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The California PCIP shutdown answers

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What if you’re suddenly moving from the California state-run Pre-existing Condition Insurance Plan (PCIP) into the federal PCIP, and you’re a kidney transplant?

You’re in luck.

“Authorization is not required for cornea or kidney transplants,” according to a PCIP benefit transition summary posted on the website of the California Managed Risk Insurance Board (MRMIB).

If you are a patient who’s getting some other type of transplant, such as a lung transplant or a liver transplant, then plan authorization is now required for those types of transplants, according to the summary.

A patient in that situation should call an 800 number and ask to speak to a transplant nurse.

“The nurse will request contact information for your current transplant coordinator to initiate transplant plans,” according to the summary.

MRMIB officials have posted that summary, along with other PCIP-related items, including a collection of PCIP-transition-related call center scripts, in a collection of documents that could be discussed at a board meeting set to start at 11 a.m. PDT Wednesday.

Drafters of the Patient Protection and Affordable Care Act of 2010 (PPACA) included the provision that created PCIP (often pronounced “P-sip”) in an effort to provide temporary emergency access to affordable health coverage for people with health problems who could not qualify for conventional commercial coverage in states that have been insurers to use medical underwriting in the individual health insurance market.

PPACA calls for insurers to begin providing health coverage without use of health status information in the sale or pricing process starting Jan. 1, 2014.

From late 2010 to Dec. 31, 2013, PCIP was supposed to use $5 billion in funding to provide moderate-deductible, comprehensive coverage for enrollees, with coverage prices comparable to rate healthy enrollees were paying in each state’s commercial individual health insurance market.

Some states were running their own PCIPs, and others were depending on the U.S. Department of Health and Human Services (HHS) to run PCIPs for their residents.

Enrollment turned out to be lower than expected, but enrollees have been averaging about $30,000 in claims each per year. To keep the PCIP program funding from running out, the U.S. Department of Health and Human Services (HHS) asked states with state-run PCIPs to accept flat-rate funding for the rest of the year or turn their enrollees over to the federal program.

California is one of the states that has shut down its state-run program and put the enrollees in the federal program.

California is letting enrollees who want to shift into another, state-run program for people with health problems, the MRMIP program, go into MRMIP rather than moving into the federal program.

The questions and answers given in the call center script reflect some of the wrinkles that have cropped up as California geared up to send PCIP enrollees into the arms of HHS.

One question, for example, deals with whether the state AIDS drug assistance program will continue to pay for PCIP for some people with AIDS.

“The federally-run PCIP program accepts third party payments,” according to the call center transcript. “California is currently in discussion with the federally-run PCIP program to see how the premium payment process for third party payments will function. Once the process has been finalized, the information will be sent to each subscriber.”

In a question about providers, the script that enrollees can generally use any provider willing to accept Medicare-level rates but must use in-network providers for organ transplants. 

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