THE NEW FEDERAL Pre-Exist- ing Condition Insurance Plan (PCIP) program is hard to get
into, too expensive for the typical
uninsured individual with a chronic
illness, and under-promoted, according to officials at the U.S. Government Accountability Office (GAO).
John Dicken, a GAO director,
writes about those findings in a
summary of a PCIP study conducted
at the request of Sen. Mike Enzi,
R-Wyo., the highest ranking Republican on the Senate Health, Education, Labor and Pensions Committee.
Health policy watchers once predicted
the federal PCIP risk pool program would
attract more than 200,000 uninsured Americans with health problems, and that program managers would soon have to shut
out many applicants. GAO officials found
that, in the real world, total PCIP enrollment
stood at just 21,454 in April.
Congress added the PCIP program to
the Patient Protection and Affordable Care
Act of 2010 (PPACA) to provide immediate relief for uninsured people with health
problems. PCIP is meant to help fill the
gap between the date PPACA was signed
in March 2010 and the day when insurers
are supposed to start selling subsidized
coverage on a guaranteed issue, mostly
community-rated basis in 2014.
PCIP provides comprehensive health
coverage for people who have a hard time
qualifying to buy ordinary individual commercial health coverage.
Eligibility is not based on income. The
price of coverage is supposed to be comparable to what healthy people would pay
for health coverage purchased through the
conventional market.
To avoid crowding out private health
coverage, Congress required that people
with health problems be uninsured for at
least 6 months before applying for PCIP.
Congress let states choose between
running PCIP risk pools themselves or
letting the U.S. Department of Health and
Human Services (HHS) provide PCIP risk
pool services for residents. The federal Of-
fice of Personnel Management (OPM) has
helped HHS hire Government
Employees Health Association
(GEHA), Lee’s Summit, Mo., to
administer the federal part of
the PCIP program. GEHA is now
providing PCIP services for 23
states and the District of Colum-
bia; 27 states are running their
own PCIP programs.
GAO officials offer various
reasons why enrollment has
been lower than expected. One
is the statutory requirement
that enrollees be uninsured for
six months before applying.
About 45% of the applicants who apply
for state PCIP coverage and 69% of the applicants who apply for federal PCIP coverage
are denied because they have had coverage
within the past 6 months, Dicken says.
Some states eased the proof-of-risk process by creating lists of conditions that
automatically qualify applicants for PCIP
participation, even if applicants have not
bothered to try to apply for commercial coverage, and about half of the PCIP enrollees
in those states used the qualifying condition
list to get PCIP coverage, Dicken says.
Another obstacle has been the cost of
program premiums, which averages about
$400 per month, Dicken says. Lack of
awareness has been another barrier, in part
because adults with pre-existing conditions
are difficult to identify and target. NU
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