Pre-existing Condition Insurance Plan (PCIP)

At a Glance
Eligibility
How To Apply
If You Are Denied
Resources and FAQs

The State of California offers two plans for individuals with pre-existing conditions who have been denied coverage and have been uninsured for at least six months: the Pre-existing Conditions Insurance Plan (PCIP) authorized by the Affordable Care Act and the Major Risk Medical Insurance Program (MRMIP). Both programs are managed by the Managed Risk Medical Insurance Board (MRMIP).

The PCIP will remain in place until December 31, 2013 when national health reform is set to begin. After that date, there will no longer be a need for high risk pools because federal rules will not allow insurers to reject persons with pre-existing conditions or charge them higher rates.

At a Glance

Click on the following for more information:

Eligibility for the PCIP
How to apply for the PCIP
If you are denied
Additional Resources
Frequently Asked Questions (FAQs) about the PCIP

Eligibility

Eligibility for the PCIP

To be eligible for California’s PCIP the applicant must satisfy all of the following requirements:

U.S. Citizen, U.S. National or lawfully present
Social Security Number required
Resident of California
No health insurance coverage in the last six months prior to application
Not enrolled in Medicare Part A & Part B; or COBRA or Cal-COBRA benefits

Additionally, the applicant must provide evidence of one of the following:

A rejection letter from a health insurance company in the last 12 months (or)
The premium cost of available insurance is higher than the cost of the MRMIP preferred provider organization (PPO) in the applicant’s geographic region. The table below lists the 2012 premiums for San Diego County.

How to Apply

How to Apply for the PCIP

The State of California has two separate programs with somewhat different eligibility criteria to provide coverage for individuals with pre-existing conditions. You must apply for both at the same time:

The Pre-existing Condition Insurance Plan (PCIP): The PCIP was established through a federal grant under the ACA and is funded by the federal government.
The Major Risk Medical Insurance Program (MRMIP) is a State funded-plan that has been available for many years for those who have become uninsurable due to their pre-existing condition(s).

You will select your plan of choice on the application form. If you do not state a preference, you will be enrolled in the PCIP if you meet the eligibility requirements.

Follow these three steps to apply:

Step 1: Go to the California PCIP website

California PCIP

Step 2: Download the handbooks, instructions and applications for the PCIP and for MRMIP.

Handbooks, instructions, and the required forms for each of the programs are available at California’s PCIP website.

Step 3: Include the following four items with your application.

Proof of pre-existing condition in the form of a rejection letter generated in the last 12 months (or) a quote for insurance that has a higher monthly premium than what the MRMIP Handbook lists as the MRMIP PPO rate in your geographic area.
Proof of US Citizenship in the form of one of the following:
- U.S. Passport;
- Birth certificate;
- Naturalization/Citizenship certificate;
- American Indian or Alaska Native enrollment document from a federally recognized tribe;
- A Certificate of Degree of Indian Blood (CDIB) from the Bureau of Indian Affairs; or
- A letter of Indian Heritage from a California Indian Health Service Clinic.
- Proof of Lawful California Residency
  - California Drivers License of Identification card
  - Military Identification or Dependent Military ID
  - Copy of unexpired immigration documents or other forms listed here.
  - A personal check, cashier's check, or money order for one month’s premium payable to the Managed Risk Medical Insurance Board (MRMIB). Caution: Please validate the accuracy of the information in the table below by downloading the most current table.

If you have questions when you fill out the applications, call the PCIP program at:

1-877-428-5060

Monday - Friday, from 8 a.m. to 8 p.m.

Saturday, from 8 a.m. to 5 p.m.

If You Are Denied

What to do if You are Incorrectly Denied

You can appeal the decision within 30 days from the date on the eligibility decision letter. You must send your appeal in writing. The PCIP cannot review a decision over the phone. There are two ways to submit your written appeal:

Send a letter to the PCIP and tell them the factual reason why you think their decision is wrong.

(or)

Complete an Appeals Form which you can download from the PCIP website using this link Appeals Form. Include any other information you think will be helpful in our review.

Be sure to write your Member Number on every document you send to the PCIP.

Send your appeal to:

Pre-Existing Condition Insurance Plan

P.O. Box 537032

Sacramento, CA 95853-7032

Resources and FAQs

Frequently Asked Questions (FAQs) about the PCIP

Answers to frequently asked questions.

Additional Resources

PCIP Program