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Life Health > Health Insurance > Your Practice

Oncology Practice Reviews PCIP

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Janet Starr, the business manager of WellSpring Oncology L.L.C., says the much-criticized Pre-Existing Condition Insurance Plan (PCIP) seems to help the patients who need it, qualify for it and can afford to pay for it.

“The insurance plan does offer coverage care for almost all diseases,” Starr said in responses to an interview conducted via e-mail. “The biggest challenge for patients is making sure they qualify under the strict guidelines set by the federal government.”

Congress put the PCIP provision in the Patient Protection and Affordable Care Act of 2010 (PPACA) in an effort to provide immediate relief for uninsured people with health problems, to help fill the gap until insurers start selling subsidized coverage on a guaranteed issue, mostly community-rated basis in 2014.

PCIP is supposed to provide comprehensive health coverage for people with health problems for a price similar to the price of ordinary individual commercial health coverage.

Eligibility is not based on income, and the risk pools cannot charge higher rates for people with more severe health problems.

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 their residents.

Program critics originally predicted that millions of uninsured Americans with health problems would rush to enroll in the program and quickly use up federal PCIP funding.

Because Congress worried PCIP would crowd out private coverage and encourage ordinary plans to dump their sickest enrollees into the program, lawmakers imposed tight eligibility requirements.

One is that an applicant must have gone without insurance for at least 6 months. Critics have noted that there is almost way for people with some serious health conditions, such as hemophilia, to survive for 6 months without some kind of health coverage, or an enormous amount of charity care.

Another challenge is that, even though the price of the coverage must be about the same as the price for ordinary individual commercial coverage, even that modest amount has proved to be high for many uninsured people with serious health problems.

A third challenge is that HHS only recently developed rules for compensating agents and brokers for helping enrolling clients in PCIP plans, and the finder’s fee will only be $100.

HHS officials estimate PCIP had a total of only about 34,000 enrollees nationwide in August.

Finding provider discussions about the program online is difficult, partly because many states have their own names for their PCIP plans. Many of the references online to provider satisfaction with “PCIP” relate to an electronic health record initiative in New York state, not the federal PCIP program.

WellSpring, Pinellas Park, Fla., raised the topic of PCIP in mid-October, when it put out a press release about a patient, Marilys Cox of St. Petersburg, Fla., who was marching in the Making Strides Against Breast Cancer walk.

Cox, who was uninsured, paid for a mammogram herself at a separate mammogram clinic. She discovered that she had breast cancer, but she was unable to afford health insurance and could not afford to have the breast cancer treated.

After 6 months, Cox was able to enroll in the PCIP program, but she had trouble finding doctors in her area who would accept the PCIP coverage, WellSpring reported.

Eventually, Cox was referred to WellSpring, and WellSpring took her coverage.

The PCIP program “is a great alternative offered for patients who don’t have coverage because of some unexpected life event,” Starr, the WellSpring business manager, said.

Starr said WellSpring strives to give patients the best possible treatment no matter insurance they have.

When asked about ways to improve the PCIP program and other plans, Starr said the key is always patient education.

“Patients need to understand what is covered by their insurance – from tests to procedures,” Starr said. “It’s also important for everyone to know what needs to be pre-authorized prior to receiving treatment.”


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