Can't get insurance coverage because of a pre-existing medical condition... like say, diabetes? A new temporary federal program allows PWDs and others to buy individual health insurance, at least for the next few years.


By D'Mine Columnist / Correspondent Wil Dubois

Until very recently, the health insurance industry commonly referred to type 1 diabetes as an "automatic denial" condition. In many states it simply wasn't possible for T1s to buy individual health insurance for any amount of money. In states where you could, the insurance company could legally include a rider denying coverage for anything related to your diabetes. So you could get health insurance; for everything but your diabetes. And they could legally charge you more, too. Lots more.

In recent years, type 2s, especially those requiring insulin, also found individual insurance either prohibitively expensive or flat-out unavailable. As have folks with cancer, HIV/AIDS, and even asthma.

Basically, if you needed health insurance, they wouldn't sell it to you.

Innovation 2015

This institutionalized prejudice is scheduled to be outlawed in 2014 when the 974-page Affordable Care Act fully rolls out. Assuming that the massive health insurance reform law survives legal challenges and threats of repeal, everyone in the country will be required to purchase health insurance; and the health insurance companies will no longer be allowed to deny anyone coverage. The infamous "pre-existing condition" will go the way of the dodo bird; as will be the ability of a health plan to charge you more if you are "sick."

Today, however, people suffering from a wide range of conditions can still be legally denied health insurance, or charged at much higher rates. To address this "market access" issue, a little-known section of the Affordable Care Act created a program called the Pre-Existing Condition Insurance Plan (PCIP). It allows people locked out of the current market to get coverage now, rather than waiting until 2014.

PCIP insurance is a good preview of what post-2014 health plans will look like. It covers primary and specialty medical care, hospitalization, and prescription drugs — along with preventative care, maternity care, imaging and lab tests, home health, hospice and more. It does not cover boob jobs (cosmetic surgeries), artificial insemination, most abortions, or experimental care.

In a press conference call last week, Steve Larsen, Deputy Administrator and Director for Consumer Information and Insurance Oversight for the Department of Health and Human Services, announced that by the end of this month 50,000 Americans will be covered by the PCIP program — a 400% growth over the last year. The annual report, released at the recent press conference, shows that an estimated 16.8 percent of these people have diabetes.

Congress appropriated $5 billion dollars to run PCIP for the less than two years the bridge program will exist. Richard Popper, Director of Insurance Programs in the Center for Consumer Information and Insurance Oversight, states while at this point the costs are running higher than expected, $4.3 billion still remains in the coffers.

Who Runs PCIP?

PCIP is actually a crazed patchwork quilt of both state and federal programs. At the time the Affordable Care Act was passed by Congress and signed by the President, half the states in the country already required insurance plans to participate in high-risk pools, to help uninsured adults who have a pre-existing medical condition. Many of these states chose to use the federal PCIP funds to build on, and subsidize, their existing programs.

In the remaining states, where health insurance plans are less regulated, the federal government officially runs the PCIP program, contracting operations to national private health plans. (It's overseen by the Government Employees Health Association, or GEHA, the same folks who handle health insurance needs for federal employees.)

Because this creates more than two dozen different versions of PCIP, the details of coverage and eligibility varies quite a bit from state to state. But in general, to qualify you must be:

  • a U.S. citizen or reside here legally
  • have a pre-existing condition for which insurance has been denied
  • and have been uninsured for at least six months

In some cases, a prohibitively expensive offer of health coverage will serve as a de facto denial. Interestingly, your income is not a factor.

You can check out this map for details on coverage in your state: it lets you know whether PCIP is run by the state or feds where you live; lists the phone number and web link to apply; and gives you a pretty detailed estimate of your out-of-pocket costs. The PCIP program is designed to "peg" costs in any given state to correspond with typical costs for individuals without pre-existing conditions, which is to say it's still expensive.

But it's available. And that's a first.



Disclaimer: Content created by the Diabetes Mine team. For more details click here.


This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.