Pre-existing Condition Insurance Program (PCIP)

The Patient Protection and Affordability Care Act, was enacted on March 23, 2010. The Health Care and Education Reconciliation Act Public Law 111-152, was enacted on March 30, 2010. Collectively, these laws are known as the "Affordable Care Act." Section 1101 of the Affordable Care Act requires that the Secretary of the Department of Health and Human Services (HHS) establish, either directly or through contracts with States or nonprofit private entities, a temporary high risk health insurance program to provide access to coverage for uninsured Americans with pre-existing conditions. (Hereafter, we generally refer to this program as the Pre-Existing Condition Insurance Plan program, or PCIP program, to avoid confusion with the existing State high risk pool programs, which will continue to operate separately.) The PCIP program remained in place from the time of its establishment until April 30, 2014.

The applicants must meet the terms and conditions outlined in the model contract. See the State PCIP Model contract at www.hhs.gov/cciio/Documents/state_hrp_model_contact.pdf

Eligibility and enrollment rules for the Federal and state-operated PCIP programs can be found at www.healthcare.gov or below as set forth in text from our Interim Final Regulation (IFR). B. Eligibility and Enrollment (Subpart C, Sec. 152.14 Through Sec. 152.15 of the PCIP IFR (45 CFR Part 152). Section 1101(d) of the Affordable Care Act provides the basic eligibility criteria for the PCIP program, which are set forth under Sec. 152.14. In addition, consistent with the Secretary's general authority under section 1101(c)(2)(D) of the Act to establish requirements for a PCIP, we set forth enrollment and disenrollment requirements in Sec. 152.15. In general, under section 1101(d) of the Affordable Care Act and subparagraphs (1), (2) and (3) of Sec. 152.14(a) of this interim final rule, an individual is eligible to enroll in a PCIP if he or she: (1) Is a citizen or national of the United States or is lawfully present in the United States as determined in accordance with section 1411 of the Affordable Care Act; (2) has not been covered under creditable coverage, as defined in section 2701(c)(1) of the Public Health Service Act as of the date of enactment, during the 6-month period prior to the date on which he or she is applying for coverage through the PCIP; and (3) has a pre-existing condition, as determined in a manner consistent with guidance issued by the Secretary. We further provide in Sec. 152.14(a)(4) that an individual must be a resident of a State that falls within the service area of a PCIP. Additional detail found in the IFR.

Applicants should review the OCIIO state model contract issued under this CFDA program for any required proof or certifications which must be submitted prior to or simultaneous with submission of an application package

Please see State PCIP Model Contract

States had option periods through 2014 For the majority of participating states, the funding is proposed to carry the program to 2014, with the last option year of the contract exercised in 2013. At the end of 2013, states were given the option to continue their respective programs on a month by month basis into 2014 and concluding on April 30, 2014. See State Model Contract for details. See the following for information on how assistance is awarded/released: Funding is distributed through the Payment Management System to pay for administrative costs and medical claims, monitored by monthly cost-reporting. Please see the State Model Contract for more detail.

See state model contract requirements.

In order to be awarded a state contract to run the Pre-existing Condition Program in an individual state, a state must have submitted a notice of intent to apply, a proposal and model contract criteria approved by HHS.