Pre-Existing Condition Insurance Plan (PCIP) Banner

Pre-Existing Condition Insurance Plan (PCIP) and Major Risk Medical Insurance Program (MRMIP) Differences

The California Major Risk Medical Insurance Program (MRMIP) is a separate state program also run by MRMIB for medically uninsurables with different eligibility rules, annual deductibles, annual/lifetime cap, and monthly premium costs compared to the 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 coverage for at least six (6) months, prior to receiving your application.

When you apply for the PCIP and/or MRMIP, your application will be reviewed for both health care programs to inform you of your coverage options. In order for your eligibility to be determined for each program, you need to fill out the PCIP/MRMIP Application. If you qualify for both programs, we will enroll you in the program that you prefer in question #2. If you do not select a program, we will enroll you in PCIP. The MRMIP has an enrollment cap which limits the number of individuals that can be enrolled.

The PCIP and MRMIP have different eligibility rules, benefits and costs. The charts below compare the two programs.

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.
  • 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.

 

PCIP and MRMIP Benefits

  PCIP MRMIP
Annual medical deductible $1,500 $500 / subscriber or subscriber and dependents
Brand name drug deductible $500 None
Annual out-of-pocket maximum $2,500 $2,500 / $4,000 subscriber and dependents
Annual benefit maximum None $75,000
Lifetime benefit maximum None $750,000
Health care provider source PCIP PPO Network
(see pages 14 – 19 of the PCIP/MRMIP Handbook)

Anthem Blue Cross, Contra Costa Health Plan, Kaiser (see pages 14 – 19 of the PCIP/MRMIP Handbook)
Pre-existing condition exclusion or
Post-enrollment waiting period		 None 3 months (see page 22 of the PCIP/MRMIP Handbook)

Download a printable version of PCIP and MRMIP Costs and Benefits Chart (PDF 284kb) or a PCIP/MRMIP Application (PDF 122kb).