Health System Reform Insight - Aug. 25, 2011
Given the many changes under way in the nation's health system, the AMA has developed Health System Reform Insight to help you understand what this new direction means to you and your patients.
Under the Affordable Care Act (ACA), uninsured children and adults who have pre-existing health conditions can secure comprehensive health care coverage through the Pre-Existing Condition Insurance Plan (PCIP) until the new insurance market rules take effect in 2014. At that time, PCIP enrollees will transition to the health insurance exchanges that will be established in every state.
Last month, the Department of Health and Human Services (HHS) outlined more flexible steps that physicians can take to help PCIP applicants secure coverage in states where the federal government administers the plan. Previously, applicants had to provide a denial letter from an insurance company to prove they had a pre-existing condition. Now physicians can supply PCIP applicants with a letter stating that the applicant either currently has a medical condition, disability or illness, or that the applicant had one within the last 12 months.
This is a major step toward ensuring that patients get the care they need. HHS has provided a simple template letter that physicians can use.
To be eligible for the PCIP, the applicant must be a U.S. citizen or reside in the country legally. In addition, the applicant must have been without health insurance coverage for at least six months before applying. Finally, the applicant must have a pre-existing condition or have been denied coverage because of his or her health. Eligibility for the program is not income-based.
For applicants who are accepted into the PCIP, all benefits—including those related to pre-existing condition treatments—are effective upon the date of coverage. The benefits include primary and specialty care as well as hospital care and prescription drugs.
Enrollees in the PCIP should not have to pay a higher premium due to a medical condition. According to HHS, many PCIP enrollees will pay significantly lower premiums than they would have paid for coverage available to them in the general insurance market.
Visit the PCIP website to learn more about PCIP eligibility. The website also explains PCIP benefits and rates and how to apply in each state. The toll-free PCIP call center is also open from 8 a.m. to 11 p.m. Eastern time. Call (866) 717-5826 or TTY (866) 561-1604.
Aug. 31
Attend an educational call hosted by the Centers for Medicare & Medicaid Services to learn how the Medicare fee-for-service program will implement the Health Insurance Portability and Accountability Act Version 5010 standard transactions. Register today.
Sept. 22
Applications are due for physicians, hospitals and other providers interested in participating in Model 1 of CMS's new Bundled Payments to Care Improvement initiative. Apply for the program.
Nov. 4
Applications are due for physicians, hospitals and other providers interested in participating in Models 2–4 of its Bundled Payments to Care Improvement initiative. Apply for the program.
AMA comments on proposed rules covering accountable care organizations
AMA letter on developing pathway toward reforming the Medicare physician payment system
Letter in support of HEALTH Act to repair nation's medical liability system
Advocating for improvements to the Affordable Care Act
AMA comments on ACA implementation regulations
New HHS Web portal to help consumers buy health insurance
Pathways for physician success under health care payment and delivery reforms
