apply for PCIP. Click here for a list of acceptable immigration documents and immigration cards.
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Can I apply for PCIP with my nickname or shortened name?

Yes. If you would like to use your nickname or shortened name, you need to send in a copy of your valid California Driver’s License or valid California Identification Card or legal documentation that states your nickname or shortened name and it matches the name you provided on your application.

If you choose to send in your California Driver’s License or California Identification Card, it has to be current. It will not be accepted if it has expired.

Otherwise, you will be enrolled with your legal name as shown on your citizenship or immigration documentation.

What type of Documentation Can I send in as Proof of a Name Change?

PCIP accepts one of the following documents as proof of name change:

  • Unexpired California Driver’s License or California Identification Card.
  • Marriage License or Marriage Certificate issued from local or state Office of Vital Statistics.
  • A Legal Name Change document that contains the legal name both before and after the name change.
  • Adoption documents that contain the legal name as a result of the adoption.
  • Dissolution of Marriage document that contains the legal name as a result of court action.
  • A Domestic Partnership Certificate, Declaration, or Registration document verifying formation of a domestic partnership.

I am a U.S. Citizen or U.S. National. Why do I have to provide my Social Security number?

PCIP is a federal program administered by the State of California. The federal law requires that U.S. Citizens or U.S. Nationals provide their Social Security Number (SSN) when applying for PCIP.

If you do not provide your SSN, your application will be considered incomplete. We will send you a letter informing you that your application is incomplete. If you do not provide us your SSN by the due date, you will be denied PCIP coverage and we will determine your eligibility for the Major Risk Medical Insurance Program (MRMIP).

How do I pay my PCIP monthly premiums, once I am enrolled? When are monthly premiums due?

Once you are enrolled in PCIP, you will receive a billing statement for your monthly PCIP premiums in the mail. We must receive your premium payment by the 15th of each month. There are different ways to pay monthly premiums:

  1. You can send us one of these:
    • Online Payment (one time or reoccurring payments) or you can call 1-877-564-6705
      • Visa - Credit/Debit Card,
      • MasterCard - Credit/Debit Card,
      • Discover Card - Credit Card,
      • Electronic Check (E-Check),
    • Personal check,
    • Cashier’s check, or
    • Money order.

    Make your payment to the “Managed Risk Medical Insurance Board (or MRMIB).” Make sure you write your Member Number on the check. Mail your payment to:

    PCIP – Finance Unit
    PO Box 537031
    Sacramento, CA 95853-7032

  2. OR, you can pay by Electronic Fund Transfers (EFT) from your bank account. You will fill out a form giving PCIP permission to automatically withdraw money from your bank account each month. EFT withdrawals will occur on the 4th of each month, once your EFT request is processed and approved. To sign up for EFT, follow the steps shown on the back of your monthly billing statement. Or, you can download the PCIP EFT Form. You will need to send PCIP the complete EFT form with a voided check or savings deposit slip from the bank account.

    The form can be mailed to:
    PCIP – Finance Unit
    PO Box 537031
    Sacramento, CA 95853-7032

In order to allow PCIP enough time to process your EFT form, you must continue paying your premiums in another way with either a personal check, cashier’s check or money order (by the due date) until the EFT withdrawal is in effect. It can take up to 6-8 weeks before the EFT is withdrawn from your account after you sign up.  

Important Reminder! If you are disenrolled from PCIP because your premiums are past due, you will have to wait 6 months to qualify for PCIP again.  

If you have questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.

Which plans and providers are available in PCIP?

There is only one PCIP PPO Provider Network plan. This is a PPO Network that has contracted health providers throughout all areas of the state. For specific questions about the PCIP PPO Provider Network, call 1-877-629-1500, Monday - Friday from 6 a.m. to 6 p.m.

Or you may visit the PCIP providers for specific information related to the providers that will be available.

Which providers are available in PCIP?

The PCIP PPO Provider Network has contracted with a wide varety of health providers throughout the state. Find out what providers are available through the PCIP PPO Network.

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Does PCIP cover dental and vision care?

No. There is no dental or vision coverage included in PCIP. If you need this coverage, you will need to obtain it separately.

If you have other PCIP related questions, please give us a call at a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.

What are the health benefits offered in PCIP?

There is a wide variety of services provided in PCIP; including preventive care, hospital care, physician office visits, prescription drugs, laboratory and x-ray services, and home health / hospice care.

Review the comprehensive list of services offered by the PCIP.

How much do subscribers pay for PCIP services?

The amount subscribers pay depends on whether the provider is "in-network" or "out-of-network."

For in-network providers, subscriber pay:
  • Preventive care services: no charge
  • Physician office visits: $25 co-payment
  • Prescription drugs:$5 for generic, $15-$30* for brand name and specialty drugs
  • All other services: 15%* of negotiated fee rate
For out-of-network providers, subscribers pay:
  • Preventive care service: 50%* of the out-of-network plan allowance and any charges in excess of the Plan Allowance
  • Physician office visits: 50%* of the out-of-network plan allowance and any charges in excess of the Plan Allowance
  • Physician office visits:50%* of the out-of-network plan allowance and any charges in excess of the plan allowance
  • Prescription drugs:50%* reimbursement (at non-participating pharmacies, subscriber pays full cost of prescription at the point of sale)
  • All other services: 50%* of the out-of-network plan allowance and any charges in excess of the plan allowance

*Annual deductible applies

For more information, visit Services.

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Is there an annual deductible for PCIP?

Yes. The annual deductible is different based on whether the services are provided "in-network" or "out of network".

In-network annual deductibles are:
  • Annual medical deductible $1,500 per subscriber
  • Annual brand name prescription drug deductible: $500 per subscriber
Out-of-network annual deductibles are:
  • Annual medical deductible: $3,000 per subscriber, does not count towards the in-network medical deductible
  • Annual brand name prescription drug deductible: $500 per subscriber, does not count towards the in-network annual brand name prescription drug deductible

More information is available in the PCIP Plan Benefits.

Does PCIP have a cap on how much I have to pay out-of-pocket each year?

Yes. The annual out-of-pocket maximum when you use in-network providers is $2,500. Once a subscriber reaches the out-of-pocket maximum for amounts paid towards in-network providers, PCIP will pay 100% of your in-network medical and prescription drug services. There is no out-of-pocket maximum for out-of-network services.

How long does it take to process my PCIP Application?

If your complete application is received with all the required documentation by the 15th of the month, and you are eligible for PCIP, coverage will begin the 1st day of the following month. For example, if we receive a complete application by October 15th, the start date of coverage will be on November 1st.

However, if your complete application is received with all required documentation after the 15th of the month, and you are eligible for PCIP, coverage will begin on the 1st day of the second month following your application. For example, if we receive a complete application after October 15th, the start date of coverage will be on December 1st. Incomplete applications will result in delayed or denied coverage. We will send you a letter informing you if you are enrolled in PCIP.

You may be eligible to have your PCIP coverage date changed to an earlier date. To request an earlier effective date, you must call PCIP within 14 calendar days from the date of the welcome letter. If you choose an earlier effective date, you will not be able to change your request at a later date.

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Once I am enrolled in PCIP, when can I access my health care coverage?

When you are enrolled in PCIP, we will send you a letter informing you when your start date of coverage begins. You can access your health care benefits once your start date of coverage begins.

Can I have an earlier effective date of coverage?

If we receive your complete application and required documents after the 15th of the month, your coverage will start the first day of the second month.

If applicable, you may be eligible to have your PCIP coverage start date changed to an earlier effective date.

To request an earlier effective date, you must call PCIP within 14 calendar days from the date of the welcome letter. If you choose an earlier effective date, you will not be able to change your request at a later date.

If you have questions, please give us a call at 1-877-428-5060 between 8:00 a.m. to 8:00 p.m. Monday through Friday and 8:00 a.m. to 5:00 p.m. Saturday.

I was previously enrolled in another state's program. I moved and want to enroll in California's PCIP program. Can I transfer my eligibility?

Yes. If you were disenrolled because you no longer reside in that state, you may transfer your eligibility to California's PCIP. We must receive your application within 6 months after you were disenrolled from the other state's PCIP program.Make sure you respond to (Section 6 on the Application).

When we ask whether or not you had coverage within the last 6 months check "yes."

Then, check the box that indicates you had coverage in "another state's PCIP program."

Make sure you identify the state where you previously had coverage.

Tell us if you have obtained other health insurance coverage after you were disenrolled form the other state's PCIP program.

Provide a copy of the Certificate of Creditable Coverage Letter issued by the PCIP program from the other state. Make sure the Certificate of Creditable Coverage Letter identifies your start date and end date of coverage with the other state's PCIP program.

Note: PCIP Subscribers moving to California from another state, are not affected by the federal direction received on February 15, 2013 to suspend enrollments for applications received after March 3, 2013, to California PCIP.

Can I transfer my (not PCIP) eligibility from another state's high risk pool to California's high risk pool, MRMIP?

Yes. You can transfer eligibility from another state's high-risk pool as long as it was within the past 12 months and it was a similar type of a program. Note: PCIP is not a state high risk pool program.

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What is the difference between my PCIP Member Number and Subscriber ID Number?

Your PCIP Member Number and Subscriber ID number are the same.  Both numbers begin with “PC” and have 7 numeric values following it.  It is a unique number that was assigned to you when you apply or are enrolled into PCIP. 

This number is shown on all letters that PCIP sends you and is also on your PCIP Identification Card.  It is important that you have your PCIP Member Number or Subscriber ID number when calling PCIP or when you access PCIP benefits that are available to you.

If you have questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.

How can I appeal a PCIP eligibility decision?

If you think PCIP made a mistake, you can send a first level appeal. The first level appeal must be filed in writing within thirty (30) days from the date of the PCIP decision. Send PCIP a letter, telling us the factual or legal reasons why you think the decision is wrong, for example that PCIP made a factual error or violated a law or program policy. Or, you can complete an Appeal Form. Include any other information you think will be helpful in the review. Write your Member Number on every document you send us. PCIP cannot review a decision over the telephone. Once PCIP receives your written appeal or Appeal Form, PCIP will send you a letter telling you the results of the review and any right to additional appeals.

Please note: PCIP eligibility appeals are available only to dispute PCIP's:

  1. enrollment decisions (decisions about whether a person is eligible)
  2. decisions about a person's effective date of enrollment; or
  3. disenrollment decisions.

You can send your first level appeal to:

Pre-Existing Condition Insurance Plan
P.O. Box 537032
Sacramento, CA 95853-7032

Or fax to: 1-877-430-0843 (The fax number is free.)

If the first level appeal is denied, you will be notified of your right to request a second level appeal to the Executive Director of the Managed Risk Medical Insurance Board (MRMIB). The MRMIB is the state agency that administers and oversees the PCIP. The second level appeal must be filed in writing within thirty (30) days of the first level appeal decision. Send a letter, telling us the factual reason why you think the decision is wrong. Include any other information you think will be helpful in the review. Write your Member Number on every document you send us. You can send your second level appeal to:

Managed Risk Medical Insurance Board
P.O. Box 2769
Sacramento, CA 95812-2769

Or fax to : 916-327-6560

If the second level appeal is denied, you have the right to submit a written request for an Administrative Hearing. At the administrative hearing, the prior decision and appeal will be reviewed by an Administrative Law Judge from the Office of Administrative Hearings. This is the final PCIP decision. You will need to send a letter, stating the factual or legal reason for the appeal. You will be notified, in writing, of the date, time, and place of the administrative hearing, at least ten (10) days prior to the date of the hearing. Please include any other information you think will be helpful in the final level of appeal. Write your Member Number on every document you send us. You can send your request for a Administrative Hearing to:

Managed Risk Medical Insurance Board
P.O. Box 2769
Sacramento, CA 95812-2769

Or fax to : 916-327-6560

Can I appeal health benefit decisions in the PCIP program?

Yes. Subscribers have the right to appeal if a health care service is delayed, denied, reduced, modified, or terminated in full or in part by the plan. The first level of appeal is an internal appeal with PCIP. If you are unhappy with the results of your appeal, you can request additional levels of appeal. For exact terms and conditions, refer to the Summary Plan Description booklet.

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Can insurance brokers/agents assist people in applying for PCIP and MRMIP?

Yes, they can assist people in applying for PCIP and MRMIP. Insurance agent's/broker's information must be included on the Application in order for them to be paid for their assistance. Insurance agents/brokers are eligible for payment for each person they assist who is successfully enrolled in PCIP or MRMIP.

If you have questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.

Can Healthy Families Certified Application Assistants help people apply for PCIP?

Yes, Certified Application Assistants registered with an Enrollment Entity (EE) and PCIP certified, can help people apply for PCIP. The EEs are eligible to receive payment. Payment will be made for each person the CAA assists who is successfully enrolled into PCIP. The CAA information must be included on the Application in order for the EE to be paid.

If you have questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.

When will the payment be issued to the Insurance Agents/Brokers or Enrollment Entities (EE)?

Payments will be issued after the applicant is enrolled in PCIP or MRMIP.

If you have questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to   8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.

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Will PCIP cover any medical expenses that I received before my coverage begins?

The PCIP program will not cover any medical expenses incurred prior to the start date of coverage.

If you have questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.

I am currently interested in enrolling in MRMIP only? Is it possible for me to enroll in MRMIP without being considered for PCIP?

Yes, if you are only interested in the MRMIP program, you can apply for the MRMIP. However, we also encourage you to apply for the PCIP program, so that you are aware of your coverage options. As a result of the federal health care reform, California now offers a federally-funded health coverage program called PCIP. The PCIP offers health coverage to medically-uninsurable individuals who live in California. This program is available for individuals who have not had health coverage 6 months prior to applying for PCIP.

Important Notice: If you are currently or will be enrolled in the MRMIP, you will not qualify for the PCIP. The PCIP requires that an individual not have health insurance coverage for at least 6 months.

For a comparison of both programs click here.

The MRMIP is a separate state program that has different eligibility rules, benefits, annual deductibles, annual/lifetime cap, and monthly premiums costs compared to the PCIP program. The MRMIP has enrollment cap which limits the number of individuals that can be enrolled. For more information about the MRMIP waiting list, please call 1-800-289-6574, Monday – Friday from 8:30 a.m. – 7:00 p.m. The call is toll free!

Both of these health coverage programs are administered and overseen by the State of California. You can choose which program you prefer to be enrolled in (see Question 2). If you qualify for both programs but don't choose one, we will enroll you in PCIP.

For more information about the MRMIP program, please visit the website at www.mrmib.ca.gov.

If you have any PCIP questions, please give us a call at a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m. or, on Saturday, from 8 a.m. to 5 p.m.

What does it mean that I cannot have health coverage for the last 6 months, in order to qualify for PCIP?

The Pre-Existing Condition Insurance Plan (PCIP) requires that a person not have had health coverage in the last 6 months. This means that a person who was enrolled and had coverage through one of the following in the last six months is not eligible for PCIP:

  • Individual or job-based health insurance, including COBRA or Cal-COBRA;
  • Medicare Part A and/or Part B;
  • No-Cost Medicaid (No-Cost Medi-Cal);
  • Children’s Health Insurance Program (Healthy Families Program);
  • A state high risk pool (Major Risk Medical Insurance Program);
  • Health coverage provided by a public health plan established by the state (i.e. CalPERS), the U.S. government such as coverage provided to veterans enrolled in VA health care or a foreign country;
  • FEHBP (health insurance for Federal employees or retirees), including Temporary Continuation of Coverage (TCC);
  • Health benefit plan provided to Peace Corps workers;
  • Services provided by the Indian Health Service or by a Tribe or Tribal organization for treating your medical condition; or
  • County Medical Services Program (CMSP).

If you have any questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.

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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.

PCIP is a federal program administered in California and the federal health care reform law requires that a person be without "creditable health coverage" for at least 6 months.

To find out who is your Congressional Representative, go to www.house.gov.

If you have questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.

What are the different eligibility rules for the PCIP and MRMIP programs?

The PCIP and MRMIP have different eligibility rules and requirements. The differences between the 2 programs are:

PCIP and MRMIP Eligibility Rules

You may qualify for
PCIP (Pre-Existing Condition Insurance Plan) if:		 You may qualify for
MRMIP (Major Risk Medical Insurance Program) if:
  • You are a resident of California.
  • You have a pre-existing condition as shown by:
    • A denial letter from a health insurance company or health plan dated within the last 12 months, or
    • A letter dated within the last 12 months, from a licensed doctor, physician assistant, or nurse practitioner, stating the individual has or had a medical condition, disability, or illness (go to PCIP website for a sample form), or
    • An offer of individual (not group) health coverage with higher premiums than the Major Risk Medical Insurance Program (MRMIP) preferred provider organization (PPO) rate in the area where you live (see pages 8–13). The offer letter must be dated within the last 12 months, or
    • A certificate of creditable coverage letter issued by another state or Federally administered PCIP program showing previous enrollment within the past 6 months (see page 20).
  • You are not enrolled in Medicare Part A and B, COBRA, or Cal-COBRA benefits.
  • You are a U.S. Citizen or U.S. National – or you are lawfully
    present in the U.S. (you must provide a Social Security Number if you are a U.S. Citizen or U.S. National).
  • You have not had health coverage for at least 6 months.

Note: PCIP does not offer coverage for dependents.
  • You are a resident of California.
  • You have a pre-existing condition as shown by:
    • A denial letter from a health insurance company or health plan dated within the last 12 months, or
    • An offer of individual (not group) health coverage with premiums that are higher than the rates of your first MRMIP plan choice (see pages 8–13). The offer letter must be dated within the last 12 months, or
    • Involuntary termination from a health plan, health insurance company or employer plan for reasons other than fraud or non-payment of premiums.The involuntary termination letter must be dated within the last 12 months.
  • You are not eligible for Medicare Part A and Part B
    (except for end-stage renal disease) or for COBRA or
    Cal-COBRA benefits.

Note:
Social Security Numbers are not required.

Deferred enrollment: If you have health coverage but it is going to end soon, you may apply now for MRMIP. This is called deferred enrollment. Get a letter from your health plan or employer that says when your coverage will end.

Medi-Cal: If you receive Medi-Cal benefits now and want to switch to MRMIP, consider the cost.

 

If you have any questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.

For more information about the MRMIP program, please visit the website at www.mrmib.ca.gov.

What is the difference in how Dependents are covered in MRMIP and PCIP?

MRMIP allow subscribers with pre-existing conditions to enroll dependents into MRMIP on the same application. Dependents include, spouse, registered domestic partner, children under the age of 23, adopted child, stepchild, natural child, or child of a domestic partner. However, dependents must meet all the same eligibility requirements except for demonstrating that they have a pre-existing condition. In addition, dependents without pre-exisitng conditions generally can purchase health coverage in the individual market at much lower rates. Some subscribers with dependents may benefit from differences in premiums or cost sharing in MRMIP, and from the option to enroll a newborn or newly adopted child.

PCIP does not allow subscribers and dependents to be enrolled on the same application. Each individual applying to PCIP must complete a separate application and meet PCIP eligibility requirements.

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What are acceptable documents to show that I am medically uninsurable and have a pre-existing condition?

Send one of the following documents:

  • A denial letter from a health insurance company or health plan dated within the last 12 months, or
  • An offer of individual (not group) health coverage with higher premiums than the Major Risk Medical Insurance Program (MRMIP) preferred provider organization (PPO) rate in the area where you live. The offer letter must be dated within the last 12 months, or
  • Letter (PDF 22kb) from a licensed doctor, physician assistant, or nurse practitioner dated within the past twelve (12) months, stating that the individual has or, at any time in the past, had a medical condition, disability, or illness.

If you have any questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.

I am currently enrolled in MRMIP. Do I qualify for PCIP?

No. If you are currently enrolled in the MRMIP, you do not qualify for the PCIP program. The PCIP requires that individuals not have health coverage for at least 6 months.

If you have any questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m. or, on Saturday, from 8 a.m. to 5 p.m.

I am currently enrolled in MRMIP. The program has an annual benefit cap of $75,000 per calendar year and a $750,000 lifetime cap. Do I qualify for PCIP, when I reach the MRMIP benefit or lifetime cap limit?

No, the PCIP requires that an individual be without health insurance for at least 6 months. To qualify for PCIP, you cannot have health coverage 6 months prior to applying. Because you are currently enrolled in the MRMIP, you do not qualify for PCIP.

If you have questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.

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If I qualify for both programs, which program will I be enrolled?

If you qualify for both PCIP and MRMIP programs, you will be enrolled in the preferred program that you identified on Question 2. It is important that you let us know on the application which program you prefer. If you do not let us know which program you prefer, we will enroll you into the PCIP program.

If you qualify for both programs and you decide to be enrolled in MRMIP, you will no longer qualify for PCIP. This is because the PCIP program requires that an individual not have health insurance coverage for at least 6 months.

If you have any questions, please give us a call at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m., or on Saturday, from 8 a.m. to 5 p.m.

I want to know if there is a waiting list for the Major Risk Medical Insurance Program (MRMIP)?

The MRMIP has an enrollment cap which limits the number of individuals that can be enrolled. MRMIP may have a waiting list due to available funding.

For more information about the MRMIP waiting list, please call 1-800-289-6574, Monday - Friday from 8:30 a.m. - 7:00 p.m. The call is toll free!

How is a person disenrolled from PCIP?

A person will be disenrolled from PCIP if any one of the following occurs:

  • The monthly premium payment is not received by the due date.
  • The individual requested disenrollment from PCIP.
  • The individual no longer lives in California.
  • The individual passed away.
  • The individual obtained other health care coverage.
  • The individual no longer is lawfully present in the U.S. or
  • The individual provided false information during the application process.
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If I am disenrolled from the PCIP, when am I eligible to re-enroll?

If you were disenrolled from the PCIP program for any reason, you cannot be re-enrolled. California PCIP has suspended enrollments as of March 3, 2013 following federal direction received on February 15, 2013.

If you have questions, please give us a call toll free at 1-877-428-5060, Monday - Friday, from 8 a.m. to 8 p.m. Or, on Saturday, from 8 a.m. to 5 p.m.

Who can I call if I have more questions?

For questions on the PCIP, you can give us a call at 1-877-428-5060, Monday - Friday 8:00 a.m. - 8:00 p.m. or, on Saturday from 8:00 a.m. - 5:00 p.m. The call is toll Free!

For MRMIP, please call 1-800-289-6574, Monday - Friday 8:30 a.m. - 7:00 p.m. The call is toll free! Or, you can go to our website at www.mrmib.ca.gov. Additional program information and Frequently Asked Questions are available on our website.

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