Pre-Existing Condition Insurance Plan (PCIP) / High Risk Pools

Do you have employees who were denied coverage in an employer-sponsored plan due to pre-existing conditions? Individuals may now have access to more affordable insurance through the Pre-Existing Condition Insurance Plan (PCIP). This temporary insurance program is intended to help people who have been unable to obtain health insurance due to pre-existing medical conditions such as cancer, diabetes, hypertension, or injury. PCIP is a transitional program that will remain in place until 2014 and will cover a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs.

The PCIP is available in every state, but the program may vary depending on the state. States were given the option to run their own programs using funds made available through the Affordable Care Act, or rely on the Department of Health and Human Services (HHS) to provide coverage. Twenty-three states and the District of Columbia have elected to have HHS run the plan; twenty-seven states are administering their own plans.

States are given flexibility in running their programs as long as the basic plan requirements are met. Participants will pay a premium that is not more than the standard individual health insurance premium in their state for insurance that covers major medical and prescription drug expenses with some cost-sharing. Plans also cannot charge a higher premium based on a medical condition.

State Plan Design:

  • Premium: $111 - $1,735
  • Deductible: $500 - $10,000
  • Out-of-Pocket Cost: $1,000 - $20,000 (some states have multiple plans to choose from, in-network and out-of-network designs, and deductibles for prescriptions)

HHS Plan Design

  • Premium: not indicated (may vary from state to state)
  • Deductible: $2,500
  • Out-of-Pocket Cost: $5,950
  • Co-Pay: $25
  • Prescriptions: $4 - $30

In states with HHS oversight, applications for enrollment began July 1. For states operating their own PCIPs, enrollment began as early as July 1, and plans must have been in operation by the end of August.

 

Who Qualifies for a PCIP?

Individual must:

  • be a United States citizen or national or be lawfully present in the United States.
  • have been uninsured for at least the last six months.
  • have had a problem getting insurance due to a pre-existing condition.

Plan eligibility is not based on income.

 

Increase Employee Retention

Information on how individuals can apply for PCIP is available at www.HealthCare.gov. Americans who live in a state where the HHS is running the PCIP will be linked directly to the federal application page. Individuals in states that are running their own programs will also find information on how and where to apply on www.HealthCare.gov.

Paychex Insurance Agency Can Help

Paychex Insurance Agency is a full service insurance agency that has taken a leadership role in transforming how businesses like yours adapt to and benefit from the rapidly changing insurance industry. We're ready to offer information and assistance to help you navigate the recent Health Care Reform initiatives.

We can help:

  • Educate you on the new requirements during health plan renewal.
  • Provide resources to help you explain the changes to your employees.
  • Follow the latest regulations to keep you informed about any legislative changes that affect you and your business.

Health Care Reform Updates

With access to legislative and regulatory specialists in Washington, D.C. and expert, in-house sources of legal and compliance guidance, Paychex Insurance Agency is your source for Health Care Reform knowledge, tools, and resources.

Whether you're looking for a Business Owner Policy, Workers' Compensation insurance or group health and life insurance, Paychex Insurance Agency offers flexible, scalable insurance solutions for you, your business and your employees. To learn more about how we can meet your insurance needs, call 877-393-8868 or have an agent call you.

The Department of Health and Human Services and the Internal Revenue Service (IRS) continue to provide specifics and guidance on the Health Care Reform Act. Paychex will monitor these regulatory developments and provide updates as appropriate.

The information in these materials should not be considered legal or accounting advice, and it should not substitute for legal, accounting, and other professional advice where the facts and circumstances warrant. It is provided for informational purposes only. If you require legal or accounting advice, or need other professional assistance, you should always consult your licensed attorney, accountant, or other federally licensed tax professional to discuss your particular facts, circumstances, and business needs.

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