Pre-existing Condition Insurance Plan Author:    Posted under: Health InsuranceHealth Insurance Types

Pre-existing condition. This is a term that most, if not all insurers or insured people are familiar with. This term refers to a medical issue which has been in existence prior to a person’s obtaining a health insurance policy. The term pre-existing condition almost always has negative undertones in that it is something that may prevent a person from acquiring health insurance coverage. In some cases, people with pre-existing conditions that are granted health insurance coverage are charged higher premiums just for that.

So what are pre-existing conditions? It could include obesity, diabetes, arthritis, thyroid disorders, cancer and even pregnancy. Policies with regards to conditions such as these vary widely from one insurance company to another. Each company has a list of pre-existing conditions and often has their own standards when it comes to providing insurance for people with the above-mentioned health issues.

In March of 2010, the U.S. Congress passed and President Barack Obama signed the new health care law called Affordable Care Act. Under the law is the new program called the Pre-Existing Condition Insurance Plan that aims to make health insurance coverage available to those who have been denied health insurance by private insurance companies because of their pre-existing condition.*

So just who are eligible for Pre-Existing Condition Insurance Plan?

To be eligible for Pre-Existing Condition Insurance Plan:

  • You must be a national or citizen of the United States or legally residing in the United States.
  • You must have been uninsured for the past six months.
  • You must have a pre-existing condition or have been denied health coverage due to your health condition.

The Pre-Existing Condition Insurance Plan covers a wide range of medical benefits including primary and specialty care, hospital care and prescription medicine. PCIP doesn’t charge individuals higher premiums just because of a medical condition, and doesn’t base one’s eligibility on his or her income.

Although each state offers the PCIP, they may have different ways of offering that coverage. While 22 of the states have chosen to take part in the federally run program by the U.S. Department of Health and Human Services, the rest have opted to manage their own plans. Depending on where you live and how your state carries the plan out may affect the rules and process. Even the program name and other plan details may vary from state to state and whether the program is run by the state or the Department of Health and Human Services. Check out the State Plans ( page of the PCIP website for more information on how the Pre-Existing Condition Insurance Plan works in your state.

If your state runs the program under the Department of Health and Human Services, you may apply online, by mail or by phone. The PCIP website ( has a link to the online application. Bear in mind though, that you may still need to send documentation to back-up your claims before you can obtain approval.

Downloadable forms are also available from the website should you wish to apply by mail. You need to fill up the application form and make copies of any required documents. You will also need to provide a copy of one of the following documents:**

  • A denial letter from an insurance company (that is licensed to operate in your state) for individual insurance, not one that is offered through a job, dated within the past six months.
  • A letter dated in the past six months from an insurance agent or broker (again, licensed in your state) that shows you aren’t eligible for individual insurance coverage from one or more insurance companies because of your pre-existing condition.
  • An offer of coverage from an insurance provider (licensed in your state) for individual insurance coverage (again, not one that is offered through a job), dated within the past six months. This offer of coverage should have a rider that states your medical condition won’t be covered.
  • If you are under age 19 OR if you live in Massachusetts or Vermont, an offer of individual insurance coverage (not health insurance offered through a job) from an insurance company licensed in your state that is dated within the past six months. This offer of coverage must reflect a premium that is at least twice as much as the Pre-Existing Condition Plan premium (which is the monthly payment you make to an insurer to get and keep  the insurance active) for the Standard Option in your state. To find out if the premium you were offered is twice as much as the premium in the Pre-Existing Condition Insurance Plan for the Standard Option in your state, check out the State Plans ( page.

You will need to mail the form and documents to:

National Finance Center
Pre-Existing Condition Insurance Plan
P.O. Box 60017
New Orleans, LA 70160-0017



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