Insurance for People with Pre-existing Conditions is Available and Affordable in Most States

by Admin on July 21, 2011

in News, Patients, Providers

This morning I attended a Small Business Roundtable held by the Phoenix Business Journal, one of forty such publications in the country. The focus of the meeting was for the Business Journal to learn what it could do to provide more help to small business in the community. Around the table were representatives from chambers of commerce, small business associations, the local chapter of NFIB, and many small business owners.

The number one issue on every small business owner’s mind? The cost of health insurance. One gentleman, an attorney, said that his pre-existing condition made health insurance unaffordable for his entire law firm. Another said that the Blue Cross insurance offered to the self-employed was cost prohibitive. And then the attorney said he had finally discovered the PCIP plan and it had lowered his cost of insurance about 40%. The conversation shifted. Everyone wanted to know more.

Somehow the entire country  has forgotten that Obama promised in the Affordable Care Act that no one would be denied health insurance because of a pre-existing condition. 18 months later, the PCIP is up and running, and hardly anyone notices it. So here are the highlights of the plan:

1. PCIP plans are administered differently in every state, sometimes by the state and sometimes by the Government Employees Health Association (GEHA). In my state, Arizona, GEHA runs the plan. The enrollment criteria and forms are here.

2. PCIP is a PPO (Preferred Provider Plan), which means that it contracts with a provider network and pays the network to provide services. If you go to a physician in the network, you will pay less of a cost-share for  services from a than from a provider outside the network. (We had this system in the 1980s, when last we tried managed care. It died with HMOs). You can go to any physician, but you will pay more outside the network.

3. The network is one of the largest in the state, at least it is in Arizona, so access to care should not be a problem.

4. There is an annual deductible, but there are no lifetime limits on what the plan will pay.

5. You are indemnified against paying for hospital-caused illnesses, and the hospitals are incentivized not to commit the kinds of medical errors that have come to frighten patients.

We have a benefit payment policy that will encourage hospitals to reduce the likelihood of hospital-acquired conditions such as certain
infections, severe bedsores and fractures; and reduce medical errors that should never happen called “Never Events.” When a Never
Event occurs, neither you nor your PCIP plan will incur costs to correct the medical error.

We have a benefit payment policy that will encourage hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores and fractures; and reduce medical errors that should never happen called “Never Events.” When a Never Event occurs, neither you nor your PCIP plan will incur costs to correct the medical error.

6. Preventive care is available at no charge.

7. A wide range of providers are paid for, including chiropractors and nurse practitioners, podiatrists and mental health providers.

A licensed doctor of medicine (M.D.) or a licensed doctor of osteopathy (D.O.).  Other covered providers include a chiropractor, nurse midwife, nurse anesthetist, audiologist, dentist, optometrist, licensed clinical social worker, licensed clinical psychologist, licensed professional counselor, licensed marriage and family therapist, podiatrist, speech, physical and occupational therapist, nurse practitioner/clinical specialist, nursing school administered clinic, physician assistant, registered nurse first assistants,  certified surgical assistants and Christian Science practitioner.

The term “doctor” includes all of these providers when the services are performed within the scope of their license or certification.

8. A wide variety of maternity benefits are included — even NICU stays in certain cases.

Just reading the fine print of the PCIP tells me it incorporates much of the best thinking on how to reconcile access to care with cost controls and the financial motivations of insurance companies. If you have a pre-existing condition and you are not afraid to “go bare” or self-insure for six months, this may be a huge help for you.

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