July 28, 2011

IMPORTANT LEGISLATIVE UPDATE

Employees enrolled in Limited Benefit Medical Plans
may be blocked from participating in the
“Pre-existing Condition Insurance Program” (PCIP) created by PPACA.

Question:

If my employees are covered by a limited benefit medical plan granted a “waiver,” are they eligible to participate in the federal Pre-existing Condition Insurance Program (PCIP), commonly referred to as the federal high-risk pool, in the event they develop a serious medical condition?

*Waivered limited medical plans are generally considered group health plans and are therefore “creditable coverage.” An employee who develops a serious medical condition will be blocked from participating in the high-risk pool if they’ve been enrolled in a plan providing creditable coverage in the last six months.


Is there any way I can I help them qualify?

Ternian’s limited-benefit medical plans are indemnity-based “excepted benefits” and are not defined as creditable coverage. As such an employee will not need to include the Ternian plan when completing the “prior health coverage” section of the federal application for PCIP coverage.  

Make sure your employees can take advantage of the federal high-risk pool in the event of a serious medical condition. Replace your expense-incurred limited-benefit medical plan with a Ternian plan and we will issue a policy for the remainder of this plan year as well as the next at a guaranteed rate.

REFERENCE
Part II Department of Health and Human Services 45 CFR Part 152 Pre-Existing Condition Insurance Plan Program; Interim Final Rule Eligibility for the PCIP Program (§ 152.14)

Under section 1101(d) of the Affordable Care Act and subparagraphs (1), (2) and (3) of § 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 § 152.14(a) (4) that an individual must be a resident of a State that falls within the service area of a PCIP.