Docstoc

MRMIP AND PCIP

Document Sample
MRMIP AND PCIP Powered By Docstoc
					Pre-Existing Condition Insurance Plan (PCIP)
                     &
Major Risk Medical Insurance Plan (MRMIP)

             Overview Presentation
 This overview will take you approximately 10 minutes.
 More detailed information can be found on this website
                    (www.MRMIP.us)
Key Learning Points

        By the end of this course we will have discussed:
            Affordable Care Act of 2010 Summary
            Pre-Existing Condition Insurance Plan (PCIP)
            Major Risk Medical Insurance Program (MRMIP)
            Eligibility Criteria
                 Other PCIP Eligibility Rules
            PCIP Application Requirements
            Premium Rates
            Payment Information
            PCIP Benefits Overview and Providers Information



011411                                   PCIP 101
                                                                2
Affordable Care Act of 2010
Summary

   As a result of the federal Affordable Care Act of 2010,
    California has a contract with the Federal Department
    of Health and Human Services to establish a federally-
    funded high risk pool program to provide health
    coverage for eligible individuals

   The federally-funded program is called the California
    Pre-Existing Condition Insurance Plan (PCIP)




011411                       PCIP 101
                                                            3
            PCIP & MRMIP Overview

 Pre-existing Conditions Insurance                 Major Risk Medical Insurance
            Program (PCIP)                              Program (MRMIP)


         A temporary high risk pool program           A     separate     program    that
         designed to provide coverage to              provides health      insurance for
         uninsured individuals who have been          Californians unable to obtain
         denied health insurance OR been              coverage in the individual health
         offered only unaffordable options            insurance market because of
         because of pre-existing conditions           their pre-existing conditions

         Funded by the Federal Government             Funded by the State

                                                      Administered by the Managed
         Administered by the Managed Risk
                                                      Risk Medical Insurance Board
         Medical Insurance Board (MRMIB) -
         managed at state level                       (MRMIB)


011411                                  PCIP 101
                                                                                     4
PCIP Eligibility Requirements
   Resident of California
   Must be a U.S. Citizen, National, or lawfully residing in the U.S.
   Social Security Number (required for U.S. Citizen/National)
   Must NOT be enrolled in other creditable coverage in the six
    months prior to the application
   Must provide proof of:
      Denial by an insurance carrier, due to a pre-existing condition dated
       within the last 12 months OR
      An offer of coverage with premium level above the MRMIP PPO rate
       within the last 12 months
   Dependent coverage is NOT available – each individual must
    apply for themselves



011411                               PCIP 101
                                                                          5
Other Creditable Coverage

   Individual or job-based health plan, including COBRA or Cal-
    COBRA
   Medicare (Part A and/or Part B)
   Medicaid
   No-Cost Medi-Cal
   Children’s Health Insurance Program (CHIP)- Healthy Families
   A state high risk pool- i.e. PCIP or MRMIP
   TRICARE- military health insurance




011411                            PCIP 101
                                                                   6
Other Creditable Coverage (cont’d)

   Health coverage provided by a public health plan
    established by the U.S. government such as:
        Coverage provided to veterans enrolled in VA health care, or a
         foreign country

   Federal Employees(or retirees) Health Benefits Plan,
    including Temporary Continuation of Coverage (TCC)
   Health benefit plan provided to Peace Corps workers
   Services provided by the Indian Health Service or by a
    Tribal organization for treating medical conditions


011411                                PCIP 101
                                                                          7
Other PCIP Eligibility Issues
   If you have moved from another state and were enrolled in the
    PCIP in the other state, you may be automatically eligible for CA
    PCIP. You must apply for the PCIP within six (6) months of
    disenrollment from the other state’s PCIP and provide validation
    from the other state’s PCIP
   If have qualified for the MRMIP but have not started coverage and
    is PCIP eligible, you may provide a Withdrawal Letter from the
    MRMIP and be enrolled in PCIP
   If you have moved from another state and were enrolled in the
    PCIP in the other state, you must not have had other non-PCIP
    coverage since disenrollment from the other state's PCIP




011411                           PCIP 101
                                                                   8
MRMIP Eligibility Requirements

 Resident of California
      Will not be considered California resident if absent for more than 210
     consecutive days
 SSN is NOT required
 Must not be eligible for:
      Medicare (except for end stage renal disease)
      COBRA or Cal-COBRA benefits
 Must provide proof of:
      Denial by an insurance carrier, due to a pre-existing condition dated within
     the last 12 months OR
      An offer of coverage with premium level above the first plan choice rate
     within the last 12 months OR
      Termination by an insurance carrier for reasons other than fraud or non-
     payment of premiums, ineligibility within the last 12 months
 Dependent coverage is available
 011411                               PCIP 101
                                                                                9
Who Can Apply?
 Person 18 years old and above
 Person under the age of 18 years may apply for themselves, if
emancipated
     The application will be forwarded to MRMIB for eligibility
    determination unless application screened to MRMIP
 The following persons may apply on behalf of an individual under
the age of 18
     Parents (natural or adoptive)
     Legal Guardians
     Step-parents
     Foster Parents
     Caretaker Relatives



011411                          PCIP 101
                                                                  10
                         How to Apply
    To apply for PCIP, you must complete both the PCIP and MRMIP applications
   which can be found on this website:
          MRMIP Application
          PCIP Supplemental Application
    If you are only interested in applying for MRMIP, the PCIP Supplemental
   application will not be required, however it is recommended to apply for both
   programs at the same time.
    To Apply For MRMIP and / or a PCIP Application on this website, applicants:
         1)     Complete the online applications
         2)     Applicant Will Receive A Call From An MRMIP / PCIP Enroller within 2 business
              days
         3)     During the telephone interview, the MRMIP / PCIP Enroller will verify the
              information and answer any questions from the applicant.
         4)     The MRMIP / PCIP Enroller will then email the application(s) to the applicant
              via pdf
         5)     The Applicant will print the PDF, sign in the appropriate areas, attach the
              requested documents along with a check or money order for the first month’s
              premium and mail to the California MRMIP / PCIP processing center.
         6)    IF the application(s) are complete and received by the 20th of the month, then
              coverage would begin on the 1st day of the following month.
    The application serves only one subscriber per application w to Apply

011411                                        PCIP 101
                                                                                                11
PCIP Application Requirements

 The PCIP application will request the following personal
information:
            First and Last Name
            DOB
            Address
            Social Security Number (required for U.S. Citizens/Nationals)
            Signature
               – If applicant requested PCIP, and is PCIP eligible, the signature
               will satisfy MRMIP Declarations initials
            Declaration of no other creditable coverage in the past 6 months
            First full month’s premium payment
            Valid proof of Citizenship/Immigration documents
            Proof of Denial or High Premium Quote from another insurance



011411                                     PCIP 101
                                                                                    12
MRMIP Application Requirements
 The MRMIP application requires the following information:
      First and Last Name
      DOB
      Gender
      Marital Status
      Contact Telephone Number
      Address
      County
      SSN (optional)
      Signature
          – If applicant requests, or is screened to MRMIP, Declarations initials will be
          required
      First full month’s premium payment
      Proof of Denial or High Premium Quote from another insurance company
      Declaration of involuntary termination other than fraud or non-payment



011411                                     PCIP 101
                                                                                       13
 In order for us to assist you in tracking your application process,
 it is required that you sign this form on the application.

Permission to Share Your PCIP
Information Form must include:

     Applicant’s name, and
    Member Number


    Broker / Enroller Information

     What type if information
    may be shared

     YOUR      Signature

An authorized MRMIP / PCIP Health Insurance
Broker Is Assisting You With This Application. Your
premiums are NOT affected in any way. The
Broker is compensated from the govt programs!
  011411                                       PCIP 101
                                                                       14
Required Documents
Citizenship/Immigration Documents

   All eligible U.S. Citizens and Nationals must provide acceptable
    citizenship documentation to be enrolled in PCIP at the time enrollment
   The acceptable documentation for a Citizen/National of the United States
    is listed below:
        U.S. Passport (even if expired)
        Birth Certificate (including hospital birth verification)
        Naturalization/Citizenship Certificate
        American Indian/Alaskan Native Documentation
   All lawfully residing individuals’ documentation must be valid/unexpired at
    the time of enrollment
        Permanent Residence
        Conditional Entry
        Asylum/Refugee, etc.
   If documentation expires, valid/unexpired documentation will be required
    to remain in PCIP


011411                                       PCIP 101
                                                                             16
Proof of Pre-Existing Condition

   If a you are currently enrolled in creditable health coverage and
    receive a letter from your health plan stating that your premium will
    be increasing to an amount above the MRMIP PPO rates, it will
    NOT be accepted
        You must not be enrolled in any creditable health coverage in the
         previous 6 continuous months
   You, the applicant, must provide one of the following as proof of a
    Pre-Existing Condition:
        Denial Letter or e-mail from an insurance company that is dated
         within the past 12 months (i.e. 365 days) from the date the application
         is received
        A letter or email offering higher rates than the MRMIP PPO rates
         dated within the past 12 months from the date the application is
         received



011411                                 PCIP 101
                                                                             17
Letter / Email Requirements

   To be considered valid proof, the letter or email must meet the
    following criteria information:
        Denial Letter Email
             Within the last 12 months
             Name of person being denied
             Must specify that coverage was denied, but reason is not required
             Sent by health insurance plan representative not an agent or broker
        High Premium Offer Letter/e-mail
             Must identify the amount being offered
                   Premium amount must be higher than the MRMIP PPO Rates
             Within the last 12 months
             Name of person being offered the high premium
             Sent by health insurance plan representative not an agent or broker



011411                                     PCIP 101
                                                                                    18
Invalid Denial Letters

   The letters listed below are NOT acceptable as proof:
        Letters from Medi-Cal are NOT acceptable proof of pre-existing
         condition
        A letter stating that the subscriber is denied due to currently
         enrolled in Medi-Cal
        A letter from an insurance company stating that the application
         was deferred because the insurance company could not request
         medical information
        Forms completed by Insurance Brokers requesting coverage
         from insurance carrier




011411                             PCIP 101
                                                                    19
So, What Happens Next?
Application Process

   Complete applications will be processed within 10
    calendar days and PCIP will determine one of the
    following:
        Subscriber is eligible for PCIP or potentially eligible for MRMIP
        Subscriber is denied for PCIP and/or potentially eligible for
         MRMIP
        Application has Missing Information (MI)




011411                              PCIP 101
                                                                        21
Complete Application Process
    If determined eligible, you will be eligible for continuous
     enrollment through the life of the program
          If the application is Complete and eligible by the 20th of the month, it
           will have an effective date of the 1st of the following month
    January 1st                   20th                           February 1st



                                                               Effective Date
            App. received and eligible


          If the application is Complete and eligible after the 20th of the month
           through the end of the month will be enrolled on the 1st of the second
           month
                                                                 February 1st
          January 1st                20th                                       March 1st



                                                                                  Effective Date
                                            App. received and eligible
011411                                              PCIP 101
                                                                                        22
What happens when you are
determined Eligible?

   When you are determined eligible the following will
    occur:
        Welcome Letter will be sent to eligible applying members

        Welcome Call will be made

        A Member Number (MN) will be assigned to each applying
         member, regardless of his/her age

        Applicants will receive a Benefit Card, and Summary of
         Benefits




011411                             PCIP 101
                                                                    23
Incomplete Application(s)

    If an application is determined incomplete:
         A Missing Information (MI) letter will be sent
         Phone calls will be made
         Applicant will have 40 calendar days from the application
          receipt date to submit the Missing Information or the
          subscriber will be denied
              Denial letter will be sent
              If the initial premium payment was sent, payment will be refunded
               within 6 to 8 weeks from denial date
    Upon denial, a new application will be required if
     applicant is still interested in enrolling in the program


 011411                                 PCIP 101
                                                                              24
Forwarding Applications to MRMIP

   Complete MRMIP applications will be forwarded to
    MRMIP Program if any of the following occurs:
        Subscriber is screened eligible for MRMIP
        Request to be forwarded
        Denial of coverage for PCIP
   If applicant submits only a complete MRMIP
    application along with MRMIP premium amount
    payment
        Applicant will be contacted to identify program preference
         within 15 calendar days
        If preference is not identified, application will be forwarded to
         MRMIP


011411                               PCIP 101
                                                                             25
Premiums and Payment Methods
PCIP and MRMIP Monthly Premium
Rates (See Rate / Cost Chart On This Website)
    Premium amounts will vary based upon subscriber’s age and
     region
     AFTER you submit your first month premium, with the application,
     via check or money order, afterward, you may choose to pay the
     monthly premiums through EFT (electronic funds transfer)




 011411                           PCIP 101
                                                                    27
Premium Facts
     Premiums will be calculated using the subscriber’s age and region at the
      time the application was received
     Upon a residential change into another region or if a subscriber falls into
      another age range bracket, premiums may increase or decrease
            If there is a premium change as a result of:
                 Address change
                       Once notification of an address change is received from the applicant,
                        PCIP will notify the applicant if a premium change will occur

                 New age bracket
                       Effective date of the new premium will be the 1 st of the month following
                        the birth date
                       Letter notifications will be sent to subscribers prior to new premium
                        effective date




    011411                                       PCIP 101
                                                                                             28
Payment Information

   A first full month’s premium is required before an effective date
    can be issued
   Monthly payments are due on the 15th of every month for the
    following month’s coverage
        i.e. coverage 12/1- 12/31, December’s premium is due by 11/15/10
   If payment is not received by the due date:
       Non-Payment Letter will be mailed

       Premium Reminder Call will be made

   If NO payment is received, applicant will be disenrolled and must
    wait 6 months to re-apply for PCIP coverage



         Note: Payments may be ‘overnighted’ to the MRMIP / PCIP office

011411                               PCIP 101
                                                                            29
Payment Methods
   Payments can be made to PCIP, by:
        Lockbox
             Personal Check
             Money Order
             Cashier’s Check
        Electronic Funds Transfer (EFT)
   To enroll in EFT, the applicant must submit:
        Complete EFT Authorization form
        Voided Check/Withdrawal Slip
   Funds for current premium will be withdrawn from the applicant’s bank
    account on the 4th of each month and posted on the 5th
   Non-Sufficient Funds (NSF) must be paid by money order or cashier’s
    check for NSF and following month’s premium

           Note: (1) PCIP does NOT offer payment discounts
           (2) Any overpayment will be credited toward future payments

011411                                     PCIP 101
                                                                            30
PCIP Medical Benefits
The Summary Plan Description (SPD) booklet summarizes the Benefits policies
and coverage under PCIP.




011411                            PCIP 101
                                                                      31
Medical Benefits (continued)




011411                   PCIP 101
                                    32
Medical Benefits (continued)




011411                   PCIP 101
                                    33
Medical Benefits (continued)




011411                   PCIP 101
                                    34
Medical Benefits (end)




011411                   PCIP 101
                                    35
Prescription Drug Benefits




011411               PCIP 101
                                36
Additional Resources

   This website is a great tool that provides useful
    information such as:
        Cost of the program
        Health Care providers
        Services Covered
        Download PCIP / MRMIP forms




011411                         PCIP 101
                                                        37
Review of Key Points

 Throughout this presentation we have discussed:
        Purpose of Pre-Existing Condition Insurance Plan (PCIP)
        Eligibility Criteria
        Application Requirements
        Premium/Payment Information
        Additional Resources

 IF you are interested in either the MRMIP or the PCIP programs, Please
  take the time to complete the online MRMIP / PCIP Application on
  this website. After that, an authorized enroller will be contacting you
  within 2 business days.



011411                             PCIP 101
                                                                      38

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:9
posted:7/26/2012
language:English
pages:38