PCIP – Know what it means? You should if you represent injury victims

Posted date in Jason D. Lazarus, J.D., LL.M. Healthcare

As everyone is well aware, in March of 2010 Congress passed and President Obama signed into law a sweeping change to American health care called the “Affordable Care Act.”  This new law created the “Pre-Existing Condition Insurance Plan” which makes health insurance available to those who have been denied coverage by private insurance companies because of a pre-existing condition.  This plan, referred to as “PCIP”, is administered either by an individual state or by the federal government.  PCIP provides a new health care coverage option for those who have been uninsured for at least six months, have a pre-existing condition or have been denied health coverage because of their health condition and are a U.S. citizen or are residing in the U.S. legally. 

The PCIP program covers a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs. All covered benefits are available to those that qualify, even to treat a pre-existing condition.  It will not charge a higher premium just because of a person’s medical condition.  The program doesn’t base eligibility on income. The eligibility criteria are that the person must be a citizen or national of the United States or lawfully present in the United States; have been uninsured for at least the last six months. This includes High Risk Pool Coverage and insurance coverage that may only exclude coverage for a pre-existing medical condition and have had a problem getting insurance due to a pre-existing condition.

The rates for this program vary by state.  By way of example though, my home state of Florida’s plan has the following premium structure (Florida’s plan is run by the federal government).  For someone age 0 to age 34, the monthly premium is $363.  For someone age 35 to age 44, the monthly premium is $435.  For someone aged 45 to age 54, the monthly premium amount is $556.  For someone age 55 or older, the monthly premium amount is $773.  In addition to the monthly premium amount, covered in-network services are subject to a $2,500 annual deductible (except for preventive services) before the plan starts to pay benefits.  Once someone meets the deductible, they will pay a $25 co-payment for doctor visits, $4 to $30 for most drugs at a retail pharmacy for the first two prescriptions and 50% of the cost of the prescriptions after that.  Out-of-pocket costs cannot be more than $5,950 per year if the person stays in network.  There is no lifetime cap on benefits. 

PCIP may be a good alternative to certain public benefit health programs for personal injury victims.  However, a careful analysis should be done before foregoing needs based governmental health benefits.  PCIP will not provide for custodial care and may not cover other medical services necessitated by a personal injury.  It is very important to note that PCIP does end in 2014.  Mandated coverage under the Obama healthcare supposedly will fill the gap at that time ( to read more about this go to ).  Despite all of the foregoing, it is something worth considering when settling a personal injury case where the client does not have medical coverage. 

To apply on-line, go to