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12/2011
Application and Handbook 2012PCIP California Pre-Existing Condition Insurance Plan
MRMIP California Major Risk Medical Insurance Program
Inside this booklet:
2 GlossaryofDefinitions
3 HealthInsuranceforCalifornians
4 AreYouEligibleforPCIPorMRMIP?
4 PCIPandMRMIPBenefits
5 Worksheet:FindOutWhichProgram IsRightforYou
6 Application Checklist: Important!
A1 PCIP and MRMIP Application Form
7 ImportantNoticesandDeclarations
8 PCIPandMRMIPMonthlyPremiums ComparisonCharts
14 PCIPandMRMIPCostsandBenefits ComparisonCharts
20 PCIPandMRMIPFrequentlyAskedQuestions
We’vegotyoucovered!Getthecoverageyouneed,evenifyouhavebeendeniedbefore.
2
Annual benefit maximum Theannual benefit maximumisthetotalamountthatyourhealth
planpaysforserviceseachyear.Iftheservicesyouusereachthatamountinanyyear,youmustpayforanyadditionalservicesuntiltheendoftheyear,whenyourplanwillstartpayingagain.PCIPhasnoannualmaximum.MRMIPhasanannualmaximumof$75,000.
Annual out-of-pocket maximum Theout-of-pocket maximum isthehighestamountthatyouwillhave
topayinagivenyearforhealthservices,excludingyourmonthlypremiums.Theout-of-pocketmaximumconsistsofthecopaymentsorthedeductibleandcoinsuranceyoupayforhealthservices.Theout-of-pocketmaximumfortheMRMIPandPCIPprogramis$2,500peryear($4,000perfamilyinMRMIP).IntheMRMIPandPCIPprograms,thereisnoout-of-pocketmaximumforservicesreceivedfromout-of-networkproviders.
Brand name drug deductible Abrand name drug deductibleistheamountyoupayevery
yearforbrand-nameprescriptionmedicinesbeforeyourhealthplanstartspayingforthem.PCIPhasa$500brandnamedrugdeductible.MRMIPhasnobrandnamedrugdeductible.
Coinsurance Coinsuranceisapercentageshareofthecostofservicesthatyou
payaftermeetingyourannualdeductible.Yourhealthplanpaystherest.Theamountofcoinsuranceyoupaycanrangefrom15%forin-networkservicesto50%forout-of-networkservices.
Copayments Acopaymentisafixeddollarshareofthecostofservices(such
asdoctorvisitsormedicines)thatyoupaywhenyougetthoseservices.Yourhealthplanpaystherest.Copaymentscounttowardyouryearlydeductible.Youmustcontinuetomakecopaymentsevenafteryoureachyouryearlydeductible.
Deductible Adeductibleisthetotalamountyoupayeveryyearforservicesand
medicationsbeforeyourhealthplanstartspaying.PCIPhasa$1,500deductibleforin-networkservicesanda$3,000deductibleforout-of-networkservices.MRMIPhasa$500deductibleforbothin-networkandout-of-networkservices.
Disenrollment Disenrollmentistheactofleavingaprograminwhichyouare
enrolled.Apersonwhoenrollsineitherprogrammayleavetheprogrambychoiceorbecauseofadecisionmadebytheprogram.Forexample,someonemaybedisenrolledbecauseheorshedidnotpaypremiums,orsomeonemaychoosetodisenrollbecauseheorshepurchasedotherinsurance.
Health Maintenance Organization (HMO) AnHMOisatypeofhealthcoveragewhereyougetallofyour
healthservicesthroughaspecificnetworkofdoctorsandhospitals.Servicesprovidedbydoctorsorhospitalsoutsideofyournetworkprobablywillnotbepaidforbyyourplan,unlessitisanemergency.HMOsrequirethatyouselectaPrimaryCarePhysician,whoisresponsibleformanagingandcoordinatingyourhealthcare,includingyourreferralstospecialists.
HIPAA HIPAAisthefederalHealthInsurancePortabilityandAccountability
Actof1996.Ithelpsprotecthealthinsurancecoveragewhenworkersleavetheirjobs.Italsoprotectstheprivacyandsecurityofindividuals’personalhealthinformationbyrequiringcertain“coveredentities”totellconsumershowtheirhealthinformationwillbeused.
Lifetime benefit maximum Thelifetime benefit maximumisthetotalamountthatyourhealth
planpaysforservicesoveryourlifetime.Iftheservicesyouusereachthatamount,younolongerhavecoverageforanyadditionalservices.PCIPhasnolifetimemaximum.MRMIPhasalifetimemaximumof$750,000.
Plan allowance Theplan allowanceistheamountthattheplanconsidersasfullpay-
mentforeachcoveredservice.In-networkprovidersagreetoacceptanegotiatedplanallowanceaspaymentinfull,sothatsubscriberspayonlytheirin-networkcoinsuranceorcopaymentaftermeetingthedeductible.However,ifasubscriberreceivesout-of-networkservices,thesubscriberwillberesponsibleforanychargesabovetheplanallowance,aswellasforhisorhercoinsuranceorcopayment.
Pre-existing condition Apre-existing conditionisanymedicalconditionthatadoctor
orotherlicensedhealthpractitionerdiagnosed,caredfor,recommendedtreatmentfor,ortreatedforaperiodoftimebeforethepersontriedtoobtainhealthcoverage.
Preferred Provider Organization (PPO) APPOisatypeofhealthcoveragewhereyoupaylessifyouget
yourhealthservicesfromanetworkof“preferred”doctorsandhospitals.Ifyougetcarefromapreferredprovider,youwillpayyourannualdeductibleand/orcoinsuranceforyourvisit.Ifyougetservicesfromdoctorsnotinthepreferrednetwork(knownasgoing“out-of-network”),youwillpayahigheramount.PPOsdonotrequireyoutoselectaPrimaryCarePhysician,anddonotrequirereferralstoseespecialists.
Premium ApremiumisamonthlyfeethatPCIPorMRMIPmembersmustpay
tostayenrolledintheplan.
Preventive care services Preventive care services areservicesthatyourhealthplanoffersto
helpyoustayhealthyandtoidentifymedicalproblemsearly.Preventivecareservicesmayincluderegularcheckups,certainimmunizationsandlabservices,PAPsmears,mammograms,well-babyandwell-childservices,prostateexams,andtestsforsexuallytransmitteddiseases.
Provider network Aprovider networkisagroupofdoctorsandhospitalsthatagree
toprovidehealthservicesatanagreedrateofpayment.IfyouareinanHMO,youwillgenerallyhavetoreceiveservicesfromprovidersinyournetwork.IfyouareinaPPO,youwillpaylessifyoureceiveservicesfromprovidersinyournetworkthanifyougetservicesfromadoctororhospitalthatisnotinyournetwork.
Glossary of Definitions
3
Health Insurance for Californians
ThestateofCaliforniaofferstwohealthinsuranceprogramsforCalifornianswhohavepre-existingmedicalconditionsandhavenotbeenabletogetcoveragebecauseofthis.
Two insurance programs but only one application!
ThetwohealthinsuranceprogramsinCaliforniaarethePre-ExistingConditionInsurancePlan(PCIP)andMajorRiskMedicalInsuranceProgram(MRMIP).Theprogramshavedifferenteligibilityrules,benefits,andmonthlypremiums.
PCIPisafederallyfundedprogram,andMRMIPisastatefundedprogram.
MRMIP: Major Risk Medical Insurance Program
MRMIPcoversdependents.MRMIPmonthlypremiumsareusually
morecomparedtoPCIP.
IfyouselectaPPO,youmayhavetowait3monthsbeforeyougethealthservicesforyourpre-existingcondition.IfyouselectanHMOyoumayhavetowait3monthsbeforeyoucanbeginthecoverage.
PCIP: Pre-Existing Condition Insurance Plan
PCIPdoesnotcoverdependents.EachindividualmustmeetthePCIPeligibilityrequirementstobeenrolled.PCIPmonthlypremiumsareusuallyless
comparedtoMRMIP.YoumustbeaU.S.CitizenorU.S.
Nationalorbelawfullypresenttoqualifyforcoverage.Youmustbewithouthealthcoveragefor
atleast6months.Afteryouareenrolled,youcangethealth
servicesrightaway.
The application
Thefour-pageapplicationforbothprogramsstartsonpageA1.Ifyouqualifyforbothprograms,youcanchoosewhichprogramyouwant.Youcancall1-877-428-5060forassistancewitheitherprogram.
Note:IfyouwantthePCIPprogramforyourselfandoneormoredependents,eachpersonmustapplyseparatelyandqualify.
IMPORTANT NOTICE:IfyouenrollinMRMIP,itwillpreventyoufromqualifyingforthePre-ExistingConditionInsurancePlan,unlessyoulaterbecomeuninsuredfor6months.
2
How did you learn about PCIP or MRMIP? (Check all that apply.)
Tell us how you learned about PCIP or MRMIP.
3
State:ZIP code:
Telephone number:
State:ZIP code:
1
Are you a California resident? Yes No
4
Are You Eligible for PCIP or MRMIP?You may qualify for PCIP if: You may qualify for MRMIP if:
YouarearesidentofCalifornia.
Youhaveapre-existingconditionasshownby:Adenialletterfromahealthinsurancecompanyorhealthplandatedwithinthelast12months,orAletterdatedwithinthelast12months,fromalicenseddoctor,physicianassistant,ornursepractitioner,statingtheindividualhasorhadamedicalcondition,disability,orillness(gotoPCIPwebsiteforasampleform),orAnofferofindividual(notgroup)healthcoveragewithhigherpremiumsthantheMajorRiskMedicalInsuranceProgram(MRMIP)preferredproviderorganization(PPO)rateintheareawhereyoulive(see pages 8–13).Theofferlettermustbedatedwithinthelast12months,orAcertificateofcreditablecoverageletterissuedbyanotherstateorFederallyadministeredPCIPprogramshowingpreviousenrollmentwithinthepast6months(see page 20).
YouarenotenrolledinMedicarePartAandB,COBRA,orCal-COBRAbenefits.
YouareaU.S.CitizenorU.S.National–oryouarelawfullypresentintheU.S.(youmustprovideaSocialSecurityNumberifyouareaU.S.CitizenorU.S.National).
Youhavenothadhealthcoverageforatleast6months.
YouarearesidentofCalifornia.
Youhaveapre-existingconditionasshownby:
Adenialletterfromahealthinsurancecompanyorhealthplandatedwithinthelast12months,orAnofferofindividual(notgroup)healthcoveragewithpremiumsthatarehigherthantheratesofyourfirstMRMIPplanchoice(see pages 8–13). Theofferlettermustbedatedwithinthelast12months,or
Involuntaryterminationfromahealthplan,healthinsurancecompanyoremployerplanforreasonsotherthanfraudornon-paymentofpremiums.Theinvoluntaryterminationlettermustbedatedwithinthelast12months.
YouarenoteligibleforMedicarePartAandPartB(exceptforend-stagerenaldisease)orforCOBRAorCal-COBRAbenefits.
Note: SocialSecurityNumbersarenotrequired.
Deferred enrollment:Ifyouhavehealthcoveragebutitisgoingtoendsoon,youmayapplynowforMRMIP.Thisiscalleddeferred enrollment.Getaletterfromyourhealthplanoremployerthatsayswhenyourcoveragewillend.
Medi-Cal:IfyoureceiveMedi-CalbenefitsnowandwanttoswitchtoMRMIP,considerthecost.
PCIP and MRMIP BenefitsPCIP MRMIP
Annual medical deductible $1,500 $500/subscriberorsubscriberand dependents
Brand name drug deductible $500 None
Annual out-of-pocket maximum $2,500 $2,500/$4,000subscriberanddependents
Annual benefit maximum None $75,000
Lifetime benefit maximum None $750,000
Health care provider sourcePCIPPPONetwork(see pages 14 – 19)
AnthemBlueCross,ContraCostaHealthPlan,Kaiser(see pages 14 – 19)
Pre-existing condition exclusion or Post-enrollment waiting period None 3months(see page 22)
5
Generally, PCIPpremiumsarelowerincomparisontoMRMIP.
In PCIP,therearenoannualorlifetimebenefitmaximums.MRMIPhasannualandlifetimebenefitmaximumsthatcanresultinyourbeingresponsibleforallcostsabovethemaximums,orbeingunabletoobtainmedicalcare.
In PCIP,thereisnowaitingperiodforimmediatetreatmentforyourpre-existingmedicalcondition.Note:MRMIPhasa3-monthpostenrollmentwaitingperiod(HMOs)orpre-existingconditionexclusion(PPO).Thesemaybewaivedundercertaincircumstances(see page 22).
IfyoucannotmeetthePCIPrequirementthatyoubeuninsuredfor6months,theMRMIPoptionisavailable.
IfyoucannotmeetthePCIPcitizenshiporimmigrationrequirements,theMRMIPoptionisavailable.
Ifyouwantmorehelp,call1-877-428-5060MondaythroughFriday8:00AM–8:00PM,Saturday8:00AM–5:00PM.
Do you qualify for PCIP? Do you qualify for MRMIP?YouarearesidentofCalifornia. Yes YouarearesidentofCalifornia. Yes
Youhaveapre-existingmedicalconditionandcansendoneofthesedocumentstoshowproof:n Adenialletterfromahealthinsurancecompanyor
healthplan,datedwithinthelast12months,orn Aletterdatedwithinthelast12months,from
alicenseddoctor,physicianassistant,ornursepractitioner,statingtheindividualhasorhadamedicalcondition,disability,orillness(gotoPCIPwebsiteforasampleform),or
n Anofferofindividual(notgroup)healthcoverageathigherpremiumsthantheMRMIPpreferredproviderorganization(PPO)ratewhereyoulive.Theofferlettermustbedatedwithinthelast12months(see pages 8 – 13 for MRMIP’s PPO monthly premiums.),or
n AcertificateofcreditablecoverageletterissuedbyanotherstateorFederallyadministeredPCIPprogramshowingpreviousenrollmentwithinthepast6months(see page 20).
Yes Youhaveapre-existingmedicalconditionandcansendoneofthesedocumentstoshowproof:n Adenialletterfromahealthinsurancecompanyor
healthplan,datedwithinthelast12months,orn Anofferofindividual(notgroup)healthcoveragewith
premiumsthatarehigherthanyourfirstMRMIPplanchoice.Theofferlettermustbedatedwithinthelast12months(see pages 8 – 13 for MRMIP’s monthly premiums),or
n Proofofinvoluntaryterminationfromahealthplan,healthinsurancecompanyoremployerplanforreasonsotherthanfraudornon-paymentofpremiums.Theinvoluntaryterminationlettermustbedatedwithinthelast12months.
Yes
YouarenotenrolledinMedicarePartsAandB,COBRA,orCal-COBRAbenefits.
Yes YouarenoteligibleforMedicarePartsAandB(exceptforendstagerenaldisease),COBRA,orCal-COBRAbenefits.
Yes
Youareoneofthefollowing:n U.S.CitizenorU.S.Nationalandhavea
SocialSecurityNumberorn LawfullypresentintheU.S.(notaU.S.Citizen)
Yes
Youhavenothadhealthcoverageforatleast6months. Yes
If you answered Yes to all the questions above, you probably qualify for PCIP.
If you answered Yes to all the questions above, you probably qualify for MRMIP.
Worksheet: Find Out Which Program Is Right for You
The PCIP is generally the best health coverage program for everyone who qualifies! ThePCIPpremiumsaremoreaffordableandPCIPhasnoannualorlifetimebenefitmaximum.Reviewtheprogramdifferencesbelow.
6
Application Checklist: Important! Usethistomakesureyousendusacompleteapplication.Anincompleteapplicationmaydelayyourenrollmentifyouqualify.Note:Donotsendthischecklistwithyourapplication.Whenyouseethisarrow ,itmeansyoumayhavetosendsupportingdocuments.
YouhavereviewedthePCIPandMRMIPcomparisoncharts,whichprovideinformationabouteligibility,benefits,andcosts. Youhaveansweredallquestionsontheapplication.(For PCIP, youmustprovideyour Social Security Number ifyouareaU.S.Citizenor
U.S.National.) Sendthesedocumentswithyourapplication:
For PCIP,includeacopyofoneofthese: Adenialletterfromindividual(notgroup)healthcoveragereceivedinthelast12months Aletterdatedwithinthelast12monthsfromalicenseddoctor,physicianassistantornursepractitioner statingtheindividualhasorhadamedicalcondition,disability,orillness Anofferletterofindividual(notgroup)healthcoveragewithpremiumsthatarehigher than the MRMIP PPO rate basedontheareawhereyoulive ACertificateofCreditableCoverageletterissuedbyPCIPfromanotherstateorFederallyadministeredPCIPprogram, (responseonpageA3ofapplication)
For PCIP,includeacopyofoneofthese: CertificateofU.S.Citizenship CertificateofU.S.Naturalization U.S.birthcertificate U.S.passport Otherproofofcitizenship Proofofimmigrationstatus(Senddocumentsthatarenotexpired.Includecopiesofbothfrontandback.) Foralistofacceptableimmigrationdocuments,gotowww.pcip.ca.gov.Thenclickonthe“FrequentlyAskedQuestions”link onthewebsite.Or,callusifyouneedassistance!
If you choose MRMIP,includeacopyofoneofthese: Adenialletterfromindividual(notgroup)healthcoveragereceivedinthelast12months Anofferletterofindividual(notgroup)healthcoveragewithpremiumsthatarehigher than your first MRMIP plan choice receivedinthelast12months Aterminationletterfromahealthplan,healthinsurancecompanyoremployerplanforreasonsotherthanfraudornon-payment ofpremiumsreceivedinthelast12months
If you choose MRMIP and: you are applying for deferred enrollmentbecauseyoubelieveyouqualifybutcurrentlyhavehealthcoverage.Includeacopy ofaletterfromtheemployerorinsurancecompanyyouhavenow,tellinguswhentheinsurancecoveragewillend. youcurrently have Medicare Part A and Part B because of end-stage renal disease.Includeacopyoftheapprovalletter fromMedicare. youwanttowaive part or all of the waiting or exclusion period.Includeacopyofproofofanyinsurancecoveragethatyou hadbefore. youhaveadependent child who is over 23 years old.Sendadoctor’sletterwiththeapplicationforeachchildover23statingthatthe personcannotworkbecauseofacontinuousphysicalormentaldisabilitythatstartedbeforeage23.Thedependentchildcannotbemarried.
Signtheapplication.
Writeacheckforonemonth’spremiumfortheprogramyouareinterestedin.MakethecheckpayabletotheManaged Risk Medical Insurance Board (MRMIB).Seepages8–13fortheprograms’monthlypremiumsbyregion.
Mailtheapplicationwithyourcheckandallrequireddocumentsto: CaliforniaPre-ExistingConditionInsurancePlan,P.O.Box537032,Sacramento,CA95853-7032 Insurance Agents/Brokers or Certified Application Assistants: Completeall applicableboxesatthebottomoftheapplication
onpageA4torequestandreceivepayment.Section1101ofthePatientProtectionandAffordableCareAct,PublicLaw111-148andInsuranceCodeSections12739.52(e),12711(a),authorizestheprogramstocollectandmaintaintheinformationsolicitedinthisapplication.
ForPCIPquestions,call1-877-428-5060MondaythroughFriday8:00AM–8:00PM,Saturday8:00AM–5:00PMorvisitwww.pcip.ca.gov.
ForMRMIPquestions,call 1-800-289-6574 MondaythroughFriday8:30AM–7:00PMorvisit www.mrmib.ca.gov.
This is an application for PCIP and MRMIP. Tell us which health insurance program you prefer.2
IfyouqualifyforbothPCIPandMRMIP,whichonedoyouwanttobeenrolledin?Checkonlyonebox: PCIP MRMIP
If you qualify for both and do not select a program, we will enroll you in PCIP.
HowdidyoulearnaboutPCIPorMRMIP?(Check all that apply.)
Tell us how you learned about PCIP or MRMIP.3
InsuranceAgent/Broker TV /radio Communityclinic Healthinsurance Employer CertifiedApplicationAssistant Website / Internet Hospital denialletter Church HealthFair /CommunityEvent Newspaper / printad Pharmacy Friend / relative Diseasemanagementorganization Doctor’soffice Governmentoffice Other____________________________________________
Application FilloutthisformtoapplyforPCIPandMRMIP.Complete allquestionsontheapplication,astheymustbefullyanswered.Ifyoudonotprovideallnecessaryinformation,theprocessingofyourapplicationmaybedelayed.Whenyouseethisarrow ,itmeansyoumayhavetosendsupportingdocuments.
Lastname:
Household information (optional)
Tell us about your ethnicity (optional)
Emailaddress:
Mailingaddress(if different from your home address):
Gender: Female Male
Homeaddress:
City:
Maritalstatus: Single Married Divorced Widowed RegisteredDomesticPartner
Firstname: Middleinitial:
State: ZIPcode: Telephonenumber:
Cellphonenumber:
City: State: ZIPcode:
White Black,AfricanAmerican
Hispanic: Cuban Mexican,MexicanAmerican PuertoRican OtherHispanic__________________________
Asian: AsianIndian Cambodian Chinese Japanese Amerasian Korean Laotian
Vietnamese Filipino OtherAsian________________________________
Pacific Islander: Hawaiian Guamanian Samoan OtherPacificIslander ______________________________
Aleut /AlaskaNative AmericanIndian,NativeAmerican Eskimo
Other, not listed above_____________________________________
Dateofbirth(month/day/year):
IfyouareaU.S.CitizenorU.S.National,youmustwriteyourSocial Security Number here (required for PCIP):
IfyouarenotaU.S.CitizenorU.S.National, areyoulawfullypresentintheU.S.? Yes No If Yes, send documentation (see application checklist on page 6).
Whatlanguagedoyouwantustousewhenspeakingwithyou? Howmanypeopleareinyourfamily?
Whatisyourannualhouseholdincome?Whatlanguageshouldweusewhenwritingtoyou?
1 Tell us about the person who needs coverage. Newenrollment Adddependents
AreyouaCaliforniaresident? Yes No
AreyouaU.S.CitizenorU.S.National? Yes NoIf Yes, send documentation (see application checklist on page 6).
A1
IfyouqualifyforMRMIP,whichhealthplandoyouwant?(see pages 14 – 19) AnthemBlueCross ContraCosta KaiserPermanente
Wereyoucoveredbyasimilarhigh-riskinsuranceprograminanotherstatewithinthelast12months? Yes No
IfyoudonotqualifyforMRMIPrightnowbutexpecttoqualifysoon,areyouapplyingfordeferredenrollment?(see page 21) Yes NoIf Yes, please provide the following information:
Haveyoumettherequirementstoavoidall(orpart)oftheMRMIPexclusion/waitingperiod?(see page 22) Yes NoIf Yes, please fill in the information below:
Nameofcurrentinsurancecompany,healthplan,orhealthprogram:
Nameofpriorinsurancecompany,healthplan,orhealthprogram:
Reasonforfuturetermination: Dateyourcoveragewillend:
Ifyouareapplyingfordeferredenrollment,sendacopyofaletterfromyourhealthinsuranceplanindicatingwhenyourcoveragewillend.
Datethatyourcoveragestarted: Datethatyourcoveragewillend:
Ifyouhavemettherequirementstoavoidall(orpart)oftheexclusion/waitingperiod,sendacopyofyourhealthinsurancepolicy,healthplan document,orproofthatyouhadcoverage(includingMedicareandMedi-Cal)indicatingwhenyourcoverageended.
Dateyourcoveragestarted:
Information for MRMIP coverage4
If you are applying for MRMIP and want coverage for dependents, list the dependents here. PCIP does not provide coverage for dependents. Each person interested in PCIP must complete a separate application. He or she must qualify to be enrolled.
5
Name of dependent Gender Date of birth Married? Relationship to applicantLast,First,MiddleInitial,andSSN(optional) FemaleorMale Month/Day/Year YesorNo Checkone:
1. F M // Y N
Spouse Child StepchildRegisteredDomesticPartnerChildofRegisteredDomesticPartnerOther_____________________________________
2. F M // Y N
Spouse Child StepchildRegisteredDomesticPartnerChildofRegisteredDomesticPartnerOther_____________________________________
3. F M // Y N
Spouse Child StepchildRegisteredDomesticPartnerChildofRegisteredDomesticPartnerOther_____________________________________
Name of dependent Name of prior health insurance company Date coverage started Date coverage ended
1. // //
2. // //
3. // //
Ifthedependenthasmettherequirementstoavoidall(orpart)oftheexclusion/waitingperiod,sendacopyofthehealthinsurancepolicy,healthplandocument,orproofthatyouhadcoverage(includingMedicareandMedi-Cal)indicatingwhenhisorhercoverageended.
If you have more dependents,photocopypageA2andfillitout.Sendtheadditionalpageswithyourapplication. Subscriberdependentsage18andunderarenotsubjecttothepre-existingconditionexclusionperiodorthepost-enrollmentwaitingperiod.
Ifadependentchildisover23yearsold,sendadoctor’sletterwiththeapplicationforeachchildover23statingthatthepersoncannotworkbecauseofacontinuousphysicalormentaldisabilitythatstartedbeforeage23.Thedependentchildcannotbemarried.Isthedependentchild(whoisover23yearsold)coveredbyMedicare? Yes No
Haveanyofyourdependentsmettherequirementstoavoidall(orpart)oftheexclusion/waitingperiod?(see page 21) Yes NoIf Yes, list their names below:
A2
A3
Tell us about your recent health insurance experience that qualifies you for PCIP or MRMIP.
Hasyouremployer,aninsurancecompanyorinsuranceAgent/Brokerdiscouragedyoufromgetting Yes Nohealthcoveragethatyouqualifiedfor?If Yes, provide more information below.
Nameofemployerorhealthinsurancecompany:
Address:
City: State: ZIPcode:
6
For PCIP: Withinthepast6months,haveyouhadanyofthefollowingtypesofhealthcoverage? Yes NoIf Yes, please indicate by checking the boxes below, and indicate date your health coverage ended _____ /_____ /_____.
AnotherPCIPprogram(see page 20).Ifso,whichstate:____________ Checkthisboxifyouobtainedotherhealthcoverageafter youweredisenrolledfromanotherPCIPprogram.
Individualorjob-basedhealthcoverage,includingCOBRAorCal-COBRA MedicarePartAandPartB Medi-Cal(Medicaid) Children’sHealthInsuranceProgram(CHIP),including
HealthyFamiliesProgram(HFP) Anotherstate'shigh-riskpoolorCalifornia'sMajorRiskMedical
InsuranceProgram(MRMIP)
TRICARE(militaryhealthinsurance) HealthbenefitplanprovidedtoPeaceCorpsworkers Healthcoverageprovidedbyapublichealthplanestablished
byastate,theU.S.government(suchascoverageprovided toveteransenrolledinVAhealthcare),oraforeigncountry
FEHBP(healthinsuranceforfederalemployeesorretirees), includingTemporaryContinuationofCoverage(TCC)
ServicesprovidedbytheIndianHealthServiceorbyaTribe orTribalorganizationfortreatingyourmedicalcondition
Ifyouhadhealthcoveragewithinthepast6months,pleaseprovidethereasonyourhealthcoverageended.
Youorsomeoneinyourfamilylostorlefthisorherjob Yourinsurancecompanystoppedcoveringdependents Youorsomeoneinyourfamilystoppedworkingfulltime
andwerenolongereligibleforbenefits Youmovedoutoftheinsurancecompany’sservicearea
(ormovedoutofstate)
Yourinsurancepremiumsweretoohigh YourCOBRAcoverageended Youvoluntarilyendedyourinsurancecoverage Youarenolongereligibleforpubliclysponsoredcoverage Other.Explainthereasonyourcoverageended:______________________
______________________________________________________________________________
Haveyoureceivedadenialletterfromahealthinsurancecompanyorhealthplanwithinthepast12months? Yes No If Yes, provide a copy of the denial letter.
For PCIP: Withinthepast12months,haveyoureceivedanofferofindividual(notgroup)healthcoverageathigher Yes No ratesthantheMRMIPPPOproduct?If Yes, provide a copy of the offer letter.For MRMIP: Withinthepast12months,haveyoureceivedanofferofindividual(notgroup)healthcoverageathigher Yes No
ratesthanyourselectedMRMIPhealthplan?If Yes, provide a copy of the offer letter.
For PCIP: Haveyoureceivedaletterfromalicenseddoctor,physicianassistant,ornursepractitionerwithinthe Yes No past12months,statingtheindividualhasorhadamedicalcondition,disabilityorillness? IfYes, provide a copy of the provider letter.
For MRMIP: Haveyoubeeninvoluntarilyterminatedfromhealthinsurancecoverageforreasonsotherthanfraud Yes No ornonpaymentofpremium?IfYes, provide a copy of the termination letter.
mo day yr
MRMIP health plan dispute resolution and PCIP dispute resolution7InMRMIP,eachplanhasitsownrulesforresolvingdisputesaboutdelivery,services,andothermatters.Someplanssayyoumustusebindingarbitrationfordisputes(notincludingdisputeswiththeprogramaboutwhichbenefitsarecovered);othersdonot.Someplanssaythatclaimsformalpracticemustbedecidedbybindingarbitration;othersdonot.Iftheplanyouchooserequiresbindingarbitration,youaregivingupyourrighttoajurytrialandcannothaveadisputedecidedincourt.Tofindouthowaplanresolvesdisputes,youcancalltheplanandrequestanEvidenceofCoveragebooklet.ToseewhichMRMIPplansrequirebindingarbitration,seepage7.
In PCIP,therearerulesforresolvingdisputesaboutdelivery,services,andothermatters.TofindouthowPCIPresolvesdisputes,youcancallPCIPat1-877-428-5060,orrefertotheSummaryPlanDescriptionbookletonourwebsiteatwww.pcip.ca.gov.
A4
Important notices and declarations, and understandings and responsibilities 8
Applicant’s signature _______________________________________________________________________________________________ Date:__________________________________________
CAAgent/BrokerLicenseNumber(ifapplicable):
Person’sName: EE/CAANumber:(ifapplicable):
IgivepermissionforPCIPorMRMIPtogiveinformationoverthetelephoneaboutmyapplicationstatusandfinaleligibilitystatustothepersonlistedbelow.
Permission to share PCIP and MRMIP information9
CAANumber: EENumber:
CAAname:
CAAgent/BrokerLicenseNumber:
Agent/Broker or CAA signature: ____________________________________________________________________________________ Date:__________________________________________
Agent/Brokername:
Streetaddress:
TaxI.D./SocialSecurityNumber(Agent/Brokeronly):
City:
State: ZIPcode: Phone: Emailaddress:
For Insurance Agents/Brokers or Certified Application Assistants (CAAs) only:
Ifyouassistedanapplicantincompletingthisapplication,pleasecompletethissection.Youmustcompleteallapplicableboxes.Youwillnotbepaidifyoudonotcompletethissectionpriortosendingtheapplication.Missinginformationcannotbesubmittedatalaterdateforpayment.(Please see page 20.)IftheapplicantwantsPCIPorMRMIPtoprovideyouwiththestatusofthisapplicationandfinaleligibilitydecision,makesuretheapplicantsignsSection9above.
Iunderstandthatpaymentwillnotbemadeunlessanduntilthisapplicantisenrolledintheprogram.IcertifythatIprovidedfreeassistancetotheapplicant.
10
IdeclarethatIhavereadthisapplication,theanswersprovided,andthedocumentsenclosed.Icertifythattheinformationprovidedwiththisapplicationistrue,complete,andcorrecttothebestofmyknowledge.IhavereadandunderstandtheNotices,andIammakingtheDeclarationsonpage7.IhavealsoreadandIunderstandtheMRMIPhealthplandisputeresolutionandPCIPdisputeresolutionexplanationonpageA3.
Signatureofapplicant/parentorlegalguardian_________________________________________________________________________Date:________________________________________
ZIPcode:
Checkyourrelationshiptothepersonapplyingforcoverage: Parent Stepparent CaretakerRelative LegalGuardian
Other________________________________________________________________________________________________
Mailingaddress:
City: State:
Fullname: Telephonenumber:
Ifyouareaparentorlegalguardianofthepersonapplyingforcoverage,youmustsignaboveandprovidethefollowinginformation:
ForMRMIP only,thedependent(s)listedonthisapplicationmustsignhere:
Signatureofapplicant’sspouse/registereddomesticpartner: ____________________________________________________________Date:________________________________________
Signatureofapplicant’sdependentage18orover: _________________________________________________________________________Date:________________________________________
Signatureofapplicant’sdependentage18orover: _________________________________________________________________________Date:________________________________________
7
Important Notices and Declarations
PCIP and MRMIP Declarations
n IunderstandthatitismyresponsibilitytoinformPCIPofanyhealthcoverageIgetinthefutureorifImoveoutofCalifornia,sothatIcanbedisenrolled.
n Iunderstandthat,ifIvoluntarilydisenrollfromPCIPorifIamdisenrolledinvoluntarily(forexample,forfailuretopaymypremiumsontime),Imaynotre-qualifyforenrollmentuntilatleast6monthsaftermycoverageends.
n IunderstandthatmyapplicationandenrollmentinformationmaybesharedwithotherFederalandStategovernmentagenciesforpurposesofestablishingPCIPeligibility.
n IunderstandthatmyapplicationmustbereviewedtodeterminewhetherornotIqualifyforcoverage.
n Iunderstandthat,ifmyapplicationisapproved,theeffectivedateofcoveragewillbedeterminedaccordingtoapplicablelawsandregulationsandIwillbeinformedinwritingoftheeffectivedateofcoverage.
n IunderstandthattheMRMIPhealthplandisputeresolutionprocessmayincludebindingarbitration,ratherthanacourttrialtoresolveanyclaim.Thisincludesaclaimformalpracticeassertedbyme,myenrolleddependents,heirs,personalrepresentatives,orsomeonewitharelationtousagainsttheparticipatinghealthplanoragainsttheemployees,partnersoragentsoftheparticipatinghealthplan.
n IunderstandthatMRMIP’sContraCostaHealthPlanDOESNOTrequirebindingarbitration.
n IunderstandthatMRMIP’sAnthemBlueCrossandKaiserPermanenteHealthPlansDOrequirebindingarbitrationofdisputesINCLUDINGmalpractice,solongasthedisputesarebeyondthejurisdictionallimitofthesmallclaimscourt.Thisdoesnotincludedisputeswiththeprogramaboutwhichbenefitsarecovered.
n IunderstandthatifIdonotprovideallthenecessaryinformationrequestedtoprocesstheapplication,theapplicationwillbedeniedorreturnedasincomplete.
n Ideclarethat,withinthelast6months,IhavenothadhealthcoveragepriortothedateIamaskingforcoverageinthePCIP.
n IdeclarethatallindividualslistedonthisapplicationareresidentsoftheStateofCalifornia.
n IdeclareandunderstandthatmakingamonthlypremiumpaymentdoesnotmeanthatIamacceptedby,or,ifaccepted,immediatelyenrolledinto,theprograms.
n IdeclarethatnopersonlistedonthisapplicationandapplyingforMRMIPiseligibleforbothMedicarePartsAandPartB,unlesstheyaresolelyeligiblebecauseofend-stagerenaldisease.
n IdeclarethatnopersonlistedonthisapplicationandapplyingforPCIPisenrolledinMedicarePartsAandB.
n Ideclarethatallindividualslistedonthisapplicationwillabidebyallrulesofprogramparticipation.
n IdeclarethatnopersonlistedonthisapplicationandapplyingforcurrentordeferredenrollmentintoMRMIPiscurrentlyeligibletopurchaseanycontinuationofemployerhealthbenefitsundertheprovisionsof29U.S.Code1161etseq.(COBRA),orundertheprovisionsofInsuranceCodeSections10128.50etseq.andHealthandSafetyCodeSections1366.20etseq.(Cal-COBRA).Thesearelawswhichallowpeopletobuyintotheiremployer’shealthinsuranceforupto36consecutivemonthsaftertheyleavetheiremployment.
n IdeclarethatnopersonlistedonthisapplicationandapplyingforPCIPisenrolledinCOBRAorCal-COBRA.
n Ideclarethatnopersonlistedonthisapplication,andapplyingforcoveragethroughtheMRMIP,wasterminatedwithinthelast12monthsfroma“Post-MRMIPGuaranteedIssuePilotProgram”asaresultofnon-paymentofpremiums,arequesttodisenrollvoluntarily,orfraud.A“PostMRMIPGuaranteedIssuePilotProgram”isahealthplaninwhichanindividualhadanopportunitytoenrollbetweenSeptember1,2003andDecember31,2007asaresultofbeingdisenrolledfromMRMIPafter36consecutivemonthsofenrollment.
n IdeclarethatIhavereadandunderstandtheinformationonthisApplicationandagreetotheseNoticesandDeclarations.
Access to Your Records
YouhavetherighttoaccessrecordsmaintainedbytheManagedRiskMedicalInsuranceBoardthatcontainyourpersonalinformation.Todoso,contact:
ManagedRiskMedicalInsuranceBoardAttn:HIPAACoordinatorP.O.Box2769Sacramento,CA95812-2769(916)324-4695
8
MRMIP InMRMIP,yougetyourhealthcarethroughahealthplan.Premiumsforthehealthplansarelistedbelow.
PCIP and MRMIP Monthly Premiums | Area 1Usethischarttocomparepremiumsbasedonyourageandwhereyoulive.
Premiums for people who live in:Alpine,Amador,Butte,Calaveras,Colusa,DelNorte,ElDorado,Glenn,Humboldt,Inyo,Kings,Lake,Lassen,Mendocino,Modoc,Mono,Monterey,Nevada,Placer,Plumas,SanBenito,Shasta,Sierra,Siskiyou,Sutter,Tehama,Trinity,Tulare,Tuolumne,Yolo,andYubacounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.
PCIP
Subscriber only
Age
PCIP
0 – 14 $119.00
15 – 18 $119.00
19 – 29 $164.00
30 – 34 $237.00
35 – 39 $264.00
40 – 44 $292.00
45 – 49 $332.00
50 – 54 $411.00
55 – 59 $492.00
60 – 64 $535.00
65 – 69 $535.00
70 – 74 $535.00
> 74 $535.00
Subscriber and 1 dependent
Anthem Blue Cross
PPO
Kaiser Permanente
N. California 1
$741.00 $561.88
$999.00 $747.59
$999.00 $747.59
$1,185.00 $850.48
$1,290.00 $937.91
$1,409.00 $1,208.78
$1,701.00 $1,078.53
$2,151.00 $1,285.99
$2,614.00 $1,424.89
$3,182.00 $1,622.08
$3,564.00 $2,402.18
$3,755.00 $2,534.53
$3,978.00 $2,680.48
Subscriber and 2 or more dependents
Anthem Blue Cross
PPO
Kaiser Permanente
N. California 1
$1,165.00 $974.04
$1,645.00 $1,224.26
$1,645.00 $1,224.26
$1,955.00 $1,481.46
$2,121.00 $1,481.46
$2,179.00 $1,503.75
$2,436.00 $1,503.75
$2,817.00 $1,663.21
$3,243.00 $1,663.21
$3,833.00 $1,879.28
$4,293.00 $3,121.43
$4,523.00 $3,299.8
$4,791.00 $3,490.98
Subscriber only
Anthem Blue Cross
PPO
Kaiser Permanente
N. California 1
$374.00 $281.50
$488.00 $354.06
$488.00 $354.06
$674.00 $418.36
$768.00 $449.24
$810.00 $504.10
$860.00 $553.86
$1,101.00 $639.58
$1,324.00 $732.16
$1,670.00 $811.03
$1,870.00 $1,354.51
$1,971.00 $1,429.93
$2,087.00 $1,517.08
1. Kaiser Permanente Northern California servestheseZIPcodesinthesecounties:Amador 95640and95669 | El Dorado 95613-14,95619,95623,95633-35,95651,95664,95667,95672,95682,and95762 | Kings
93230and93232 | Placer 95602-04,95648,95650,95658,95661,95663,
95677-78,95681,95703,95722,95736,95746-47,and95765| Sutter
95659,95668,95674,and95676 | Tulare 93261,93618,93666,and93673 | Yolo95605,95607,95612,95616-18,95645,95691,95694-95,95697-98,95776,and95798-99 | Yuba 95692,95903,and95961
PremiumseffectivethroughDecember31,2012
9
PCIP and MRMIP Monthly Premiums | Area 2 Usethischarttocomparepremiumsbasedonyourageandwhereyoulive.
Premiums for people who live in: Fresno,Imperial,Kern,Madera,Mariposa,Merced,Napa,Sacramento,SanJoaquin,SanLuisObispo,SantaCruz,Solano,Sonoma,andStanislauscounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.
2. Kaiser Permanente Northern California servesallZIPcodesinSacramento,
San Joaquin, and SolanocountiesandtheseZIPcodesinthesecounties:Fresno93242,93602,93606-07,93609,93611-13,93616,93619,93624-27,93630-31,93646,93648-52,93654,93656-57,93660,93662,93667-68,93675,93701-12,93714-18,93720-30,93737,93741,93744-45,93747,93750,93755,93760-61,93764-65,93771-79,93786,93790-94,93844,and93888| Madera 93601-02,93604,93614,93636-39,93643-45,93653,and93669| Mariposa 93623 |
Napa 94503,94508,94515,94558-59,94562,94567(exceptthecommunityof
Knoxville),94573-74,94576,94581,and94599| Sonoma 94922-23,94926-28,94931,94951-55,94972,94975,94999,95401-07,95409,95416,95419,95421,95425,95430-31,95433,95436,95439,95441-42,95444,95446,95448,95450,95452,95462,95465,95471-73,95476,95486-87,and95492.
3. Kaiser Permanente Southern CaliforniaservestheseZIPcodesinthiscounty:Kern 93203,93205-06,93215-16,93220,93222,93224-26,93238,93240-41,93243,93250-52,93263,93268,93276,93280,93285,93287,93301-09,93311-14,93380,93383-90,93501-02,93504-05,93518-19,93531,93560-61,and93581.
PCIP
Subscriber only
Age
PCIP
0 – 14 $118.00
15 – 18 $118.00
19 – 29 $162.00
30 – 34 $234.00
35 – 39 $261.00
40 – 44 $289.00
45 – 49 $329.00
50 – 54 $406.00
55 – 59 $487.00
60 – 64 $530.00
65 – 69 $530.00
70 – 74 $530.00
> 74 $530.00
Subscriber and 1 dependent
Anthem Blue Cross
PPO
Kaiser Permanente
N. 2 & S. 3 California
$691.00 $561.88
$932.00 $747.59
$932.00 $747.59
$1,106.00 $850.48
$1,204.00 $937.91
$1,314.00 $1,028.78
$1,587.00 $1,078.53
$2,007.00 $1,285.99
$2,440.00 $1,424.89
$2,970.00 $1,622.08
$3,326.00 $2,402.18
$3,505.00 $2,534.53
$3,712.00 $2,680.48
Subscriber and 2 or more dependents
Anthem Blue Cross
PPO
Kaiser Permanente
N. 2 & S. 3 California
$1,087.00 $974.04
$1,536.00 $1,224.26
$1,536.00 $1,224.26
$1,824.00 $1,481.46
$1,979.00 $1,481.46
$2,033.00 $1,503.75
$2,274.00 $1,503.75
$2,629.00 $1,663.21
$3,026.00 $1,663.21
$3,577.000 $1,879.28
$4,007.00 $3,121.43
$4,221.00 $3,299.80
$4,472.00 $3,490.98
Subscriber only
Anthem Blue Cross
PPO
Kaiser Permanente
N. 2 & S. 3 California
$349.00 $281.50
$455.00 $354.06
$455.00 $354.06
$629.00 $418.36
$717.00 $449.24
$756.00 $504.10
$802.00 $553.86
$1,028.00 $639.58
$1,235.00 $732.16
$1,558.00 $811.03
$1,745.00 $1,354.51
$1,839.00 $1,429.93
$1,948.00 $1,517.08
MRMIP InMRMIP,yougetyourhealthcarethroughahealthplan.Premiumsforthehealthplansarelistedbelow.
PremiumseffectivethroughDecember31,2012
10
MRMIP InMRMIP,yougetyourhealthcarethroughahealthplan.Premiumsforthehealthplansarelistedbelow.
PCIP and MRMIP Monthly Premiums | Area 3 Usethischarttocomparepremiumsbasedonyourageandwhereyoulive.
Premiums for people who live in: Alameda,ContraCosta,Marin,SanFrancisco,SanMateo,andSantaClaracounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.
Subscriber only
Anthem Blue Cross
PPO
Contra Costa Health Plan 4
Kaiser Permanente
N. California 5
$396.00 $268.35 $281.50
$518.00 $341.28 $354.06
$518.00 $341.28 $354.06
$715.00 $495.84 $418.36
$815.00 $495.84 $449.24
$859.00 $571.16 $504.10
$912.00 $571.16 $553.86
$1,168.00 $762.59 $639.58
$1,404.00 $762.59 $732.16
$1,771.00 $963.45 $811.03
$1,984.00 $1,292.97 $1,354.51
$2,090.00 $1,292.97 $1,429.93
$2,214.00 $1,292.97 $1,517.08
PCIP
Subscriber only
Age
PCIP
0 – 14 $124.00
15 – 18 $124.00
19 – 29 $171.00
30 – 34 $247.00
35 – 39 $275.00
40 – 44 $305.00
45 – 49 $346.00
50 – 54 $428.00
55 – 59 $514.00
60 – 64 $557.00
65 – 69 $557.00
70 – 74 $557.00
> 74 $557.00
Subscriber and 1 dependent
Anthem Blue Cross
PPO
Contra Costa Health Plan 4
Kaiser Permanente
N. California 5
$785.00 $662.17 $561.88
$1,060.00 $662.17 $747.59
$1,060.00 $662.17 $747.59
$1,257.00 $878.70 $850.48
$1,368.00 $878.70 $937.91
$1,494.00 $1,085.82 $1,028.78
$1,804.00 $1,085.82 $1,078.53
$2,281.00 $1,487.56 $1,285.99
$2,773.00 $1,487.56 $1,424.89
$3,375.00 $1,920.65 $1,622.08
$3,780.00 $2,520.04 $2,402.18
$3,983.00 $2,520.04 $2,534.53
$4,219.00 $2,520.04 $2,680.48
Subscriber and 2 or more dependents
Anthem Blue Cross
PPO
Contra Costa Health Plan 4
Kaiser Permanente
N. California 5
$1,235.00 $1,220.80 $974.04
$1,745.00 $1,220.80 $1,224.26
$1,745.00 $1,220.80 $1,224.26
$2,073.00 $1,349.45 $1,481.46
$2,250.00 $1,349.45 $1,481.46
$2,311.00 $1,606.81 $1,503.75
$2,584.00 $1,606.81 $1,503.75
$2,987.00 $1,839.03 $1,663.21
$3,439.00 $1,839.03 $1,663.21
$4,065.00 $2,231.32 $1,879.28
$4,553.00 $2,988.48 $3,121.43
$4,797.00 $2,988.48 $3,299.80
$5,082.00 $2,988.48 $3,490.98
4. Contra Costa Health Plan isavailableonlyinContra Costa County.
5. Kaiser Permanente Northern California servesallZIPcodesinAlameda, Contra Costa, Marin, San Francisco, and San Mateo countiesandtheseZIPcodesinthiscounty:Santa Clara 94022-24,94035,94039-43,94085-89,
94301-06,94309,95002,95008-09,95011,95013-15,95020-21,95026,95030-33,95035-38,95042,95044,95046,95050-56,95070-71,95101,95103,95106,95108-13,95115-36,95138-41,95148,95150-61,95164,95170,95172-73,95190-94,and95196.
PremiumseffectivethroughDecember31,2012
11
MRMIP InMRMIP,yougetyourhealthcarethroughahealthplan.Premiumsforthehealthplansarelistedbelow.
PCIP and MRMIP Monthly Premiums | Area 4 Usethischarttocomparepremiumsbasedonyourageandwhereyoulive.
Premiums for people who live in: Orange,SantaBarbara,andVenturacounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.
6. Kaiser Permanente Southern California servesallZIPcodesin Orange county,andtheseZIPcodesinthiscounty:Ventura 91319-20,91358-62,91377,
93001-07,93009-93012,93015-16,93020-22,93030-36,93040-44,93060-66,93094,and93099.
Subscriber and 1 dependent
Anthem Blue Cross
PPO
Kaiser Permanente
S. California 6
$665.00 $515.68
$898.00 $697.13
$898.00 $697.13
$1,064.00 $792.53
$1,159.00 $875.75
$1,266.00 $960.73
$1,528.00 $1,005.79
$1,933.00 $1,200.04
$2,349.00 $1,330.11
$2,860.00 $1,513.91
$3,203.00 $2,305.54
$3,374.00 $2,432.19
$3,574.00 $2,584.93
Subscriber and 2 or more dependents
Anthem Blue Cross
PPO
Kaiser Permanente
S. California 6
$1,046.00 $894.15
$1,479.00 $1,238.20
$1,479.00 $1,238.20
$1,757.00 $1,382.11
$1,906.00 $1,382.11
$1,958.00 $1,404.66
$2,189.00 $1,404.66
$2,531.00 $1,552.08
$2,914.00 $1,552.08
$3,444.00 $1,754.98
$3,858.00 $2,919.93
$4,064.00 $3,081.30
$4,305.00 $3,274.44
Subscriber only
Anthem Blue Cross
PPO
Kaiser Permanente
S. California 6
$336.00 $258.41
$439.00 $330.34
$439.00 $330.34
$606.00 $390.19
$690.00 $419.66
$728.00 $471.68
$772.00 $516.79
$990.00 $596.56
$1,189.00 $683.25
$1,500.00 $757.83
$1,680.00 $1,295.81
$1,770.00 $1,365.71
$1,875.00 $1,446.86
Age
0 – 14
15 – 18
19 – 29
30 – 34
35 – 39
40 – 44
45 – 49
50 – 54
55 – 59
60 – 64
65 – 69
70 – 74
> 74
PCIP
Subscriber only
PCIP
$107.00
$107.00
$147.00
$211.00
$237.00
$261.00
$297.00
$370.00
$442.00
$481.00
$481.00
$481.00
$481.00
PremiumseffectivethroughDecember31,2012
12
PCIP
Subscriber only
Age
PCIP
0 – 14 $110.00
15 – 18 $110.00
19 – 29 $152.00
30 – 34 $218.00
35 – 39 $244.00
40 – 44 $269.00
45 – 49 $306.00
50 – 54 $381.00
55 – 59 $455.00
60 – 64 $494.00
65 – 69 $494.00
70 – 74 $494.00
> 74 $494.00
MRMIP InMRMIP,yougetyourhealthcarethroughahealthplan.Premiumsforthehealthplansarelistedbelow.
PCIP and MRMIP Monthly Premiums | Area 5Usethischarttocomparepremiumsbasedonyourageandwhereyoulive.
Premiums for people who live in: LosAngelesCounty.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.
Subscriber and 1 dependent
Anthem Blue Cross
PPO
Kaiser Permanente
S. California 7
$745.00 $515.68
$1,006.00 $697.13
$1,006.00 $697.13
$1,192.00 $792.53
$1,298.00 $875.75
$1,417.00 $960.73
$1,711.00 $1,005.79
$2,165.00 $1,200.04
$2,631.00 $1,330.11
$3,203.00 $1,513.91
$3,587.00 $2,305.54
$3,780.00 $2,432.19
$4,004.00 $2,584.93
Subscriber and 2 or more dependents
Anthem Blue Cross
PPO
Kaiser Permanente
S. California 7
$1,172.00 $894.15
$1,656.00 $1,238.20
$1,656.00 $1,238.20
$1,967.00 $1,382.11
$2,135.00 $1,382.11
$2,193.00 $1,404.66
$2,452.00 $1,404.66
$2,835.00 $1,552.08
$3,264.00 $1,552.08
$3,858.00 $1,754.98
$4,321.00 $2,919.93
$4,552.00 $3,081.30
$4,822.00 $3,274.44
Subscriber only
Anthem Blue Cross
PPO
Kaiser Permanente
S. California 7
$376.00 $258.41
$491.00 $330.34
$491.00 $330.34
$678.00 $390.19
$773.00 $419.66
$816.00 $471.68
$865.00 $516.79
$1,108.00 $596.56
$1,332.00 $683.25
$1,681.00 $757.83
$1,882.00 $1,295.81
$1,983.00 $1,365.71
$2,101.00 $1,446.86
7. Kaiser Permanente Southern California servesallZIPcodesin Los Angeles County except90704(CatalinaIsland).
PremiumseffectivethroughDecember31,2012
13
MRMIP InMRMIP,yougetyourhealthcarethroughahealthplan.Premiumsforthehealthplansarelistedbelow.
PCIP and MRMIP Monthly Premiums | Area 6 Usethischarttocomparepremiumsbasedonyourageandwhereyoulive.
Premiums for people who live in: Riverside,SanBernardino,andSanDiegocounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.
Subscriber and 1 dependent
Anthem Blue Cross
PPO
Kaiser Permanente
S. California 8
$683.00 $515.68
$922.00 $697.13
$922.00 $697.13
$1,093.00 $792.53
$1,190.00 $875.75
$1,299.00 $960.73
$1,569.00 $1,005.79
$1,984.00 $1,200.04
$2,412.00 $1,330.11
$2,936.00 $1,513.91
$3,288.00 $2,305.54
$3,464.00 $2,432.19
$3,670.00 $2,584.93
Subscriber and 2 or more dependents
Anthem Blue Cross
PPO
Kaiser Permanente
S. California 8
$1,074.00 $894.15
$1,518.00 $1,238.20
$1,518.00 $1,238.20
$1,804.00 $1,382.11
$1,956.00 $1,382.11
$2,010.00 $1,404.66
$2,247.00 $1,404.66
$2,598.00 $1,552.08
$2,991.00 $1,552.08
$3,536.00 $1,754.98
$3,960.00 $2,919.93
$4,173.00 $3,081.30
$4,420.00 $3,274.44
Subscriber only
Anthem Blue Cross
PPO
Kaiser Permanente
S. California 8
$345.00 $258.41
$450.00 $330.34
$450.00 $330.34
$622.00 $390.19
$708.00 $419.66
$748.00 $471.68
$793.00 $516.79
$1,016.00 $596.56
$1,221.00 $683.25
$1,540.00 $757.83
$1,725.00 $1,295.81
$1,818.00 $1,365.71
$1,925.00 $1,446.86
PCIP
Subscriber only
Age
PCIP
0 – 14 $108.00
15 – 18 $108.00
19 – 29 $149.00
30 – 34 $214.00
35 – 39 $240.00
40 – 44 $265.00
45 – 49 $301.00
50 – 54 $375.00
55 – 59 $447.00
60 – 64 $485.00
65 – 69 $485.00
70 – 74 $485.00
> 74 $485.00
8. Kaiser Permanente Southern California servesZIPcodesinthesecounties:Riverside 91752,92220,92223,92320,92501-09,92513-19,92521-22,92530-32,92543-46,92548,92551-57,92562-64,92567,92570-72,92581-87,92589-93,92595-96,92599,92860,and92877-83|San Bernardino 91701,91708-10,91729-30,91737,91739,91743,91758,91761-64,91784-86,92252,92256,92268,92277-78,92284-86,92305,92307-08,92313-18,92321-22,92324-26,92329,92331,92333-37,92339-41,92344-46,92350,92352,92354,
92357-59,92369,92371-78,92382,92385-86,92391-95,92397,92399,92401-08,92410-15,92418,92423-24,and92427|San Diego 91901-03,91908-17,91921,91931-33,91935,91941-47,91950-51,91962-63,91976-80,91987,92007-92011,92013-14,92018-27,92029-30,92033,92037-40,92046,92049,92051-52,92054-58,92064-65,92067-69,92071-72,92074-75,92078-79,92081-85,92091-93,92096,92101-24,92126-32,92134-40,92142-43,92145,92147,92149-50,92152-55,92158-79,92182,92184,92186-87,and92190-99.
PremiumseffectivethroughDecember31,2012
14
PCIP MRMIP Health Plan Options
Plan areaYoucanchoosethePCIPPPONetworkifyouliveinany countyinCalifornia(statewide).
Plan areaYoucanchoosethisplanifyouliveinany countyinCalifornia(statewide).
Plan areaYoucanchoosethisplanifyouliveinContra CostaCounty.
Plan areaNorthern CA counties:Alameda,Amador,ContraCosta,ElDorado,Fresno,Kings,Madera,Marin,Mariposa,Napa,Placer,Sacramento,SanFrancisco,SanJoaquin,SanMateo,SantaClara,Solano,Sonoma,Sutter,Tulare,Yolo,Yuba
Southern CA counties:Kern,LosAngeles,Orange,Riverside,SanBernardino,SanDiego,Ventura
Provider networkn11,000primarycarephysiciansn43,300specialistsn321hospitalsn250urgentcaren359ambulatorysurgerycenters(ASC)
Provider networkn40,000PPOphysiciansn29,000HMOphysiciansnMorethan400hospitals
Provider network3,000providersandspecialistsinchoiceoftwoprovidernetworks:nRegionalMedicalCenterNetwork
orn CommunityProviderNetwork
Provider networkYouchooseadoctortobeyourprimarycarephysician(PCP).YourPCPworkscloselywithyouandcanreferyoutospecialistswhenneeded.YoureceivecareatKaiserPermanentemedicalfacilitiesthroughoutthearea.
Annual deductibleDoes not apply to in-network preventive care.$1,500persubscriber(in-networkproviders)$3,000persubscriber(out-of-networkproviders)Thereareseparatedeductiblesforin-networkandout-of-networkservices.
Annual deductibleDoes not apply to preventive care.
$500persubscriber
$500perhouseholdServicesprovidedbyin-networkandout-of-networkprovidersandprescriptiondrugsapplytowardthe$500deductible.
Annual deductibleDoes not apply to in-network preventive care.$500perhouseholdTheannualdeductibleappliesonlytoinpatienthospitalservices.Allotherservicesarenotsubjecttothedeductible.
Annual deductibleDoes not apply to in-network preventive care.
$500perhousehold
Servicesprovidedbyin-networkandout-of-networkprovidersandprescriptiondrugsapplytowardthe$500deductible.
Brand name drug deductible$500forin-networkpharmacies
$500forout-of-networkpharmaciesThereareseparatedeductiblesforin-networkandout-of-networkpharmacies.
Brand name drug deductibleNoseparatebrandnamedeductible
Brand name drug deductibleNoseparatebrandnamedeductible
Brand name drug deductibleNoseparatebrandnamedeductible
1-877-661-6230 (press2)8:00amto5:00pm,Monday–Friday
www.cchealth.org/health_plan
1-877-687-05498:30amto7:00pm,Monday–Friday
www.anthem.com
1-877-428-50608:00amto8:00pm,Monday–Friday
8:00amto5:00pm,Saturdaywww.pcip.ca.gov
PCIP and MRMIP Costs and Benefits Usethischarttocompareplans.
Northern & Southern California
1-800-464-40007:00amto7:00pm,Monday–Friday
7:00amto3:00pm,Saturday–Sundaywww.kaiserpermanente.org
ForPCIPquestions,call1-877-428-5060MondaythroughFriday8:00AM–8:00PM,Saturday8:00AM–5:00PMorvisitwww.pcip.ca.gov.
ForMRMIPquestions,call 1-800-289-6574 MondaythroughFriday8:30AM–7:00PMorvisit www.mrmib.ca.gov.
15
PCIP MRMIP Health Plan Options
Cost sharing15%coinsurance(in-network)50%coinsurance(out-of-network)
Theshareyoupayoftheplanallowanceforacoveredserviceaftermeetingyourdeductible.Forout-of-networkservices,youmayalsohavetopayanyamountthatexceedstheplanallowance.
Cost sharing15%coinsurance(in-network)50%coinsurance(out-of-network)
Theshareyoupayoftheplanallowanceforacoveredserviceaftermeetingyourdeductible.Forout-of-networkservices,youmayalsohavetopayanyamountthatexceedstheplanallowance.
Cost sharing$15copaymentforofficevisitsandmanyotherservices$25copaymentforemergencyroomvisits$200perdayforinpatienthospitalstays
Youpayasetamountforcoveredservices.
Cost sharing$20copaymentforofficevisitsandmanyotherservices$100copaymentforemergencyroomvisits$200perdayforinpatienthospitalstays
Youpayasetamountforcoveredservices.
Annual out-of-pocket maximum$2,500persubscriberforin-networkservices Themaximumincludesin-networkmedicalandbrandnamedrugdeductibles,andanyin-networkcopaymentsandcoinsurancepaid.Afteryoumeetthemaximum,theplanpays100%ofin-networkservicesfortherestoftheyear.Paymentsmadeforout-of-networkservicesdonotcounttowardstheout-of-pocketmaximum,andthereisnomaximumforout-of-networkservices.
Annual out-of-pocket maximum$2,500persubscriber$4,000perfamilyThemaximumincludesanyin-networkcopaymentsandcoinsurance.Afteryoumeetthemaximum,theplanpays100%ofin-networkservicesfortherestoftheyearuntilyoureachtheannualbenefitmaximum.Thereisnoout-of-pocketmaximumforout-of-networkservices.
Annual out-of-pocket maximum$2,500persubscriber$4,000perfamilyThemaximumincludesanycopaymentsandcoinsurance.Afteryoumeetthemaximum,theplanpays100%ofin-networkservicesfortherestoftheyearuntilyoureachtheannualbenefitmaximum.Thereisnoout-of-pocketmaximumforout-of-networkservices.
Annual out-of-pocket maximum$2,500persubscriber$4,000perfamilyThemaximumincludesanycopaymentsandcoinsurance.Afteryoumeetthemaximum,theplanpays100%ofin-networkservicesfortherestoftheyearuntilyoureachtheannualbenefitmaximum.Thereisnoout-of-pocketmaximumforout-of-networkservices.
Annual benefit maximumNo limit
Annual benefit maximum$75,000persubscriber
Annual benefit maximum$75,000persubscriber
Annual benefit maximum$75,000persubscriber
Lifetime benefit maximumNo limit
Lifetime benefit maximum$750,000persubscriber
Lifetime benefit maximum$750,000persubscriber
Lifetime benefit maximum$750,000persubscriber
Prior authorizationSomeservicesrequirepriorauthorization.SeethePCIPSummaryPlanDescriptionforalistingofallservicesthatrequirepriorauthorization.Thisdocumentcanbefoundatwww.pcip.ca.gov.
Prior authorizationSeetheAnthemEvidenceofCoveragebookletforalistingofservicesthatrequirepriorauthorization.
Prior authorizationSeetheContraCostaHealthPlanEvidenceofCoveragebookletforalistingofservicesthatrequirepriorauthorization.
Prior authorizationSeetheKaiserNorthernCaliforniaorKaiserSouthernCaliforniaEvidenceofCoveragebookletforalistingofservicesthatrequirepriorauthorization.
PCIP and MRMIP Costs and Benefits (continued)
Thisisonlyasummaryofplanprovisionsandisintendedforcomparisonpurposesonly.Forexacttermsandconditionsofcoverage,refertotheSummaryPlanDescription(forPCIP)ortheapplicableplan’sEvidenceofCoveragebooklet(forMRMIP).
Northern & Southern California
16
PCIP
Youpayifyougoto:
In-network provider Out-of-network provider
Ambulance• Limitedtotransportduringamedicalemergency 15%pertrip 15%pertrip
Doctor services• Inpatientvisits(doctorvisitswhileyouareinthehospital)• Officevisits
15%perinpatientvisit$25copaymentperofficevisit(nodeductible)
50%perinpatientvisit50%perofficevisit
Durable medical equipment• Authorizedbyaphysicianforcareofanillnessorinjury 15%perpurchase/rental 50%perpurchase/rental
Emergency room services• Limitedtotreatmentofamedicalemergency 15%pervisit 15%pervisit
Home health care• Medicallynecessaryvisitsbyhomehealthpersonnel 15%pervisit 50%pervisit
Hospice care• Hospicecareforsubscriberswhoarenotexpectedtolivemorethan12months 15%pervisit 50%pervisit
Hospital services• Inpatient(semi-privateroom)
• Outpatient
15%perinpatientday
15%peroutpatientvisit
50%perinpatientday
50%peroutpatientvisit
Mental health care services• Inpatient(limitedto10dayspercalendaryear)
• Outpatient(limitedto15visitspercalendaryear)• Unlimitedinpatientdaysandoutpatientvisitsfortreatmentofseriousemotional
disturbances(SED)inchildrenorseverementalillness(SMI)
15%perinpatientday
15%peroutpatientvisit
50%perinpatientday
50%peroutpatientvisit
Alcohol and substance abuse treatment• Inpatient(servicestoremovetoxicsubstancesfromthesystem)• Outpatient(limitedto20visitspercalendaryear)
15%perinpatientday15%peroutpatientvisit
50%perinpatientday50%peroutpatientvisit
Orthotics and prosthetics• Orthoticsandprostheticdevices 15%perdevice 50%perdevice
Physical/occupational/speech therapy• Servicesofphysicaltherapists/occupationaltherapists/speechtherapistsasmedically
appropriateonanoutpatientbasis15%pervisit 50%pervisit
PCIP and MRMIP Costs and Benefits Usethischarttocompareplans. (continued)
Thisisonlyasummaryofplanprovisionsandisintendedforcomparisonpurposesonly.Forexacttermsandconditionsofcoverage,refertotheSummaryPlanDescription(forPCIP)ortheapplicableplan’sEvidenceofCoveragebooklet(forMRMIP).
17
MRMIP Health Plan Options |Usethischarttocompareplans
Youpayifyougoto: Youpay: Youpay:
In-network provider Out-of-network provider
15%pertrip 15%pertrip $15pertrip $75pertrip
$25perofficevisit(nodeductible)
50%perofficevisit
$15perofficevisit
$20perofficevisit
15%perpurchase/rental 50%perpurchase/rental $0perpurchase/rental 20%perpurchase/rental
15%pervisit 15%pervisit $25pervisit(waivedifadmittedtoahospital)
$100pervisit(waivedifadmittedtoahospital)
15%pervisit 50%pervisit $0pervisit $0pervisit
15%pervisit 50%pervisit $0pervisit $0pervisit
15%perinpatientday
15%peroutpatientvisit
Allchargesafter$650perinpatientdayAllchargesafter$380perday
$200perinpatientday
$15peroutpatientvisit
$200perinpatientday
$20peroutpatientvisit
15%perinpatientday
15%peroutpatientvisit
Allchargesafter$175perinpatientday50%peroutpatientvisit
$200perinpatientday
$15peroutpatientvisit
$200perinpatientday
$20peroutpatientvisit
15%perinpatientdayoutpatientvisitsnotcovered
15%perinpatientdayoutpatientvisitsnotcovered
$200perinpatientday$15peroutpatientvisit
$200perinpatientdayoutpatientvisitsnotcovered
15%perdevice 50%perdevice $0perdevice $0perdevice
15%pervisit Allchargesafter$25pervisit $15pervisit $20pervisit
Northern & Southern California
Questions?ForPCIP,call1-877-428-5060MondaythroughFriday8:00AM–8:00PM,Saturday8:00AM–5:00PMorvisitwww.pcip.ca.gov.ForMRMIP,call1-800-289-6574MondaythroughFriday8:30AM–7:00PMorvisitwww.mrmib.ca.gov.
18
PCIP
Youpayifyougoto:
In-network provider Out-of-network provider
Pregnancy and maternity care• Inpatient(deliveryservices)
• Outpatient(prenatalandpostnatalcare)
•Excludescoverageforpaidsurrogates
15%perinpatientday
15%peroutpatientvisit
50%perinpatientday
50%peroutpatientvisit
Prescription drugs• Generic
• Brandname
• Non-preferredbrandnameorspecialtydrug
$5pergenericdrug(30-daysupply)$15perbrandnamedrug(30-daysupply)$30pernon-preferredbrandnameorspecialtydrug(30-daysupply)
50%pergenericdrug(30-daysupply)50%perbrandnamedrug(30-daysupply)50%pernon-preferredbrandnameorspecialtydrug(30-daysupply)
Preventive care • Cytologyexams• Diseasemanagementprograms• Familyplanningcounselingservices• Healtheducationservices• Hearingandeyetestsforchildren• Immunizationsforadultsandchildren• Newbornbloodtests• Prostateexamsformen• Routineexams,mammograms,Papsmears,HumanPapillomavirus(HPV)tests,
andovarianandcervicalcancerscreeningforwomen• Routinephysicalsandlabservices• TestsforHumanImmunodeficiencyVirus(HIV)andsexuallytransmittedinfections• Well-babyandwell-childcare• Routinecolonoscopies
Nocharge 50%pervisit(subjecttotheout-of-networkdeductibleandcoinsurance)
Skilled nursing facility• Servicesareavailableonlywhendeterminedtobeamedicallyappropriatealternative
planoftreatmentthatismorecosteffective15%pervisit 50%pervisit
X-ray and laboratory services• Diagnosticx-raysandlaboratorytests 15%pervisit 50%pervisit
PCIP and MRMIP Costs and Benefits Usethischarttocompareplans. (continued)
Thisisonlyasummaryofplanprovisionsandisintendedforcomparisonpurposesonly.Forexacttermsandconditionsofcoverage,refertotheSummaryPlanDescription(forPCIP)ortheapplicableplan’sEvidenceofCoveragebooklet(forMRMIP).
19
MRMIP Health Plan Options |Usethischarttocompareplans
Youpayifyougoto: Youpay: Youpay:
In-network provider Out-of-network provider
15%perinpatientday
15%peroutpatientvisit
Allchargesafter$650perinpatientday50%peroutpatientvisit
$200perinpatientday
$15peroutpatientvisit
$200perinpatientday
$15peroutpatientvisit
$5pergenericdrug(30-daysupply)$15perbrandnamedrug(30-daysupply)
Allchargesover50%ofgenericdrugAllchargesover50%ofbrandnamedrug
20%ofgenericdrugcost
20%ofbrandnamedrugcost
$10pergenericdrug(upto100-daysupply)$35perbrandnamedrug(upto100-daysupply)
15%pervisit(nodeductible)
50%pervisit(nodeductible)
$15pervisit $0to$20pervisit,dependingontheserviceyoureceive
notcoveredunlessmedicallyrecommended
notcoveredunlessmedicallyrecommended
$0perday(onlycoveredwhenauthorizedbytheplan)
$0perday(upto100daysperbenefitperiod)
15%pervisit 50%pervisit $0pervisit $0to$5pervisit,dependingontheserviceyoureceive
Northern & Southern California
Questions?ForPCIP,call1-877-428-5060MondaythroughFriday8:00AM–8:00PM,Saturday8:00AM–5:00PMorvisitwww.pcip.ca.gov.ForMRMIP,call1-800-289-6574MondaythroughFriday8:30AM–7:00PMorvisitwww.mrmib.ca.gov.
20
PCIP and MRMIP Frequently Asked Questions (FAQ)
How long does it take to process my Application?
Ifyourcompleteapplicationisreceivedwithalltherequireddocumentationby the 15thofthemonth,coveragewillbeginthe1stdayofthefollowingmonth.Forexample,wereceiveacompleteapplicationbyOctober15ththestartdateofcoveragewillbeonNovember1st.
However,ifyourcompleteapplicationisreceivedwithallrequireddocumentationafter the 15thofthemonth,coveragewillbeginonthe1stdayofthesecondmonthfollowingyourapplication.Forexample,wereceiveacompleteapplicationafterOctober15ththestartdateofcoveragewillbeonDecember1st.Incompleteapplicationswillresultindelayedordeniedcoverage.WewillsendyoualetterinformingyouifyouareenrolledinPCIP.
Can Insurance Agents/Brokers assist people in applying for PCIP and MRMIP?
Yes,theycanassistpeopleinapplyingforPCIPandMRMIP.Theinsuranceagent’s/broker’sinformationmustbeincludedontheApplicationinorderforthemtobepaidfortheirassistance.Insuranceagents/brokersareeligibleforpaymentforeachpersontheyassistwhoissuccessfully enrolledintoPCIPorMRMIP.
Can Healthy Families Certified Application Assistants help people apply for PCIP?
Yes,CertifiedApplicationAssistants(CAAs)registeredwithanEnrollmentEntity(EE)andPCIPcertifiedcanhelppeopleapplyforPCIP.TheEEsareeligibletoreceivepayment.ThepaymentwillbemadeforeachpersontheCAAassistswhoissuccessfully enrolledintoPCIP.TheCAAinformationmustbeincludedontheApplicationinorderfortheEEtobepaid.
When will the payment be issued to the Insurance Agents/Brokers or Enrollment Entities (EEs)?
PaymentswillbeissuedaftertheapplicantisenrolledinPCIPorMRMIP.
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.
PCIPisafederalprogramadministeredinCaliforniaandthefederalhealthcarereformlawrequiresthatapersonbewithout“creditablehealthcoverage”foratleast6months.
I am a U.S. Citizen or U.S. National. Why do I have to provide my Social Security Number?
PCIPisafederalprogramadministeredinCaliforniaandthefederallawrequiresthatU.S.CitizensorU.S.NationalsprovidetheirSocialSecurityNumber. If you do not provide your Social Security Number,yourapplicationwillbeconsideredincomplete.Wewillsendyoualetterinformingyouthatyourapplicationisincomplete.Ifyoudonotsendustheinformationbytheduedate,youwillbedeniedPCIPcoverageandwewilldetermineyoureligibilityfortheMRMIP.
What is the difference in how Dependents are covered in MRMIP and PCIP?
MRMIPallowssubscriberswithpre-existingconditionstoenrolldependentsintoMRMIPonthesameapplication.Dependentsinclude,spouse,registereddomesticpartner,childrenundertheageof23,adoptedchild,stepchild,naturalchild,orchildofadomesticpartner.However,dependentsmustmeetallthesameeligibilityrequirementsexceptfordemonstratingthattheyhaveapre-existingcondition.Inaddition,dependentswithoutpre-existingconditionsgenerallycanpurchasehealthcoverageintheindividualmarketatmuchlowerrates.SomesubscriberswithdependentsmaybenefitfromdifferencesinpremiumsorcostsharinginMRMIP,andfromtheoptiontoenrollanewbornornewlyadoptedchild.
PCIPdoesnotallowsubscribersanddependentstobeenrolledonthesameapplication.EachindividualapplyingtothePCIPmustcompleteaseparateapplicationandmeetthePCIPeligibilityrequirements.
I was previously enrolled in another state or federally administered PCIP program. I moved and want to enroll in California’s PCIP program. Can I transfer my eligibility?n Yes.Ifyouweredisenrolledbecauseyounolongerresideinthat
state,youmaybeabletotransferyoureligibilitytoCalifornia’sPCIP.Wemustreceiveyourapplicationwithin6monthsafteryouweredisenrolledfromtheotherstateorfederallyadministeredPCIPprogram.Make sureyourespondtoSection6ontheApplication(see page A3): Whenweaskwhetherornotyouhadcoveragewithinthe
last6months,check“yes.” Then,checktheboxthatindicatesyouhadcoveragein
“another PCIP program.” Makesureyouidentifythestatewhereyoupreviously
hadcoverage. Tellusifyouhaveobtainedotherhealthcoverageafteryou
weredisenrolledfromtheotherPCIPprogram.
21
PCIP and MRMIP Frequently Asked Questions (continued)
Provide a copyofaCertificateofCreditableCoverageLetterissuedbythePCIPprogramfromtheotherstate.MakesuretheCertificateofCreditableCoverageLetteridentifiesyourstartdateandenddateofcoveragewiththeotherPCIPprogram.
Can I transfer my eligibility from another state’s high-risk pool?
Yes.Youcantransfereligibilityfromanotherstate’shigh-riskpoolaslongasitwaswithinthepast12monthsanditwasasimilartypeofaprogram.
I am currently enrolled in the MRMIP program. Do I qualify for PCIP?
No.IfyouarecurrentlyenrolledintheMRMIP,youdo notqualifyforthePCIPprogram.ThePCIPrequiresthatindividualnothavehealthcoverageforatleast6months.
I am currently enrolled in Medi-Cal. Do I qualify for MRMIP?
Yes,youmayqualifyforMRMIPaslongasyoumeetalloftheprogramrequirementsbutyoushouldcarefullyconsiderthecostofMRMIPcoverage.MRMIPsubscribersareresponsibleforpayingtheirmonthlypremiums,annualdeductible,costsharingandcopaymentsforcoveredservices.
What if I do not qualify for MRMIP right now, but will be eligible for MRMIP coverage soon? Can I apply for deferred enrollment?
Yes.IfyoucurrentlydonotqualifyforMRMIP,butwillbeeligibleinthenearfuture,youmayapplyfor“deferredenrollment.”Deferredenrollmentisappropriatewhenyoucurrentlyhavehealthcoverage(i.e.COBRA,Cal-COBRA,oremployercoverage),butyourhealthcoveragewillbeendingsometimeinthefuture.Ifyouwanttoapplyfordeferredenrollment,completetheinformationontheApplication(pageA2,section4).Youmustprovideacopyofaletter,showingthatyourcurrenthealthcoveragewillterminate.Thelettermustbeissuedfromahealthinsurancecarrier,healthplan,healthmaintenanceorganization,oranemployerplan.Thelettermust specifytheexact datewhenyourcurrentcoveragewillend.Deferred enrollment is not allowed for temporary health insurance policies.
IftheMRMIPplacesyouondeferredenrollmentstatus,youwillbeenrolledintheMRMIPonceyoubecomeeligiblefortheprogram.
Makesureyoustillsendinyourinitialpremiumpaymentwithyourapplication.Yourpaymentwillberefundedtoyou,ifyourMRMIPeligibilityfordeferredenrollmentismorethan60daysfromthedateyourcompleteapplicationwasreceived.
Which providers are available in PCIP?
ThePCIPPPOProviderNetworkhascontractedwithawidevarietyofhealthprovidersthroughoutthestate.Gotowww.pcip.ca.govtofindoutwhatprovidersareavailablethroughthePCIPPPONetwork.Then,clickonthe“Providers”tab.
Which plans are available in MRMIP?
MRMIPbenefitsandservicesaredeliveredthroughlicensedhealthplans(AnthemBlueCross,ContraCostaHealthPlanandKaiser).(See MRMIP Benefits Chart on pages 14 – 19.)Eachplanhasitsownin-networkproviders.TofindaproviderforaspecificMRMIPhealthplan,calltheplansdirectly.
Once I am enrolled, when can I access my health care coverage?
WhenyouareenrolledinPCIP,wewillsendyoualetterinformingyouwhenyourstartdateofcoveragebegins.Youcanaccessyourhealthcarebenefitsonceyourstartdateofcoveragebegins.
WhenyouareenrolledinMRMIP,wewillsendyoualetterinformingyouwhenyourstartdateofcoveragebegins.Youmaybesubjectedtoeitherthepre-existingconditionexclusionorthepostenrollmentwaitingperiod.(Seepage22formoreinformationabouttheexclusion/waitingperiod.)
Is dental and vision care included?
No.ThereisnodentalorvisioncoverageinPCIPorMRMIP.Ifyouneedthiscoverage,youwillneedtoobtainitseparately.
I am currently enrolled in MRMIP and also have other health care coverage. How does MRMIP coordinate benefits with my other insurance?
YourMRMIPhealthplanwillcoordinatecoverageofbenefitswithanyotherhealthcoverageyouhave.TheMRMIPissecondarytootherinsurancecoverage.ByStatelaw,MRMIPwillonlypayafteryourotherinsurancehaspaid(notincludingMedi-CalorothertypesofStateprograms).MRMIPwillnotduplicateothercoverageyouhave(whetheryouuseitornot).
22
PCIP and MRMIP Frequently Asked Questions (continued)
What is a MRMIP pre-existing condition exclusion?
MRMIPsubscribersenrolledinaPreferredProviderOrganization(PPO)havetowait 3 months aftertheirstartdateofcoveragetobeginreceivinghealthcarebenefitsrelatedtotheir“pre-existingcondition.”TheMRMIPPPOplanisAnthemBlueCross.
Duringthefirst3months,no benefits or services related to a pre-existing condition are covered.However,othertypesofbenefitsandservicesmaybecoveredduringthisperiod.Subscribersarerequiredtopaymonthlypremiumsduringthepre-existingconditionexclusion.
What is a MRMIP post-enrollment waiting period?
MRMIPsubscribersenrolledinaHealthMaintenanceOrganization(HMO)havetowait 3 months beforetheybeginreceivinganyhealthcarebenefits(includinganypre-existingconditiontreatment).No benefits or services are provided to subscribers during the post-enrollment period and no premiums are paid for this period.MRMIPwillinformsubscriberswhenthepost-enrollmentperiodbeginsandends.ThepremiumpaymentincludedwiththeapplicationwillbeappliedtowardsyourfirstmonthofMRMIPcoverage,afterthepost-enrollmentwaitingperiodends.
MRMIPHMOplansareKaiserPermanente(Northern&SouthernCalifornia)andContraCostaHealthPlan.
I previously had other health coverage or was on the MRMIP waiting list. Can I waive all (or part) of the MRMIP pre-existing condition exclusion or post enrollment waiting period?
Yes,youcanwaiveall(orpart)oftheMRMIPexclusion/waitingperiodifoneofthefollowingoccurs:
n YouareontheMRMIPwaitinglistfor180daysorlonger.Theexclusion/waitingperiodwillbecompletelywaived.
n Youpreviouslyhadhealthcoverage(includingMedicareandMedi-Cal)andyouapplyfortheMRMIPwithin 63 daysfromthedateyourinsuranceended.
n Youpreviouslyhadhealthcoverageanditendedbecauseofoneofthefollowing: Lossofemployment, Employerstoppedofferinghealthcoverage,or Employerstoppedmakingcontributionstowardsthehealth
coverage.
YoumustapplyforMRMIPwithin 180 daysfromthedateyourhealthcoverageended.
n Youreceivedhealthcoveragefromasimilarhigh-riskprograminanotherstatewithinthelast12months.TheMRMIPexclusion/waitingperiodwillbecompletelywaived.
OnpageA2oftheApplication,makesureyoutellusthatyouwouldliketowaiveall(orpart)oftheexclusion/waitingperiod.Sendusaletterissuedfromyourprevioushealthinsurancecarrier,healthplan,healthmaintenanceorganization,oranemployerhealthplan.Thelettermustidentifythenameofthepreviousinsurancecompanyorplanandthestartandenddatesofcoverage.
Pleasenote:Dependentsage18yearsoryoungerqualifyforafullMRMIPpre-existingconditionexclusionorpostenrollmentwaitingperiodwaiver.
How do I get a copy of a MRMIP Evidence of Coverage and Disclosure Form booklet?
EachhealthplanhasanEvidenceofCoverageandDisclosureFormbooklet.Contacttheplansdirectlytoobtainacopy.Theplans’contactinformationisshownonpage14.
How can I appeal a PCIP eligibility decision?
IfyouthinkPCIPmadeamistake,youcansendafirst level appeal.Thefirstlevelappealmustbefiledinwritingwithinthirty(30)daysfromthedateofthePCIPdecision.SendPCIPaletter,tellingusthefactualorlegalreasonswhyyouthinkthedecisioniswrong,forexamplethatPCIPmadeafactualerrororviolatedalaworprogrampolicy.Or,youcancompleteanAppealsFormwhichyoucandownloadfromthePCIPwebsiteatwww.pcip.ca.gov.Then,clickonthe“Downloads”tab.Includeanyotherinformationyouthinkwillbehelpfulinthereview.WriteyourMemberNumberoneverydocumentyousendus.PCIPcannotreviewadecisionoverthetelephone.OncePCIPreceivesyourwrittenappealorAppealForm,PCIPwillsendyoualettertellingyoutheresultsofthereviewandanyrighttoadditionalappeals.
Please note:PCIPeligibilityappealsareavailableonlytodisputePCIP’s:1)enrollmentdecisions(decisionsaboutwhetherapersoniseligible)2)decisionsaboutaperson’seffectivedateofenrollment;or3)disenrollmentdecisions.
You can send your first level appeal to:
Pre-ExistingConditionInsurancePlanP.O.Box537032Sacramento,CA95853-7032Orfaxto:1-877-430-0843.(Thefaxnumberisfree.)
Ifthefirstlevelappealisdenied,youwillbenotifiedofyourrighttorequesta second level appealtotheExecutiveDirectoroftheManagedRiskMedicalInsuranceBoard(MRMIB).TheMRMIBisthestateagencythatadministersandoverseesthePCIP.Thesecondlevelappealmustbefiledinwritingwithinthirty(30)days
23
PCIP and MRMIP Frequently Asked Questions (continued)
ofthefirstlevelappealdecision.Sendaletter,tellingusthefactualreasonwhyyouthinkthedecisioniswrong.Includeanyotherinformationyouthinkwillbehelpfulinthereview.WriteyourMemberNumberoneverydocumentyousendus.
You can send your second level appeal to:
ManagedRiskMedicalInsuranceBoardP.O.Box2769Sacramento,CA95812-2769Orfaxto:916-327-6560
Ifthesecondlevelappealisdenied,youhavetherighttosubmitawrittenrequestforanAdministrative Hearing.Attheadministrativehearing,thepriordecisionsandappealwillbereviewedbyanAdministrativeLawJudgefromtheOfficeofAdministrativeHearings.ThisisthefinalPCIPlevelofadministrativeappeal.Theadministrativehearingmustbefiledinwritingwithinthirty(30)daysfromthedateofthesecondleveldecision.Youwillneedtosendaletter,statingthefactualorlegalreasonsfortheappeal.Youwillbenotified,inwriting,ofthedate,time,andplaceoftheadministrativehearing,atleastten(10)dayspriortothedateofthehearing.Pleaseincludeanyotherinformationyouthinkwillbehelpfulinthefinallevelofappeal.WriteyourMemberNumberoneverydocumentyousendus.
You can send your request for an Administrative Hearing to:
ManagedRiskMedicalInsuranceBoardP.O.Box2769Sacramento,CA95812-2769Orfaxto:916-327-6560
How can I appeal a MRMIP decision?
TheMRMIPisaStateprogramandthesubscriber’srightsandobligationswillbedeterminedunderPart6.5,Division2,oftheCaliforniaInsuranceCodeandtheTitle10,CaliforniaCodeofRegulations,Chapter5.5,MRMIPRegulations.
ApplicantsorsubscribersmayfileanappealwiththeManagedRiskMedicalInsuranceBoard(MRMIB)onthefollowingissues:
n Anyactionorfailuretoactwhichhasoccurredinconnectionwithaparticipatinghealthplan’scoverage,
n Determinationofanapplicant’sordependent’seligibilityfortheMRMIP,
n Determinationtodisenrollasubscriberordependent,andn Determinationtodenyasubscriber’srequestortogranta
participatinghealthplan’srequesttotransferthesubscribertoadifferenthealthplan.
Anappealmustbefiledinwritingwithin60calendardaysoftheaction,failuretoact,orreceiptofnoticeofthedecisionbeingappealedto:
ManagedRiskMedicalInsuranceBoardBenefitsDivisionP.O.Box2769Sacramento,CA95812-2769
Orfaxto:916-327-6560
IncludeanyotherinformationyouthinkwillbehelpfulinMRMIB’sreview.WriteyourHealthCareIdentificationNumber(HCID)orSubscriberNumberoneverydocumentyousendus.
MRMIBcannotreviewadecisionoverthetelephone.OnceMRMIBreceivesyourwrittenappeal,MRMIBwillsendyoualettertellingyoutheresultsofthereviewandanyrighttoadditionalappeals.
Can I appeal health benefit decisions in the PCIP program?
Yes.Subscribershavetherighttoappealifahealthcareserviceisdelayed,denied,reduced,modified,orterminatedinfullorinpartbytheplan.ThefirstlevelofappealisaninternalappealwithPCIP.Ifyouareunhappywiththeresultsofyourappeal,youcanrequestadditionallevelsofappeal.Forexacttermsandconditions,refertotheSummaryPlanDescriptionbooklet.
How do I resolve a dispute with my MRMIP health plan?
Ifasubscriberisdissatisfiedwithanyaction(orinaction)ofthehealthplan,thesubscribershouldfirstattempttoresolvethedisputewiththeparticipatingplan.Thesubscribermustfollowtheplan’sestablishedpoliciesandproceduresinresolvingdispute.
Who can I call if I have more questions?
ForquestionsonthePCIP,youcangiveusacallat1-877-428-5060,MondaythroughFriday8:00AM–8:00PMor,onSaturdayfrom8:00AM–5:00PM.Thecallistollfree!Or,youcangotoourwebsiteatwww.pcip.ca.gov.AdditionalprograminformationandFrequentlyAskedQuestionsareavailableonourwebsite.
ForMRMIP,pleasecall1-800-289-6574,MondaythroughFriday8:30AM–7:00PM.Thecallistollfree!Or,youcangotoourwebsiteatwww.mrmib.ca.gov.AdditionalprograminformationandFrequentlyAskedQuestionsareavailableonourwebsite.
P.O.Box2769Sacramento,CA95812-27691-916-324-4695
ForPCIPquestions,call1-877-428-5060MondaythroughFriday8:00AM–8:00PM,Saturday8:00AM–5:00PMorvisitwww.pcip.ca.gov.
ForMRMIPquestions,call 1-800-289-6574 MondaythroughFriday8:30AM–7:00PMorvisit www.mrmib.ca.gov.