pcip mrmib handbook

12/2011

Application and Handbook 2012PCIP California Pre-Existing Condition Insurance Plan

MRMIP California Major Risk Medical Insurance Program

Inside this booklet:

2 GlossaryofDefinitions

3 HealthInsuranceforCalifornians

4 AreYouEligibleforPCIPorMRMIP?

4 PCIPandMRMIPBenefits

5 Worksheet:FindOutWhichProgram IsRightforYou

6 Application Checklist: Important!

A1 PCIP and MRMIP Application Form

7 ImportantNoticesandDeclarations

8 PCIPandMRMIPMonthlyPremiums ComparisonCharts

14 PCIPandMRMIPCostsandBenefits ComparisonCharts

20 PCIPandMRMIPFrequentlyAskedQuestions

We’vegotyoucovered!Getthecoverageyouneed,evenifyouhavebeendeniedbefore.

2

Annual benefit maximum Theannual benefit maximumisthetotalamountthatyourhealth

planpaysforserviceseachyear.Iftheservicesyouusereachthatamountinanyyear,youmustpayforanyadditionalservicesuntiltheendoftheyear,whenyourplanwillstartpayingagain.PCIPhasnoannualmaximum.MRMIPhasanannualmaximumof$75,000.

Annual out-of-pocket maximum Theout-of-pocket maximum isthehighestamountthatyouwillhave

topayinagivenyearforhealthservices,excludingyourmonthlypremiums.Theout-of-pocketmaximumconsistsofthecopaymentsorthedeductibleandcoinsuranceyoupayforhealthservices.Theout-of-pocketmaximumfortheMRMIPandPCIPprogramis$2,500peryear($4,000perfamilyinMRMIP).IntheMRMIPandPCIPprograms,thereisnoout-of-pocketmaximumforservicesreceivedfromout-of-networkproviders.

Brand name drug deductible Abrand name drug deductibleistheamountyoupayevery

yearforbrand-nameprescriptionmedicinesbeforeyourhealthplanstartspayingforthem.PCIPhasa$500brandnamedrugdeductible.MRMIPhasnobrandnamedrugdeductible.

Coinsurance Coinsuranceisapercentageshareofthecostofservicesthatyou

payaftermeetingyourannualdeductible.Yourhealthplanpaystherest.Theamountofcoinsuranceyoupaycanrangefrom15%forin-networkservicesto50%forout-of-networkservices.

Copayments Acopaymentisafixeddollarshareofthecostofservices(such

asdoctorvisitsormedicines)thatyoupaywhenyougetthoseservices.Yourhealthplanpaystherest.Copaymentscounttowardyouryearlydeductible.Youmustcontinuetomakecopaymentsevenafteryoureachyouryearlydeductible.

Deductible Adeductibleisthetotalamountyoupayeveryyearforservicesand

medicationsbeforeyourhealthplanstartspaying.PCIPhasa$1,500deductibleforin-networkservicesanda$3,000deductibleforout-of-networkservices.MRMIPhasa$500deductibleforbothin-networkandout-of-networkservices.

Disenrollment Disenrollmentistheactofleavingaprograminwhichyouare

enrolled.Apersonwhoenrollsineitherprogrammayleavetheprogrambychoiceorbecauseofadecisionmadebytheprogram.Forexample,someonemaybedisenrolledbecauseheorshedidnotpaypremiums,orsomeonemaychoosetodisenrollbecauseheorshepurchasedotherinsurance.

Health Maintenance Organization (HMO) AnHMOisatypeofhealthcoveragewhereyougetallofyour

healthservicesthroughaspecificnetworkofdoctorsandhospitals.Servicesprovidedbydoctorsorhospitalsoutsideofyournetworkprobablywillnotbepaidforbyyourplan,unlessitisanemergency.HMOsrequirethatyouselectaPrimaryCarePhysician,whoisresponsibleformanagingandcoordinatingyourhealthcare,includingyourreferralstospecialists.

HIPAA HIPAAisthefederalHealthInsurancePortabilityandAccountability

Actof1996.Ithelpsprotecthealthinsurancecoveragewhenworkersleavetheirjobs.Italsoprotectstheprivacyandsecurityofindividuals’personalhealthinformationbyrequiringcertain“coveredentities”totellconsumershowtheirhealthinformationwillbeused.

Lifetime benefit maximum Thelifetime benefit maximumisthetotalamountthatyourhealth

planpaysforservicesoveryourlifetime.Iftheservicesyouusereachthatamount,younolongerhavecoverageforanyadditionalservices.PCIPhasnolifetimemaximum.MRMIPhasalifetimemaximumof$750,000.

Plan allowance Theplan allowanceistheamountthattheplanconsidersasfullpay-

mentforeachcoveredservice.In-networkprovidersagreetoacceptanegotiatedplanallowanceaspaymentinfull,sothatsubscriberspayonlytheirin-networkcoinsuranceorcopaymentaftermeetingthedeductible.However,ifasubscriberreceivesout-of-networkservices,thesubscriberwillberesponsibleforanychargesabovetheplanallowance,aswellasforhisorhercoinsuranceorcopayment.

Pre-existing condition Apre-existing conditionisanymedicalconditionthatadoctor

orotherlicensedhealthpractitionerdiagnosed,caredfor,recommendedtreatmentfor,ortreatedforaperiodoftimebeforethepersontriedtoobtainhealthcoverage.

Preferred Provider Organization (PPO) APPOisatypeofhealthcoveragewhereyoupaylessifyouget

yourhealthservicesfromanetworkof“preferred”doctorsandhospitals.Ifyougetcarefromapreferredprovider,youwillpayyourannualdeductibleand/orcoinsuranceforyourvisit.Ifyougetservicesfromdoctorsnotinthepreferrednetwork(knownasgoing“out-of-network”),youwillpayahigheramount.PPOsdonotrequireyoutoselectaPrimaryCarePhysician,anddonotrequirereferralstoseespecialists.

Premium ApremiumisamonthlyfeethatPCIPorMRMIPmembersmustpay

tostayenrolledintheplan.

Preventive care services Preventive care services areservicesthatyourhealthplanoffersto

helpyoustayhealthyandtoidentifymedicalproblemsearly.Preventivecareservicesmayincluderegularcheckups,certainimmunizationsandlabservices,PAPsmears,mammograms,well-babyandwell-childservices,prostateexams,andtestsforsexuallytransmitteddiseases.

Provider network Aprovider networkisagroupofdoctorsandhospitalsthatagree

toprovidehealthservicesatanagreedrateofpayment.IfyouareinanHMO,youwillgenerallyhavetoreceiveservicesfromprovidersinyournetwork.IfyouareinaPPO,youwillpaylessifyoureceiveservicesfromprovidersinyournetworkthanifyougetservicesfromadoctororhospitalthatisnotinyournetwork.

Glossary of Definitions

3

Health Insurance for Californians

ThestateofCaliforniaofferstwohealthinsuranceprogramsforCalifornianswhohavepre-existingmedicalconditionsandhavenotbeenabletogetcoveragebecauseofthis.

Two insurance programs but only one application!

ThetwohealthinsuranceprogramsinCaliforniaarethePre-ExistingConditionInsurancePlan(PCIP)andMajorRiskMedicalInsuranceProgram(MRMIP).Theprogramshavedifferenteligibilityrules,benefits,andmonthlypremiums.

PCIPisafederallyfundedprogram,andMRMIPisastatefundedprogram.

MRMIP: Major Risk Medical Insurance Program

MRMIPcoversdependents.MRMIPmonthlypremiumsareusually

morecomparedtoPCIP.

IfyouselectaPPO,youmayhavetowait3monthsbeforeyougethealthservicesforyourpre-existingcondition.IfyouselectanHMOyoumayhavetowait3monthsbeforeyoucanbeginthecoverage.

PCIP: Pre-Existing Condition Insurance Plan

PCIPdoesnotcoverdependents.EachindividualmustmeetthePCIPeligibilityrequirementstobeenrolled.PCIPmonthlypremiumsareusuallyless

comparedtoMRMIP.YoumustbeaU.S.CitizenorU.S.

Nationalorbelawfullypresenttoqualifyforcoverage.Youmustbewithouthealthcoveragefor

atleast6months.Afteryouareenrolled,youcangethealth

servicesrightaway.

The application

Thefour-pageapplicationforbothprogramsstartsonpageA1.Ifyouqualifyforbothprograms,youcanchoosewhichprogramyouwant.Youcancall1-877-428-5060forassistancewitheitherprogram.

Note:IfyouwantthePCIPprogramforyourselfandoneormoredependents,eachpersonmustapplyseparatelyandqualify.

IMPORTANT NOTICE:IfyouenrollinMRMIP,itwillpreventyoufromqualifyingforthePre-ExistingConditionInsurancePlan,unlessyoulaterbecomeuninsuredfor6months.

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How did you learn about PCIP or MRMIP? (Check all that apply.)

Tell us how you learned about PCIP or MRMIP.

3

State:ZIP code:

Telephone number:

State:ZIP code:

1

Are you a California resident? Yes No

4

Are You Eligible for PCIP or MRMIP?You may qualify for PCIP if: You may qualify for MRMIP if:

YouarearesidentofCalifornia.

Youhaveapre-existingconditionasshownby:Adenialletterfromahealthinsurancecompanyorhealthplandatedwithinthelast12months,orAletterdatedwithinthelast12months,fromalicenseddoctor,physicianassistant,ornursepractitioner,statingtheindividualhasorhadamedicalcondition,disability,orillness(gotoPCIPwebsiteforasampleform),orAnofferofindividual(notgroup)healthcoveragewithhigherpremiumsthantheMajorRiskMedicalInsuranceProgram(MRMIP)preferredproviderorganization(PPO)rateintheareawhereyoulive(see pages 8–13).Theofferlettermustbedatedwithinthelast12months,orAcertificateofcreditablecoverageletterissuedbyanotherstateorFederallyadministeredPCIPprogramshowingpreviousenrollmentwithinthepast6months(see page 20).

YouarenotenrolledinMedicarePartAandB,COBRA,orCal-COBRAbenefits.

YouareaU.S.CitizenorU.S.National–oryouarelawfullypresentintheU.S.(youmustprovideaSocialSecurityNumberifyouareaU.S.CitizenorU.S.National).

Youhavenothadhealthcoverageforatleast6months.

YouarearesidentofCalifornia.

Youhaveapre-existingconditionasshownby:

Adenialletterfromahealthinsurancecompanyorhealthplandatedwithinthelast12months,orAnofferofindividual(notgroup)healthcoveragewithpremiumsthatarehigherthantheratesofyourfirstMRMIPplanchoice(see pages 8–13). Theofferlettermustbedatedwithinthelast12months,or

Involuntaryterminationfromahealthplan,healthinsurancecompanyoremployerplanforreasonsotherthanfraudornon-paymentofpremiums.Theinvoluntaryterminationlettermustbedatedwithinthelast12months.

YouarenoteligibleforMedicarePartAandPartB(exceptforend-stagerenaldisease)orforCOBRAorCal-COBRAbenefits.

Note: SocialSecurityNumbersarenotrequired.

Deferred enrollment:Ifyouhavehealthcoveragebutitisgoingtoendsoon,youmayapplynowforMRMIP.Thisiscalleddeferred enrollment.Getaletterfromyourhealthplanoremployerthatsayswhenyourcoveragewillend.

Medi-Cal:IfyoureceiveMedi-CalbenefitsnowandwanttoswitchtoMRMIP,considerthecost.

PCIP and MRMIP BenefitsPCIP MRMIP

Annual medical deductible $1,500 $500/subscriberorsubscriberand dependents

Brand name drug deductible $500 None

Annual out-of-pocket maximum $2,500 $2,500/$4,000subscriberanddependents

Annual benefit maximum None $75,000

Lifetime benefit maximum None $750,000

Health care provider sourcePCIPPPONetwork(see pages 14 – 19)

AnthemBlueCross,ContraCostaHealthPlan,Kaiser(see pages 14 – 19)

Pre-existing condition exclusion or Post-enrollment waiting period None 3months(see page 22)

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Generally, PCIPpremiumsarelowerincomparisontoMRMIP.

In PCIP,therearenoannualorlifetimebenefitmaximums.MRMIPhasannualandlifetimebenefitmaximumsthatcanresultinyourbeingresponsibleforallcostsabovethemaximums,orbeingunabletoobtainmedicalcare.

In PCIP,thereisnowaitingperiodforimmediatetreatmentforyourpre-existingmedicalcondition.Note:MRMIPhasa3-monthpostenrollmentwaitingperiod(HMOs)orpre-existingconditionexclusion(PPO).Thesemaybewaivedundercertaincircumstances(see page 22).

IfyoucannotmeetthePCIPrequirementthatyoubeuninsuredfor6months,theMRMIPoptionisavailable.

IfyoucannotmeetthePCIPcitizenshiporimmigrationrequirements,theMRMIPoptionisavailable.

Ifyouwantmorehelp,call1-877-428-5060MondaythroughFriday8:00AM–8:00PM,Saturday8:00AM–5:00PM.

Do you qualify for PCIP? Do you qualify for MRMIP?YouarearesidentofCalifornia. Yes YouarearesidentofCalifornia. Yes

Youhaveapre-existingmedicalconditionandcansendoneofthesedocumentstoshowproof:n Adenialletterfromahealthinsurancecompanyor

healthplan,datedwithinthelast12months,orn Aletterdatedwithinthelast12months,from

alicenseddoctor,physicianassistant,ornursepractitioner,statingtheindividualhasorhadamedicalcondition,disability,orillness(gotoPCIPwebsiteforasampleform),or

n Anofferofindividual(notgroup)healthcoverageathigherpremiumsthantheMRMIPpreferredproviderorganization(PPO)ratewhereyoulive.Theofferlettermustbedatedwithinthelast12months(see pages 8 – 13 for MRMIP’s PPO monthly premiums.),or

n AcertificateofcreditablecoverageletterissuedbyanotherstateorFederallyadministeredPCIPprogramshowingpreviousenrollmentwithinthepast6months(see page 20).

Yes Youhaveapre-existingmedicalconditionandcansendoneofthesedocumentstoshowproof:n Adenialletterfromahealthinsurancecompanyor

healthplan,datedwithinthelast12months,orn Anofferofindividual(notgroup)healthcoveragewith

premiumsthatarehigherthanyourfirstMRMIPplanchoice.Theofferlettermustbedatedwithinthelast12months(see pages 8 – 13 for MRMIP’s monthly premiums),or

n Proofofinvoluntaryterminationfromahealthplan,healthinsurancecompanyoremployerplanforreasonsotherthanfraudornon-paymentofpremiums.Theinvoluntaryterminationlettermustbedatedwithinthelast12months.

Yes

YouarenotenrolledinMedicarePartsAandB,COBRA,orCal-COBRAbenefits.

Yes YouarenoteligibleforMedicarePartsAandB(exceptforendstagerenaldisease),COBRA,orCal-COBRAbenefits.

Yes

Youareoneofthefollowing:n U.S.CitizenorU.S.Nationalandhavea

SocialSecurityNumberorn LawfullypresentintheU.S.(notaU.S.Citizen)

Yes

Youhavenothadhealthcoverageforatleast6months. Yes

If you answered Yes to all the questions above, you probably qualify for PCIP.

If you answered Yes to all the questions above, you probably qualify for MRMIP.

Worksheet: Find Out Which Program Is Right for You

The PCIP is generally the best health coverage program for everyone who qualifies! ThePCIPpremiumsaremoreaffordableandPCIPhasnoannualorlifetimebenefitmaximum.Reviewtheprogramdifferencesbelow.

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Application Checklist: Important! Usethistomakesureyousendusacompleteapplication.Anincompleteapplicationmaydelayyourenrollmentifyouqualify.Note:Donotsendthischecklistwithyourapplication.Whenyouseethisarrow ,itmeansyoumayhavetosendsupportingdocuments.

YouhavereviewedthePCIPandMRMIPcomparisoncharts,whichprovideinformationabouteligibility,benefits,andcosts. Youhaveansweredallquestionsontheapplication.(For PCIP, youmustprovideyour Social Security Number ifyouareaU.S.Citizenor

U.S.National.) Sendthesedocumentswithyourapplication:

For PCIP,includeacopyofoneofthese: Adenialletterfromindividual(notgroup)healthcoveragereceivedinthelast12months Aletterdatedwithinthelast12monthsfromalicenseddoctor,physicianassistantornursepractitioner statingtheindividualhasorhadamedicalcondition,disability,orillness Anofferletterofindividual(notgroup)healthcoveragewithpremiumsthatarehigher than the MRMIP PPO rate basedontheareawhereyoulive ACertificateofCreditableCoverageletterissuedbyPCIPfromanotherstateorFederallyadministeredPCIPprogram, (responseonpageA3ofapplication)

For PCIP,includeacopyofoneofthese: CertificateofU.S.Citizenship CertificateofU.S.Naturalization U.S.birthcertificate U.S.passport Otherproofofcitizenship Proofofimmigrationstatus(Senddocumentsthatarenotexpired.Includecopiesofbothfrontandback.) Foralistofacceptableimmigrationdocuments,gotowww.pcip.ca.gov.Thenclickonthe“FrequentlyAskedQuestions”link onthewebsite.Or,callusifyouneedassistance!

If you choose MRMIP,includeacopyofoneofthese: Adenialletterfromindividual(notgroup)healthcoveragereceivedinthelast12months Anofferletterofindividual(notgroup)healthcoveragewithpremiumsthatarehigher than your first MRMIP plan choice receivedinthelast12months Aterminationletterfromahealthplan,healthinsurancecompanyoremployerplanforreasonsotherthanfraudornon-payment ofpremiumsreceivedinthelast12months

If you choose MRMIP and: you are applying for deferred enrollmentbecauseyoubelieveyouqualifybutcurrentlyhavehealthcoverage.Includeacopy ofaletterfromtheemployerorinsurancecompanyyouhavenow,tellinguswhentheinsurancecoveragewillend. youcurrently have Medicare Part A and Part B because of end-stage renal disease.Includeacopyoftheapprovalletter fromMedicare. youwanttowaive part or all of the waiting or exclusion period.Includeacopyofproofofanyinsurancecoveragethatyou hadbefore. youhaveadependent child who is over 23 years old.Sendadoctor’sletterwiththeapplicationforeachchildover23statingthatthe personcannotworkbecauseofacontinuousphysicalormentaldisabilitythatstartedbeforeage23.Thedependentchildcannotbemarried.

Signtheapplication.

Writeacheckforonemonth’spremiumfortheprogramyouareinterestedin.MakethecheckpayabletotheManaged Risk Medical Insurance Board (MRMIB).Seepages8–13fortheprograms’monthlypremiumsbyregion.

Mailtheapplicationwithyourcheckandallrequireddocumentsto: CaliforniaPre-ExistingConditionInsurancePlan,P.O.Box537032,Sacramento,CA95853-7032 Insurance Agents/Brokers or Certified Application Assistants: Completeall applicableboxesatthebottomoftheapplication

onpageA4torequestandreceivepayment.Section1101ofthePatientProtectionandAffordableCareAct,PublicLaw111-148andInsuranceCodeSections12739.52(e),12711(a),authorizestheprogramstocollectandmaintaintheinformationsolicitedinthisapplication.

ForPCIPquestions,call1-877-428-5060MondaythroughFriday8:00AM–8:00PM,Saturday8:00AM–5:00PMorvisitwww.pcip.ca.gov.

ForMRMIPquestions,call 1-800-289-6574 MondaythroughFriday8:30AM–7:00PMorvisit www.mrmib.ca.gov.

This is an application for PCIP and MRMIP. Tell us which health insurance program you prefer.2

IfyouqualifyforbothPCIPandMRMIP,whichonedoyouwanttobeenrolledin?Checkonlyonebox: PCIP MRMIP

If you qualify for both and do not select a program, we will enroll you in PCIP.

HowdidyoulearnaboutPCIPorMRMIP?(Check all that apply.)

Tell us how you learned about PCIP or MRMIP.3

InsuranceAgent/Broker TV /radio Communityclinic Healthinsurance Employer CertifiedApplicationAssistant Website / Internet Hospital denialletter Church HealthFair /CommunityEvent Newspaper / printad Pharmacy Friend / relative Diseasemanagementorganization Doctor’soffice Governmentoffice Other____________________________________________

Application FilloutthisformtoapplyforPCIPandMRMIP.Complete allquestionsontheapplication,astheymustbefullyanswered.Ifyoudonotprovideallnecessaryinformation,theprocessingofyourapplicationmaybedelayed.Whenyouseethisarrow ,itmeansyoumayhavetosendsupportingdocuments.

Lastname:

Household information (optional)

Tell us about your ethnicity (optional)

Emailaddress:

Mailingaddress(if different from your home address):

Gender: Female Male

Homeaddress:

City:

Maritalstatus: Single Married Divorced Widowed RegisteredDomesticPartner

Firstname: Middleinitial:

State: ZIPcode: Telephonenumber:

Cellphonenumber:

City: State: ZIPcode:

White Black,AfricanAmerican

Hispanic: Cuban Mexican,MexicanAmerican PuertoRican OtherHispanic__________________________

Asian: AsianIndian Cambodian Chinese Japanese Amerasian Korean Laotian

Vietnamese Filipino OtherAsian________________________________

Pacific Islander: Hawaiian Guamanian Samoan OtherPacificIslander ______________________________

Aleut /AlaskaNative AmericanIndian,NativeAmerican Eskimo

Other, not listed above_____________________________________

Dateofbirth(month/day/year):

IfyouareaU.S.CitizenorU.S.National,youmustwriteyourSocial Security Number here (required for PCIP):

IfyouarenotaU.S.CitizenorU.S.National, areyoulawfullypresentintheU.S.? Yes No If Yes, send documentation (see application checklist on page 6).

Whatlanguagedoyouwantustousewhenspeakingwithyou? Howmanypeopleareinyourfamily?

Whatisyourannualhouseholdincome?Whatlanguageshouldweusewhenwritingtoyou?

1 Tell us about the person who needs coverage. Newenrollment Adddependents

AreyouaCaliforniaresident? Yes No

AreyouaU.S.CitizenorU.S.National? Yes NoIf Yes, send documentation (see application checklist on page 6).

A1

IfyouqualifyforMRMIP,whichhealthplandoyouwant?(see pages 14 – 19) AnthemBlueCross ContraCosta KaiserPermanente

Wereyoucoveredbyasimilarhigh-riskinsuranceprograminanotherstatewithinthelast12months? Yes No

IfyoudonotqualifyforMRMIPrightnowbutexpecttoqualifysoon,areyouapplyingfordeferredenrollment?(see page 21) Yes NoIf Yes, please provide the following information:

Haveyoumettherequirementstoavoidall(orpart)oftheMRMIPexclusion/waitingperiod?(see page 22) Yes NoIf Yes, please fill in the information below:

Nameofcurrentinsurancecompany,healthplan,orhealthprogram:

Nameofpriorinsurancecompany,healthplan,orhealthprogram:

Reasonforfuturetermination: Dateyourcoveragewillend:

Ifyouareapplyingfordeferredenrollment,sendacopyofaletterfromyourhealthinsuranceplanindicatingwhenyourcoveragewillend.

Datethatyourcoveragestarted: Datethatyourcoveragewillend:

Ifyouhavemettherequirementstoavoidall(orpart)oftheexclusion/waitingperiod,sendacopyofyourhealthinsurancepolicy,healthplan document,orproofthatyouhadcoverage(includingMedicareandMedi-Cal)indicatingwhenyourcoverageended.

Dateyourcoveragestarted:

Information for MRMIP coverage4

If you are applying for MRMIP and want coverage for dependents, list the dependents here. PCIP does not provide coverage for dependents. Each person interested in PCIP must complete a separate application. He or she must qualify to be enrolled.

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Name of dependent Gender Date of birth Married? Relationship to applicantLast,First,MiddleInitial,andSSN(optional) FemaleorMale Month/Day/Year YesorNo Checkone:

1. F M // Y N

Spouse Child StepchildRegisteredDomesticPartnerChildofRegisteredDomesticPartnerOther_____________________________________

2. F M // Y N


3. F M // Y N


Name of dependent Name of prior health insurance company Date coverage started Date coverage ended

1. // //

2. // //

3. // //

Ifthedependenthasmettherequirementstoavoidall(orpart)oftheexclusion/waitingperiod,sendacopyofthehealthinsurancepolicy,healthplandocument,orproofthatyouhadcoverage(includingMedicareandMedi-Cal)indicatingwhenhisorhercoverageended.

If you have more dependents,photocopypageA2andfillitout.Sendtheadditionalpageswithyourapplication. Subscriberdependentsage18andunderarenotsubjecttothepre-existingconditionexclusionperiodorthepost-enrollmentwaitingperiod.

Ifadependentchildisover23yearsold,sendadoctor’sletterwiththeapplicationforeachchildover23statingthatthepersoncannotworkbecauseofacontinuousphysicalormentaldisabilitythatstartedbeforeage23.Thedependentchildcannotbemarried.Isthedependentchild(whoisover23yearsold)coveredbyMedicare? Yes No

Haveanyofyourdependentsmettherequirementstoavoidall(orpart)oftheexclusion/waitingperiod?(see page 21) Yes NoIf Yes, list their names below:

A2

A3

Tell us about your recent health insurance experience that qualifies you for PCIP or MRMIP.

Hasyouremployer,aninsurancecompanyorinsuranceAgent/Brokerdiscouragedyoufromgetting Yes Nohealthcoveragethatyouqualifiedfor?If Yes, provide more information below.

Nameofemployerorhealthinsurancecompany:

Address:

City: State: ZIPcode:

6

For PCIP: Withinthepast6months,haveyouhadanyofthefollowingtypesofhealthcoverage? Yes NoIf Yes, please indicate by checking the boxes below, and indicate date your health coverage ended _____ /_____ /_____.

AnotherPCIPprogram(see page 20).Ifso,whichstate:____________ Checkthisboxifyouobtainedotherhealthcoverageafter youweredisenrolledfromanotherPCIPprogram.

Individualorjob-basedhealthcoverage,includingCOBRAorCal-COBRA MedicarePartAandPartB Medi-Cal(Medicaid) Children’sHealthInsuranceProgram(CHIP),including

HealthyFamiliesProgram(HFP) Anotherstate'shigh-riskpoolorCalifornia'sMajorRiskMedical

InsuranceProgram(MRMIP)

TRICARE(militaryhealthinsurance) HealthbenefitplanprovidedtoPeaceCorpsworkers Healthcoverageprovidedbyapublichealthplanestablished

byastate,theU.S.government(suchascoverageprovided toveteransenrolledinVAhealthcare),oraforeigncountry

FEHBP(healthinsuranceforfederalemployeesorretirees), includingTemporaryContinuationofCoverage(TCC)

ServicesprovidedbytheIndianHealthServiceorbyaTribe orTribalorganizationfortreatingyourmedicalcondition

Ifyouhadhealthcoveragewithinthepast6months,pleaseprovidethereasonyourhealthcoverageended.

Youorsomeoneinyourfamilylostorlefthisorherjob Yourinsurancecompanystoppedcoveringdependents Youorsomeoneinyourfamilystoppedworkingfulltime

andwerenolongereligibleforbenefits Youmovedoutoftheinsurancecompany’sservicearea

(ormovedoutofstate)

Yourinsurancepremiumsweretoohigh YourCOBRAcoverageended Youvoluntarilyendedyourinsurancecoverage Youarenolongereligibleforpubliclysponsoredcoverage Other.Explainthereasonyourcoverageended:______________________

______________________________________________________________________________

Haveyoureceivedadenialletterfromahealthinsurancecompanyorhealthplanwithinthepast12months? Yes No If Yes, provide a copy of the denial letter.

For PCIP: Withinthepast12months,haveyoureceivedanofferofindividual(notgroup)healthcoverageathigher Yes No ratesthantheMRMIPPPOproduct?If Yes, provide a copy of the offer letter.For MRMIP: Withinthepast12months,haveyoureceivedanofferofindividual(notgroup)healthcoverageathigher Yes No

ratesthanyourselectedMRMIPhealthplan?If Yes, provide a copy of the offer letter.

For PCIP: Haveyoureceivedaletterfromalicenseddoctor,physicianassistant,ornursepractitionerwithinthe Yes No past12months,statingtheindividualhasorhadamedicalcondition,disabilityorillness? IfYes, provide a copy of the provider letter.

For MRMIP: Haveyoubeeninvoluntarilyterminatedfromhealthinsurancecoverageforreasonsotherthanfraud Yes No ornonpaymentofpremium?IfYes, provide a copy of the termination letter.

mo day yr

MRMIP health plan dispute resolution and PCIP dispute resolution7InMRMIP,eachplanhasitsownrulesforresolvingdisputesaboutdelivery,services,andothermatters.Someplanssayyoumustusebindingarbitrationfordisputes(notincludingdisputeswiththeprogramaboutwhichbenefitsarecovered);othersdonot.Someplanssaythatclaimsformalpracticemustbedecidedbybindingarbitration;othersdonot.Iftheplanyouchooserequiresbindingarbitration,youaregivingupyourrighttoajurytrialandcannothaveadisputedecidedincourt.Tofindouthowaplanresolvesdisputes,youcancalltheplanandrequestanEvidenceofCoveragebooklet.ToseewhichMRMIPplansrequirebindingarbitration,seepage7.

In PCIP,therearerulesforresolvingdisputesaboutdelivery,services,andothermatters.TofindouthowPCIPresolvesdisputes,youcancallPCIPat1-877-428-5060,orrefertotheSummaryPlanDescriptionbookletonourwebsiteatwww.pcip.ca.gov.

A4

Important notices and declarations, and understandings and responsibilities 8

Applicant’s signature _______________________________________________________________________________________________ Date:__________________________________________

CAAgent/BrokerLicenseNumber(ifapplicable):

Person’sName: EE/CAANumber:(ifapplicable):

IgivepermissionforPCIPorMRMIPtogiveinformationoverthetelephoneaboutmyapplicationstatusandfinaleligibilitystatustothepersonlistedbelow.

Permission to share PCIP and MRMIP information9

CAANumber: EENumber:

CAAname:

CAAgent/BrokerLicenseNumber:

Agent/Broker or CAA signature: ____________________________________________________________________________________ Date:__________________________________________

Agent/Brokername:

Streetaddress:

TaxI.D./SocialSecurityNumber(Agent/Brokeronly):

City:

State: ZIPcode: Phone: Emailaddress:

For Insurance Agents/Brokers or Certified Application Assistants (CAAs) only:

Ifyouassistedanapplicantincompletingthisapplication,pleasecompletethissection.Youmustcompleteallapplicableboxes.Youwillnotbepaidifyoudonotcompletethissectionpriortosendingtheapplication.Missinginformationcannotbesubmittedatalaterdateforpayment.(Please see page 20.)IftheapplicantwantsPCIPorMRMIPtoprovideyouwiththestatusofthisapplicationandfinaleligibilitydecision,makesuretheapplicantsignsSection9above.

Iunderstandthatpaymentwillnotbemadeunlessanduntilthisapplicantisenrolledintheprogram.IcertifythatIprovidedfreeassistancetotheapplicant.

10

IdeclarethatIhavereadthisapplication,theanswersprovided,andthedocumentsenclosed.Icertifythattheinformationprovidedwiththisapplicationistrue,complete,andcorrecttothebestofmyknowledge.IhavereadandunderstandtheNotices,andIammakingtheDeclarationsonpage7.IhavealsoreadandIunderstandtheMRMIPhealthplandisputeresolutionandPCIPdisputeresolutionexplanationonpageA3.

Signatureofapplicant/parentorlegalguardian_________________________________________________________________________Date:________________________________________

ZIPcode:

Checkyourrelationshiptothepersonapplyingforcoverage: Parent Stepparent CaretakerRelative LegalGuardian

Other________________________________________________________________________________________________

Mailingaddress:

City: State:

Fullname: Telephonenumber:

Ifyouareaparentorlegalguardianofthepersonapplyingforcoverage,youmustsignaboveandprovidethefollowinginformation:

ForMRMIP only,thedependent(s)listedonthisapplicationmustsignhere:

Signatureofapplicant’sspouse/registereddomesticpartner: ____________________________________________________________Date:________________________________________

Signatureofapplicant’sdependentage18orover: _________________________________________________________________________Date:________________________________________

Signatureofapplicant’sdependentage18orover: _________________________________________________________________________Date:________________________________________

7

Important Notices and Declarations

PCIP and MRMIP Declarations

n IunderstandthatitismyresponsibilitytoinformPCIPofanyhealthcoverageIgetinthefutureorifImoveoutofCalifornia,sothatIcanbedisenrolled.

n Iunderstandthat,ifIvoluntarilydisenrollfromPCIPorifIamdisenrolledinvoluntarily(forexample,forfailuretopaymypremiumsontime),Imaynotre-qualifyforenrollmentuntilatleast6monthsaftermycoverageends.

n IunderstandthatmyapplicationandenrollmentinformationmaybesharedwithotherFederalandStategovernmentagenciesforpurposesofestablishingPCIPeligibility.

n IunderstandthatmyapplicationmustbereviewedtodeterminewhetherornotIqualifyforcoverage.

n Iunderstandthat,ifmyapplicationisapproved,theeffectivedateofcoveragewillbedeterminedaccordingtoapplicablelawsandregulationsandIwillbeinformedinwritingoftheeffectivedateofcoverage.

n IunderstandthattheMRMIPhealthplandisputeresolutionprocessmayincludebindingarbitration,ratherthanacourttrialtoresolveanyclaim.Thisincludesaclaimformalpracticeassertedbyme,myenrolleddependents,heirs,personalrepresentatives,orsomeonewitharelationtousagainsttheparticipatinghealthplanoragainsttheemployees,partnersoragentsoftheparticipatinghealthplan.

n IunderstandthatMRMIP’sContraCostaHealthPlanDOESNOTrequirebindingarbitration.

n IunderstandthatMRMIP’sAnthemBlueCrossandKaiserPermanenteHealthPlansDOrequirebindingarbitrationofdisputesINCLUDINGmalpractice,solongasthedisputesarebeyondthejurisdictionallimitofthesmallclaimscourt.Thisdoesnotincludedisputeswiththeprogramaboutwhichbenefitsarecovered.

n IunderstandthatifIdonotprovideallthenecessaryinformationrequestedtoprocesstheapplication,theapplicationwillbedeniedorreturnedasincomplete.

n Ideclarethat,withinthelast6months,IhavenothadhealthcoveragepriortothedateIamaskingforcoverageinthePCIP.

n IdeclarethatallindividualslistedonthisapplicationareresidentsoftheStateofCalifornia.

n IdeclareandunderstandthatmakingamonthlypremiumpaymentdoesnotmeanthatIamacceptedby,or,ifaccepted,immediatelyenrolledinto,theprograms.

n IdeclarethatnopersonlistedonthisapplicationandapplyingforMRMIPiseligibleforbothMedicarePartsAandPartB,unlesstheyaresolelyeligiblebecauseofend-stagerenaldisease.

n IdeclarethatnopersonlistedonthisapplicationandapplyingforPCIPisenrolledinMedicarePartsAandB.

n Ideclarethatallindividualslistedonthisapplicationwillabidebyallrulesofprogramparticipation.

n IdeclarethatnopersonlistedonthisapplicationandapplyingforcurrentordeferredenrollmentintoMRMIPiscurrentlyeligibletopurchaseanycontinuationofemployerhealthbenefitsundertheprovisionsof29U.S.Code1161etseq.(COBRA),orundertheprovisionsofInsuranceCodeSections10128.50etseq.andHealthandSafetyCodeSections1366.20etseq.(Cal-COBRA).Thesearelawswhichallowpeopletobuyintotheiremployer’shealthinsuranceforupto36consecutivemonthsaftertheyleavetheiremployment.

n IdeclarethatnopersonlistedonthisapplicationandapplyingforPCIPisenrolledinCOBRAorCal-COBRA.

n Ideclarethatnopersonlistedonthisapplication,andapplyingforcoveragethroughtheMRMIP,wasterminatedwithinthelast12monthsfroma“Post-MRMIPGuaranteedIssuePilotProgram”asaresultofnon-paymentofpremiums,arequesttodisenrollvoluntarily,orfraud.A“PostMRMIPGuaranteedIssuePilotProgram”isahealthplaninwhichanindividualhadanopportunitytoenrollbetweenSeptember1,2003andDecember31,2007asaresultofbeingdisenrolledfromMRMIPafter36consecutivemonthsofenrollment.

n IdeclarethatIhavereadandunderstandtheinformationonthisApplicationandagreetotheseNoticesandDeclarations.

Access to Your Records

YouhavetherighttoaccessrecordsmaintainedbytheManagedRiskMedicalInsuranceBoardthatcontainyourpersonalinformation.Todoso,contact:

ManagedRiskMedicalInsuranceBoardAttn:HIPAACoordinatorP.O.Box2769Sacramento,CA95812-2769(916)324-4695

8

MRMIP InMRMIP,yougetyourhealthcarethroughahealthplan.Premiumsforthehealthplansarelistedbelow.

PCIP and MRMIP Monthly Premiums | Area 1Usethischarttocomparepremiumsbasedonyourageandwhereyoulive.

Premiums for people who live in:Alpine,Amador,Butte,Calaveras,Colusa,DelNorte,ElDorado,Glenn,Humboldt,Inyo,Kings,Lake,Lassen,Mendocino,Modoc,Mono,Monterey,Nevada,Placer,Plumas,SanBenito,Shasta,Sierra,Siskiyou,Sutter,Tehama,Trinity,Tulare,Tuolumne,Yolo,andYubacounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.

PCIP

Subscriber only

Age

PCIP

0 – 14 $119.00

15 – 18 $119.00

19 – 29 $164.00

30 – 34 $237.00

35 – 39 $264.00

40 – 44 $292.00

45 – 49 $332.00

50 – 54 $411.00

55 – 59 $492.00

60 – 64 $535.00

65 – 69 $535.00

70 – 74 $535.00

> 74 $535.00

Subscriber and 1 dependent

Anthem Blue Cross

PPO

Kaiser Permanente

N. California 1

$741.00 $561.88

$999.00 $747.59

$999.00 $747.59

$1,185.00 $850.48

$1,290.00 $937.91

$1,409.00 $1,208.78

$1,701.00 $1,078.53

$2,151.00 $1,285.99

$2,614.00 $1,424.89

$3,182.00 $1,622.08

$3,564.00 $2,402.18

$3,755.00 $2,534.53

$3,978.00 $2,680.48

Subscriber and 2 or more dependents

Anthem Blue Cross

PPO

Kaiser Permanente

N. California 1

$1,165.00 $974.04

$1,645.00 $1,224.26

$1,645.00 $1,224.26

$1,955.00 $1,481.46

$2,121.00 $1,481.46

$2,179.00 $1,503.75

$2,436.00 $1,503.75

$2,817.00 $1,663.21

$3,243.00 $1,663.21

$3,833.00 $1,879.28

$4,293.00 $3,121.43

$4,523.00 $3,299.8

$4,791.00 $3,490.98

Subscriber only

Anthem Blue Cross

PPO

Kaiser Permanente

N. California 1

$374.00 $281.50

$488.00 $354.06

$488.00 $354.06

$674.00 $418.36

$768.00 $449.24

$810.00 $504.10

$860.00 $553.86

$1,101.00 $639.58

$1,324.00 $732.16

$1,670.00 $811.03

$1,870.00 $1,354.51

$1,971.00 $1,429.93

$2,087.00 $1,517.08

1. Kaiser Permanente Northern California servestheseZIPcodesinthesecounties:Amador 95640and95669 | El Dorado 95613-14,95619,95623,95633-35,95651,95664,95667,95672,95682,and95762 | Kings

93230and93232 | Placer 95602-04,95648,95650,95658,95661,95663,

95677-78,95681,95703,95722,95736,95746-47,and95765| Sutter

95659,95668,95674,and95676 | Tulare 93261,93618,93666,and93673 | Yolo95605,95607,95612,95616-18,95645,95691,95694-95,95697-98,95776,and95798-99 | Yuba 95692,95903,and95961

PremiumseffectivethroughDecember31,2012

9

PCIP and MRMIP Monthly Premiums | Area 2 Usethischarttocomparepremiumsbasedonyourageandwhereyoulive.

Premiums for people who live in: Fresno,Imperial,Kern,Madera,Mariposa,Merced,Napa,Sacramento,SanJoaquin,SanLuisObispo,SantaCruz,Solano,Sonoma,andStanislauscounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.

2. Kaiser Permanente Northern California servesallZIPcodesinSacramento,

San Joaquin, and SolanocountiesandtheseZIPcodesinthesecounties:Fresno93242,93602,93606-07,93609,93611-13,93616,93619,93624-27,93630-31,93646,93648-52,93654,93656-57,93660,93662,93667-68,93675,93701-12,93714-18,93720-30,93737,93741,93744-45,93747,93750,93755,93760-61,93764-65,93771-79,93786,93790-94,93844,and93888| Madera 93601-02,93604,93614,93636-39,93643-45,93653,and93669| Mariposa 93623 |

Napa 94503,94508,94515,94558-59,94562,94567(exceptthecommunityof

Knoxville),94573-74,94576,94581,and94599| Sonoma 94922-23,94926-28,94931,94951-55,94972,94975,94999,95401-07,95409,95416,95419,95421,95425,95430-31,95433,95436,95439,95441-42,95444,95446,95448,95450,95452,95462,95465,95471-73,95476,95486-87,and95492.

3. Kaiser Permanente Southern CaliforniaservestheseZIPcodesinthiscounty:Kern 93203,93205-06,93215-16,93220,93222,93224-26,93238,93240-41,93243,93250-52,93263,93268,93276,93280,93285,93287,93301-09,93311-14,93380,93383-90,93501-02,93504-05,93518-19,93531,93560-61,and93581.

PCIP

Subscriber only

Age

PCIP

0 – 14 $118.00

15 – 18 $118.00

19 – 29 $162.00

30 – 34 $234.00

35 – 39 $261.00

40 – 44 $289.00

45 – 49 $329.00

50 – 54 $406.00

55 – 59 $487.00

60 – 64 $530.00

65 – 69 $530.00

70 – 74 $530.00

> 74 $530.00


Anthem Blue Cross

PPO

Kaiser Permanente

N. 2 & S. 3 California

$691.00 $561.88

$932.00 $747.59

$932.00 $747.59

$1,106.00 $850.48

$1,204.00 $937.91

$1,314.00 $1,028.78

$1,587.00 $1,078.53

$2,007.00 $1,285.99

$2,440.00 $1,424.89

$2,970.00 $1,622.08

$3,326.00 $2,402.18

$3,505.00 $2,534.53

$3,712.00 $2,680.48


Anthem Blue Cross

PPO

Kaiser Permanente


$1,087.00 $974.04

$1,536.00 $1,224.26

$1,536.00 $1,224.26

$1,824.00 $1,481.46

$1,979.00 $1,481.46

$2,033.00 $1,503.75

$2,274.00 $1,503.75

$2,629.00 $1,663.21

$3,026.00 $1,663.21

$3,577.000 $1,879.28

$4,007.00 $3,121.43

$4,221.00 $3,299.80

$4,472.00 $3,490.98

Subscriber only

Anthem Blue Cross

PPO

Kaiser Permanente


$349.00 $281.50

$455.00 $354.06

$455.00 $354.06

$629.00 $418.36

$717.00 $449.24

$756.00 $504.10

$802.00 $553.86

$1,028.00 $639.58

$1,235.00 $732.16

$1,558.00 $811.03

$1,745.00 $1,354.51

$1,839.00 $1,429.93

$1,948.00 $1,517.08



10



Premiums for people who live in: Alameda,ContraCosta,Marin,SanFrancisco,SanMateo,andSantaClaracounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.

Subscriber only

Anthem Blue Cross

PPO

Contra Costa Health Plan 4

Kaiser Permanente

N. California 5

$396.00 $268.35 $281.50

$518.00 $341.28 $354.06

$518.00 $341.28 $354.06

$715.00 $495.84 $418.36

$815.00 $495.84 $449.24

$859.00 $571.16 $504.10

$912.00 $571.16 $553.86

$1,168.00 $762.59 $639.58

$1,404.00 $762.59 $732.16

$1,771.00 $963.45 $811.03

$1,984.00 $1,292.97 $1,354.51

$2,090.00 $1,292.97 $1,429.93

$2,214.00 $1,292.97 $1,517.08

PCIP

Subscriber only

Age

PCIP

0 – 14 $124.00

15 – 18 $124.00

19 – 29 $171.00

30 – 34 $247.00

35 – 39 $275.00

40 – 44 $305.00

45 – 49 $346.00

50 – 54 $428.00

55 – 59 $514.00

60 – 64 $557.00

65 – 69 $557.00

70 – 74 $557.00

> 74 $557.00


Anthem Blue Cross

PPO


Kaiser Permanente

N. California 5

$785.00 $662.17 $561.88

$1,060.00 $662.17 $747.59

$1,060.00 $662.17 $747.59

$1,257.00 $878.70 $850.48

$1,368.00 $878.70 $937.91

$1,494.00 $1,085.82 $1,028.78

$1,804.00 $1,085.82 $1,078.53

$2,281.00 $1,487.56 $1,285.99

$2,773.00 $1,487.56 $1,424.89

$3,375.00 $1,920.65 $1,622.08

$3,780.00 $2,520.04 $2,402.18

$3,983.00 $2,520.04 $2,534.53

$4,219.00 $2,520.04 $2,680.48


Anthem Blue Cross

PPO


Kaiser Permanente

N. California 5

$1,235.00 $1,220.80 $974.04

$1,745.00 $1,220.80 $1,224.26

$1,745.00 $1,220.80 $1,224.26

$2,073.00 $1,349.45 $1,481.46

$2,250.00 $1,349.45 $1,481.46

$2,311.00 $1,606.81 $1,503.75

$2,584.00 $1,606.81 $1,503.75

$2,987.00 $1,839.03 $1,663.21

$3,439.00 $1,839.03 $1,663.21

$4,065.00 $2,231.32 $1,879.28

$4,553.00 $2,988.48 $3,121.43

$4,797.00 $2,988.48 $3,299.80

$5,082.00 $2,988.48 $3,490.98

4. Contra Costa Health Plan isavailableonlyinContra Costa County.

5. Kaiser Permanente Northern California servesallZIPcodesinAlameda, Contra Costa, Marin, San Francisco, and San Mateo countiesandtheseZIPcodesinthiscounty:Santa Clara 94022-24,94035,94039-43,94085-89,

94301-06,94309,95002,95008-09,95011,95013-15,95020-21,95026,95030-33,95035-38,95042,95044,95046,95050-56,95070-71,95101,95103,95106,95108-13,95115-36,95138-41,95148,95150-61,95164,95170,95172-73,95190-94,and95196.


11



Premiums for people who live in: Orange,SantaBarbara,andVenturacounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.

6. Kaiser Permanente Southern California servesallZIPcodesin Orange county,andtheseZIPcodesinthiscounty:Ventura 91319-20,91358-62,91377,

93001-07,93009-93012,93015-16,93020-22,93030-36,93040-44,93060-66,93094,and93099.


Anthem Blue Cross

PPO

Kaiser Permanente

S. California 6

$665.00 $515.68

$898.00 $697.13

$898.00 $697.13

$1,064.00 $792.53

$1,159.00 $875.75

$1,266.00 $960.73

$1,528.00 $1,005.79

$1,933.00 $1,200.04

$2,349.00 $1,330.11

$2,860.00 $1,513.91

$3,203.00 $2,305.54

$3,374.00 $2,432.19

$3,574.00 $2,584.93


Anthem Blue Cross

PPO

Kaiser Permanente

S. California 6

$1,046.00 $894.15

$1,479.00 $1,238.20

$1,479.00 $1,238.20

$1,757.00 $1,382.11

$1,906.00 $1,382.11

$1,958.00 $1,404.66

$2,189.00 $1,404.66

$2,531.00 $1,552.08

$2,914.00 $1,552.08

$3,444.00 $1,754.98

$3,858.00 $2,919.93

$4,064.00 $3,081.30

$4,305.00 $3,274.44

Subscriber only

Anthem Blue Cross

PPO

Kaiser Permanente

S. California 6

$336.00 $258.41

$439.00 $330.34

$439.00 $330.34

$606.00 $390.19

$690.00 $419.66

$728.00 $471.68

$772.00 $516.79

$990.00 $596.56

$1,189.00 $683.25

$1,500.00 $757.83

$1,680.00 $1,295.81

$1,770.00 $1,365.71

$1,875.00 $1,446.86

Age

0 – 14

15 – 18

19 – 29

30 – 34

35 – 39

40 – 44

45 – 49

50 – 54

55 – 59

60 – 64

65 – 69

70 – 74

> 74

PCIP

Subscriber only

PCIP

$107.00

$107.00

$147.00

$211.00

$237.00

$261.00

$297.00

$370.00

$442.00

$481.00

$481.00

$481.00

$481.00


12

PCIP

Subscriber only

Age

PCIP

0 – 14 $110.00

15 – 18 $110.00

19 – 29 $152.00

30 – 34 $218.00

35 – 39 $244.00

40 – 44 $269.00

45 – 49 $306.00

50 – 54 $381.00

55 – 59 $455.00

60 – 64 $494.00

65 – 69 $494.00

70 – 74 $494.00

> 74 $494.00


PCIP and MRMIP Monthly Premiums | Area 5Usethischarttocomparepremiumsbasedonyourageandwhereyoulive.

Premiums for people who live in: LosAngelesCounty.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.


Anthem Blue Cross

PPO

Kaiser Permanente

S. California 7

$745.00 $515.68

$1,006.00 $697.13

$1,006.00 $697.13

$1,192.00 $792.53

$1,298.00 $875.75

$1,417.00 $960.73

$1,711.00 $1,005.79

$2,165.00 $1,200.04

$2,631.00 $1,330.11

$3,203.00 $1,513.91

$3,587.00 $2,305.54

$3,780.00 $2,432.19

$4,004.00 $2,584.93


Anthem Blue Cross

PPO

Kaiser Permanente

S. California 7

$1,172.00 $894.15

$1,656.00 $1,238.20

$1,656.00 $1,238.20

$1,967.00 $1,382.11

$2,135.00 $1,382.11

$2,193.00 $1,404.66

$2,452.00 $1,404.66

$2,835.00 $1,552.08

$3,264.00 $1,552.08

$3,858.00 $1,754.98

$4,321.00 $2,919.93

$4,552.00 $3,081.30

$4,822.00 $3,274.44

Subscriber only

Anthem Blue Cross

PPO

Kaiser Permanente

S. California 7

$376.00 $258.41

$491.00 $330.34

$491.00 $330.34

$678.00 $390.19

$773.00 $419.66

$816.00 $471.68

$865.00 $516.79

$1,108.00 $596.56

$1,332.00 $683.25

$1,681.00 $757.83

$1,882.00 $1,295.81

$1,983.00 $1,365.71

$2,101.00 $1,446.86

7. Kaiser Permanente Southern California servesallZIPcodesin Los Angeles County except90704(CatalinaIsland).


13



Premiums for people who live in: Riverside,SanBernardino,andSanDiegocounties.Somehealthplansmaynotbeavailableinyourarea–seenotesbelow.


Anthem Blue Cross

PPO

Kaiser Permanente

S. California 8

$683.00 $515.68

$922.00 $697.13

$922.00 $697.13

$1,093.00 $792.53

$1,190.00 $875.75

$1,299.00 $960.73

$1,569.00 $1,005.79

$1,984.00 $1,200.04

$2,412.00 $1,330.11

$2,936.00 $1,513.91

$3,288.00 $2,305.54

$3,464.00 $2,432.19

$3,670.00 $2,584.93


Anthem Blue Cross

PPO

Kaiser Permanente

S. California 8

$1,074.00 $894.15

$1,518.00 $1,238.20

$1,518.00 $1,238.20

$1,804.00 $1,382.11

$1,956.00 $1,382.11

$2,010.00 $1,404.66

$2,247.00 $1,404.66

$2,598.00 $1,552.08

$2,991.00 $1,552.08

$3,536.00 $1,754.98

$3,960.00 $2,919.93

$4,173.00 $3,081.30

$4,420.00 $3,274.44

Subscriber only

Anthem Blue Cross

PPO

Kaiser Permanente

S. California 8

$345.00 $258.41

$450.00 $330.34

$450.00 $330.34

$622.00 $390.19

$708.00 $419.66

$748.00 $471.68

$793.00 $516.79

$1,016.00 $596.56

$1,221.00 $683.25

$1,540.00 $757.83

$1,725.00 $1,295.81

$1,818.00 $1,365.71

$1,925.00 $1,446.86

PCIP

Subscriber only

Age

PCIP

0 – 14 $108.00

15 – 18 $108.00

19 – 29 $149.00

30 – 34 $214.00

35 – 39 $240.00

40 – 44 $265.00

45 – 49 $301.00

50 – 54 $375.00

55 – 59 $447.00

60 – 64 $485.00

65 – 69 $485.00

70 – 74 $485.00

> 74 $485.00

8. Kaiser Permanente Southern California servesZIPcodesinthesecounties:Riverside 91752,92220,92223,92320,92501-09,92513-19,92521-22,92530-32,92543-46,92548,92551-57,92562-64,92567,92570-72,92581-87,92589-93,92595-96,92599,92860,and92877-83|San Bernardino 91701,91708-10,91729-30,91737,91739,91743,91758,91761-64,91784-86,92252,92256,92268,92277-78,92284-86,92305,92307-08,92313-18,92321-22,92324-26,92329,92331,92333-37,92339-41,92344-46,92350,92352,92354,

92357-59,92369,92371-78,92382,92385-86,92391-95,92397,92399,92401-08,92410-15,92418,92423-24,and92427|San Diego 91901-03,91908-17,91921,91931-33,91935,91941-47,91950-51,91962-63,91976-80,91987,92007-92011,92013-14,92018-27,92029-30,92033,92037-40,92046,92049,92051-52,92054-58,92064-65,92067-69,92071-72,92074-75,92078-79,92081-85,92091-93,92096,92101-24,92126-32,92134-40,92142-43,92145,92147,92149-50,92152-55,92158-79,92182,92184,92186-87,and92190-99.


14

PCIP MRMIP Health Plan Options

Plan areaYoucanchoosethePCIPPPONetworkifyouliveinany countyinCalifornia(statewide).

Plan areaYoucanchoosethisplanifyouliveinany countyinCalifornia(statewide).

Plan areaYoucanchoosethisplanifyouliveinContra CostaCounty.

Plan areaNorthern CA counties:Alameda,Amador,ContraCosta,ElDorado,Fresno,Kings,Madera,Marin,Mariposa,Napa,Placer,Sacramento,SanFrancisco,SanJoaquin,SanMateo,SantaClara,Solano,Sonoma,Sutter,Tulare,Yolo,Yuba

Southern CA counties:Kern,LosAngeles,Orange,Riverside,SanBernardino,SanDiego,Ventura

Provider networkn11,000primarycarephysiciansn43,300specialistsn321hospitalsn250urgentcaren359ambulatorysurgerycenters(ASC)

Provider networkn40,000PPOphysiciansn29,000HMOphysiciansnMorethan400hospitals

Provider network3,000providersandspecialistsinchoiceoftwoprovidernetworks:nRegionalMedicalCenterNetwork

orn CommunityProviderNetwork

Provider networkYouchooseadoctortobeyourprimarycarephysician(PCP).YourPCPworkscloselywithyouandcanreferyoutospecialistswhenneeded.YoureceivecareatKaiserPermanentemedicalfacilitiesthroughoutthearea.

Annual deductibleDoes not apply to in-network preventive care.$1,500persubscriber(in-networkproviders)$3,000persubscriber(out-of-networkproviders)Thereareseparatedeductiblesforin-networkandout-of-networkservices.

Annual deductibleDoes not apply to preventive care.

$500persubscriber

$500perhouseholdServicesprovidedbyin-networkandout-of-networkprovidersandprescriptiondrugsapplytowardthe$500deductible.

Annual deductibleDoes not apply to in-network preventive care.$500perhouseholdTheannualdeductibleappliesonlytoinpatienthospitalservices.Allotherservicesarenotsubjecttothedeductible.

Annual deductibleDoes not apply to in-network preventive care.

$500perhousehold

Servicesprovidedbyin-networkandout-of-networkprovidersandprescriptiondrugsapplytowardthe$500deductible.

Brand name drug deductible$500forin-networkpharmacies

$500forout-of-networkpharmaciesThereareseparatedeductiblesforin-networkandout-of-networkpharmacies.

Brand name drug deductibleNoseparatebrandnamedeductible



1-877-661-6230 (press2)8:00amto5:00pm,Monday–Friday

www.cchealth.org/health_plan

1-877-687-05498:30amto7:00pm,Monday–Friday

www.anthem.com


8:00amto5:00pm,Saturdaywww.pcip.ca.gov

PCIP and MRMIP Costs and Benefits Usethischarttocompareplans.

Northern & Southern California


7:00amto3:00pm,Saturday–Sundaywww.kaiserpermanente.org



15

PCIP MRMIP Health Plan Options

Cost sharing15%coinsurance(in-network)50%coinsurance(out-of-network)

Theshareyoupayoftheplanallowanceforacoveredserviceaftermeetingyourdeductible.Forout-of-networkservices,youmayalsohavetopayanyamountthatexceedstheplanallowance.

Cost sharing15%coinsurance(in-network)50%coinsurance(out-of-network)

Theshareyoupayoftheplanallowanceforacoveredserviceaftermeetingyourdeductible.Forout-of-networkservices,youmayalsohavetopayanyamountthatexceedstheplanallowance.

Cost sharing$15copaymentforofficevisitsandmanyotherservices$25copaymentforemergencyroomvisits$200perdayforinpatienthospitalstays

Youpayasetamountforcoveredservices.

Cost sharing$20copaymentforofficevisitsandmanyotherservices$100copaymentforemergencyroomvisits$200perdayforinpatienthospitalstays

Youpayasetamountforcoveredservices.

Annual out-of-pocket maximum$2,500persubscriberforin-networkservices Themaximumincludesin-networkmedicalandbrandnamedrugdeductibles,andanyin-networkcopaymentsandcoinsurancepaid.Afteryoumeetthemaximum,theplanpays100%ofin-networkservicesfortherestoftheyear.Paymentsmadeforout-of-networkservicesdonotcounttowardstheout-of-pocketmaximum,andthereisnomaximumforout-of-networkservices.

Annual out-of-pocket maximum$2,500persubscriber$4,000perfamilyThemaximumincludesanyin-networkcopaymentsandcoinsurance.Afteryoumeetthemaximum,theplanpays100%ofin-networkservicesfortherestoftheyearuntilyoureachtheannualbenefitmaximum.Thereisnoout-of-pocketmaximumforout-of-networkservices.

Annual out-of-pocket maximum$2,500persubscriber$4,000perfamilyThemaximumincludesanycopaymentsandcoinsurance.Afteryoumeetthemaximum,theplanpays100%ofin-networkservicesfortherestoftheyearuntilyoureachtheannualbenefitmaximum.Thereisnoout-of-pocketmaximumforout-of-networkservices.

Annual out-of-pocket maximum$2,500persubscriber$4,000perfamilyThemaximumincludesanycopaymentsandcoinsurance.Afteryoumeetthemaximum,theplanpays100%ofin-networkservicesfortherestoftheyearuntilyoureachtheannualbenefitmaximum.Thereisnoout-of-pocketmaximumforout-of-networkservices.

Annual benefit maximumNo limit

Annual benefit maximum$75,000persubscriber



Lifetime benefit maximumNo limit

Lifetime benefit maximum$750,000persubscriber



Prior authorizationSomeservicesrequirepriorauthorization.SeethePCIPSummaryPlanDescriptionforalistingofallservicesthatrequirepriorauthorization.Thisdocumentcanbefoundatwww.pcip.ca.gov.

Prior authorizationSeetheAnthemEvidenceofCoveragebookletforalistingofservicesthatrequirepriorauthorization.

Prior authorizationSeetheContraCostaHealthPlanEvidenceofCoveragebookletforalistingofservicesthatrequirepriorauthorization.

Prior authorizationSeetheKaiserNorthernCaliforniaorKaiserSouthernCaliforniaEvidenceofCoveragebookletforalistingofservicesthatrequirepriorauthorization.

PCIP and MRMIP Costs and Benefits (continued)

Thisisonlyasummaryofplanprovisionsandisintendedforcomparisonpurposesonly.Forexacttermsandconditionsofcoverage,refertotheSummaryPlanDescription(forPCIP)ortheapplicableplan’sEvidenceofCoveragebooklet(forMRMIP).


16

PCIP

Youpayifyougoto:

In-network provider Out-of-network provider

Ambulance• Limitedtotransportduringamedicalemergency 15%pertrip 15%pertrip

Doctor services• Inpatientvisits(doctorvisitswhileyouareinthehospital)• Officevisits

15%perinpatientvisit$25copaymentperofficevisit(nodeductible)

50%perinpatientvisit50%perofficevisit

Durable medical equipment• Authorizedbyaphysicianforcareofanillnessorinjury 15%perpurchase/rental 50%perpurchase/rental

Emergency room services• Limitedtotreatmentofamedicalemergency 15%pervisit 15%pervisit

Home health care• Medicallynecessaryvisitsbyhomehealthpersonnel 15%pervisit 50%pervisit

Hospice care• Hospicecareforsubscriberswhoarenotexpectedtolivemorethan12months 15%pervisit 50%pervisit

Hospital services• Inpatient(semi-privateroom)

• Outpatient

15%perinpatientday

15%peroutpatientvisit

50%perinpatientday


Mental health care services• Inpatient(limitedto10dayspercalendaryear)

• Outpatient(limitedto15visitspercalendaryear)• Unlimitedinpatientdaysandoutpatientvisitsfortreatmentofseriousemotional

disturbances(SED)inchildrenorseverementalillness(SMI)

15%perinpatientday


50%perinpatientday


Alcohol and substance abuse treatment• Inpatient(servicestoremovetoxicsubstancesfromthesystem)• Outpatient(limitedto20visitspercalendaryear)

15%perinpatientday15%peroutpatientvisit

50%perinpatientday50%peroutpatientvisit

Orthotics and prosthetics• Orthoticsandprostheticdevices 15%perdevice 50%perdevice

Physical/occupational/speech therapy• Servicesofphysicaltherapists/occupationaltherapists/speechtherapistsasmedically

appropriateonanoutpatientbasis15%pervisit 50%pervisit

PCIP and MRMIP Costs and Benefits Usethischarttocompareplans. (continued)


17

MRMIP Health Plan Options |Usethischarttocompareplans

Youpayifyougoto: Youpay: Youpay:


15%pertrip 15%pertrip $15pertrip $75pertrip

$25perofficevisit(nodeductible)

50%perofficevisit

$15perofficevisit

$20perofficevisit

15%perpurchase/rental 50%perpurchase/rental $0perpurchase/rental 20%perpurchase/rental

15%pervisit 15%pervisit $25pervisit(waivedifadmittedtoahospital)

$100pervisit(waivedifadmittedtoahospital)

15%pervisit 50%pervisit $0pervisit $0pervisit

15%pervisit 50%pervisit $0pervisit $0pervisit

15%perinpatientday


Allchargesafter$650perinpatientdayAllchargesafter$380perday

$200perinpatientday

$15peroutpatientvisit

$200perinpatientday


15%perinpatientday


Allchargesafter$175perinpatientday50%peroutpatientvisit

$200perinpatientday


$200perinpatientday


15%perinpatientdayoutpatientvisitsnotcovered

15%perinpatientdayoutpatientvisitsnotcovered

$200perinpatientday$15peroutpatientvisit

$200perinpatientdayoutpatientvisitsnotcovered

15%perdevice 50%perdevice $0perdevice $0perdevice

15%pervisit Allchargesafter$25pervisit $15pervisit $20pervisit


Questions?ForPCIP,call1-877-428-5060MondaythroughFriday8:00AM–8:00PM,Saturday8:00AM–5:00PMorvisitwww.pcip.ca.gov.ForMRMIP,call1-800-289-6574MondaythroughFriday8:30AM–7:00PMorvisitwww.mrmib.ca.gov.

18

PCIP

Youpayifyougoto:


Pregnancy and maternity care• Inpatient(deliveryservices)

• Outpatient(prenatalandpostnatalcare)

•Excludescoverageforpaidsurrogates

15%perinpatientday


50%perinpatientday


Prescription drugs• Generic

• Brandname

• Non-preferredbrandnameorspecialtydrug

$5pergenericdrug(30-daysupply)$15perbrandnamedrug(30-daysupply)$30pernon-preferredbrandnameorspecialtydrug(30-daysupply)

50%pergenericdrug(30-daysupply)50%perbrandnamedrug(30-daysupply)50%pernon-preferredbrandnameorspecialtydrug(30-daysupply)

Preventive care • Cytologyexams• Diseasemanagementprograms• Familyplanningcounselingservices• Healtheducationservices• Hearingandeyetestsforchildren• Immunizationsforadultsandchildren• Newbornbloodtests• Prostateexamsformen• Routineexams,mammograms,Papsmears,HumanPapillomavirus(HPV)tests,

andovarianandcervicalcancerscreeningforwomen• Routinephysicalsandlabservices• TestsforHumanImmunodeficiencyVirus(HIV)andsexuallytransmittedinfections• Well-babyandwell-childcare• Routinecolonoscopies

Nocharge 50%pervisit(subjecttotheout-of-networkdeductibleandcoinsurance)

Skilled nursing facility• Servicesareavailableonlywhendeterminedtobeamedicallyappropriatealternative

planoftreatmentthatismorecosteffective15%pervisit 50%pervisit

X-ray and laboratory services• Diagnosticx-raysandlaboratorytests 15%pervisit 50%pervisit

PCIP and MRMIP Costs and Benefits Usethischarttocompareplans. (continued)


19

MRMIP Health Plan Options |Usethischarttocompareplans

Youpayifyougoto: Youpay: Youpay:


15%perinpatientday


Allchargesafter$650perinpatientday50%peroutpatientvisit

$200perinpatientday


$200perinpatientday


$5pergenericdrug(30-daysupply)$15perbrandnamedrug(30-daysupply)

Allchargesover50%ofgenericdrugAllchargesover50%ofbrandnamedrug

20%ofgenericdrugcost

20%ofbrandnamedrugcost

$10pergenericdrug(upto100-daysupply)$35perbrandnamedrug(upto100-daysupply)

15%pervisit(nodeductible)

50%pervisit(nodeductible)

$15pervisit $0to$20pervisit,dependingontheserviceyoureceive

notcoveredunlessmedicallyrecommended

notcoveredunlessmedicallyrecommended

$0perday(onlycoveredwhenauthorizedbytheplan)

$0perday(upto100daysperbenefitperiod)

15%pervisit 50%pervisit $0pervisit $0to$5pervisit,dependingontheserviceyoureceive


Questions?ForPCIP,call1-877-428-5060MondaythroughFriday8:00AM–8:00PM,Saturday8:00AM–5:00PMorvisitwww.pcip.ca.gov.ForMRMIP,call1-800-289-6574MondaythroughFriday8:30AM–7:00PMorvisitwww.mrmib.ca.gov.

20

PCIP and MRMIP Frequently Asked Questions (FAQ)

How long does it take to process my Application?

Ifyourcompleteapplicationisreceivedwithalltherequireddocumentationby the 15thofthemonth,coveragewillbeginthe1stdayofthefollowingmonth.Forexample,wereceiveacompleteapplicationbyOctober15ththestartdateofcoveragewillbeonNovember1st.

However,ifyourcompleteapplicationisreceivedwithallrequireddocumentationafter the 15thofthemonth,coveragewillbeginonthe1stdayofthesecondmonthfollowingyourapplication.Forexample,wereceiveacompleteapplicationafterOctober15ththestartdateofcoveragewillbeonDecember1st.Incompleteapplicationswillresultindelayedordeniedcoverage.WewillsendyoualetterinformingyouifyouareenrolledinPCIP.

Can Insurance Agents/Brokers assist people in applying for PCIP and MRMIP?

Yes,theycanassistpeopleinapplyingforPCIPandMRMIP.Theinsuranceagent’s/broker’sinformationmustbeincludedontheApplicationinorderforthemtobepaidfortheirassistance.Insuranceagents/brokersareeligibleforpaymentforeachpersontheyassistwhoissuccessfully enrolledintoPCIPorMRMIP.

Can Healthy Families Certified Application Assistants help people apply for PCIP?

Yes,CertifiedApplicationAssistants(CAAs)registeredwithanEnrollmentEntity(EE)andPCIPcertifiedcanhelppeopleapplyforPCIP.TheEEsareeligibletoreceivepayment.ThepaymentwillbemadeforeachpersontheCAAassistswhoissuccessfully enrolledintoPCIP.TheCAAinformationmustbeincludedontheApplicationinorderfortheEEtobepaid.

When will the payment be issued to the Insurance Agents/Brokers or Enrollment Entities (EEs)?

PaymentswillbeissuedaftertheapplicantisenrolledinPCIPorMRMIP.

If I had health coverage in the last 6 months, why don’t I qualify for PCIP? I have a pre-existing condition and I cannot be without health coverage for 6 months.

PCIPisafederalprogramadministeredinCaliforniaandthefederalhealthcarereformlawrequiresthatapersonbewithout“creditablehealthcoverage”foratleast6months.

I am a U.S. Citizen or U.S. National. Why do I have to provide my Social Security Number?

PCIPisafederalprogramadministeredinCaliforniaandthefederallawrequiresthatU.S.CitizensorU.S.NationalsprovidetheirSocialSecurityNumber. If you do not provide your Social Security Number,yourapplicationwillbeconsideredincomplete.Wewillsendyoualetterinformingyouthatyourapplicationisincomplete.Ifyoudonotsendustheinformationbytheduedate,youwillbedeniedPCIPcoverageandwewilldetermineyoureligibilityfortheMRMIP.

What is the difference in how Dependents are covered in MRMIP and PCIP?

MRMIPallowssubscriberswithpre-existingconditionstoenrolldependentsintoMRMIPonthesameapplication.Dependentsinclude,spouse,registereddomesticpartner,childrenundertheageof23,adoptedchild,stepchild,naturalchild,orchildofadomesticpartner.However,dependentsmustmeetallthesameeligibilityrequirementsexceptfordemonstratingthattheyhaveapre-existingcondition.Inaddition,dependentswithoutpre-existingconditionsgenerallycanpurchasehealthcoverageintheindividualmarketatmuchlowerrates.SomesubscriberswithdependentsmaybenefitfromdifferencesinpremiumsorcostsharinginMRMIP,andfromtheoptiontoenrollanewbornornewlyadoptedchild.

PCIPdoesnotallowsubscribersanddependentstobeenrolledonthesameapplication.EachindividualapplyingtothePCIPmustcompleteaseparateapplicationandmeetthePCIPeligibilityrequirements.

I was previously enrolled in another state or federally administered PCIP program. I moved and want to enroll in California’s PCIP program. Can I transfer my eligibility?n Yes.Ifyouweredisenrolledbecauseyounolongerresideinthat

state,youmaybeabletotransferyoureligibilitytoCalifornia’sPCIP.Wemustreceiveyourapplicationwithin6monthsafteryouweredisenrolledfromtheotherstateorfederallyadministeredPCIPprogram.Make sureyourespondtoSection6ontheApplication(see page A3): Whenweaskwhetherornotyouhadcoveragewithinthe

last6months,check“yes.” Then,checktheboxthatindicatesyouhadcoveragein

“another PCIP program.” Makesureyouidentifythestatewhereyoupreviously

hadcoverage. Tellusifyouhaveobtainedotherhealthcoverageafteryou

weredisenrolledfromtheotherPCIPprogram.

21

PCIP and MRMIP Frequently Asked Questions (continued)

Provide a copyofaCertificateofCreditableCoverageLetterissuedbythePCIPprogramfromtheotherstate.MakesuretheCertificateofCreditableCoverageLetteridentifiesyourstartdateandenddateofcoveragewiththeotherPCIPprogram.

Can I transfer my eligibility from another state’s high-risk pool?

Yes.Youcantransfereligibilityfromanotherstate’shigh-riskpoolaslongasitwaswithinthepast12monthsanditwasasimilartypeofaprogram.

I am currently enrolled in the MRMIP program. Do I qualify for PCIP?

No.IfyouarecurrentlyenrolledintheMRMIP,youdo notqualifyforthePCIPprogram.ThePCIPrequiresthatindividualnothavehealthcoverageforatleast6months.

I am currently enrolled in Medi-Cal. Do I qualify for MRMIP?

Yes,youmayqualifyforMRMIPaslongasyoumeetalloftheprogramrequirementsbutyoushouldcarefullyconsiderthecostofMRMIPcoverage.MRMIPsubscribersareresponsibleforpayingtheirmonthlypremiums,annualdeductible,costsharingandcopaymentsforcoveredservices.

What if I do not qualify for MRMIP right now, but will be eligible for MRMIP coverage soon? Can I apply for deferred enrollment?

Yes.IfyoucurrentlydonotqualifyforMRMIP,butwillbeeligibleinthenearfuture,youmayapplyfor“deferredenrollment.”Deferredenrollmentisappropriatewhenyoucurrentlyhavehealthcoverage(i.e.COBRA,Cal-COBRA,oremployercoverage),butyourhealthcoveragewillbeendingsometimeinthefuture.Ifyouwanttoapplyfordeferredenrollment,completetheinformationontheApplication(pageA2,section4).Youmustprovideacopyofaletter,showingthatyourcurrenthealthcoveragewillterminate.Thelettermustbeissuedfromahealthinsurancecarrier,healthplan,healthmaintenanceorganization,oranemployerplan.Thelettermust specifytheexact datewhenyourcurrentcoveragewillend.Deferred enrollment is not allowed for temporary health insurance policies.

IftheMRMIPplacesyouondeferredenrollmentstatus,youwillbeenrolledintheMRMIPonceyoubecomeeligiblefortheprogram.

Makesureyoustillsendinyourinitialpremiumpaymentwithyourapplication.Yourpaymentwillberefundedtoyou,ifyourMRMIPeligibilityfordeferredenrollmentismorethan60daysfromthedateyourcompleteapplicationwasreceived.

Which providers are available in PCIP?

ThePCIPPPOProviderNetworkhascontractedwithawidevarietyofhealthprovidersthroughoutthestate.Gotowww.pcip.ca.govtofindoutwhatprovidersareavailablethroughthePCIPPPONetwork.Then,clickonthe“Providers”tab.

Which plans are available in MRMIP?

MRMIPbenefitsandservicesaredeliveredthroughlicensedhealthplans(AnthemBlueCross,ContraCostaHealthPlanandKaiser).(See MRMIP Benefits Chart on pages 14 – 19.)Eachplanhasitsownin-networkproviders.TofindaproviderforaspecificMRMIPhealthplan,calltheplansdirectly.

Once I am enrolled, when can I access my health care coverage?

WhenyouareenrolledinPCIP,wewillsendyoualetterinformingyouwhenyourstartdateofcoveragebegins.Youcanaccessyourhealthcarebenefitsonceyourstartdateofcoveragebegins.

WhenyouareenrolledinMRMIP,wewillsendyoualetterinformingyouwhenyourstartdateofcoveragebegins.Youmaybesubjectedtoeitherthepre-existingconditionexclusionorthepostenrollmentwaitingperiod.(Seepage22formoreinformationabouttheexclusion/waitingperiod.)

Is dental and vision care included?

No.ThereisnodentalorvisioncoverageinPCIPorMRMIP.Ifyouneedthiscoverage,youwillneedtoobtainitseparately.

I am currently enrolled in MRMIP and also have other health care coverage. How does MRMIP coordinate benefits with my other insurance?

YourMRMIPhealthplanwillcoordinatecoverageofbenefitswithanyotherhealthcoverageyouhave.TheMRMIPissecondarytootherinsurancecoverage.ByStatelaw,MRMIPwillonlypayafteryourotherinsurancehaspaid(notincludingMedi-CalorothertypesofStateprograms).MRMIPwillnotduplicateothercoverageyouhave(whetheryouuseitornot).

22


What is a MRMIP pre-existing condition exclusion?

MRMIPsubscribersenrolledinaPreferredProviderOrganization(PPO)havetowait 3 months aftertheirstartdateofcoveragetobeginreceivinghealthcarebenefitsrelatedtotheir“pre-existingcondition.”TheMRMIPPPOplanisAnthemBlueCross.

Duringthefirst3months,no benefits or services related to a pre-existing condition are covered.However,othertypesofbenefitsandservicesmaybecoveredduringthisperiod.Subscribersarerequiredtopaymonthlypremiumsduringthepre-existingconditionexclusion.

What is a MRMIP post-enrollment waiting period?

MRMIPsubscribersenrolledinaHealthMaintenanceOrganization(HMO)havetowait 3 months beforetheybeginreceivinganyhealthcarebenefits(includinganypre-existingconditiontreatment).No benefits or services are provided to subscribers during the post-enrollment period and no premiums are paid for this period.MRMIPwillinformsubscriberswhenthepost-enrollmentperiodbeginsandends.ThepremiumpaymentincludedwiththeapplicationwillbeappliedtowardsyourfirstmonthofMRMIPcoverage,afterthepost-enrollmentwaitingperiodends.

MRMIPHMOplansareKaiserPermanente(Northern&SouthernCalifornia)andContraCostaHealthPlan.

I previously had other health coverage or was on the MRMIP waiting list. Can I waive all (or part) of the MRMIP pre-existing condition exclusion or post enrollment waiting period?

Yes,youcanwaiveall(orpart)oftheMRMIPexclusion/waitingperiodifoneofthefollowingoccurs:

n YouareontheMRMIPwaitinglistfor180daysorlonger.Theexclusion/waitingperiodwillbecompletelywaived.

n Youpreviouslyhadhealthcoverage(includingMedicareandMedi-Cal)andyouapplyfortheMRMIPwithin 63 daysfromthedateyourinsuranceended.

n Youpreviouslyhadhealthcoverageanditendedbecauseofoneofthefollowing: Lossofemployment, Employerstoppedofferinghealthcoverage,or Employerstoppedmakingcontributionstowardsthehealth

coverage.

YoumustapplyforMRMIPwithin 180 daysfromthedateyourhealthcoverageended.

n Youreceivedhealthcoveragefromasimilarhigh-riskprograminanotherstatewithinthelast12months.TheMRMIPexclusion/waitingperiodwillbecompletelywaived.

OnpageA2oftheApplication,makesureyoutellusthatyouwouldliketowaiveall(orpart)oftheexclusion/waitingperiod.Sendusaletterissuedfromyourprevioushealthinsurancecarrier,healthplan,healthmaintenanceorganization,oranemployerhealthplan.Thelettermustidentifythenameofthepreviousinsurancecompanyorplanandthestartandenddatesofcoverage.

Pleasenote:Dependentsage18yearsoryoungerqualifyforafullMRMIPpre-existingconditionexclusionorpostenrollmentwaitingperiodwaiver.

How do I get a copy of a MRMIP Evidence of Coverage and Disclosure Form booklet?

EachhealthplanhasanEvidenceofCoverageandDisclosureFormbooklet.Contacttheplansdirectlytoobtainacopy.Theplans’contactinformationisshownonpage14.

How can I appeal a PCIP eligibility decision?

IfyouthinkPCIPmadeamistake,youcansendafirst level appeal.Thefirstlevelappealmustbefiledinwritingwithinthirty(30)daysfromthedateofthePCIPdecision.SendPCIPaletter,tellingusthefactualorlegalreasonswhyyouthinkthedecisioniswrong,forexamplethatPCIPmadeafactualerrororviolatedalaworprogrampolicy.Or,youcancompleteanAppealsFormwhichyoucandownloadfromthePCIPwebsiteatwww.pcip.ca.gov.Then,clickonthe“Downloads”tab.Includeanyotherinformationyouthinkwillbehelpfulinthereview.WriteyourMemberNumberoneverydocumentyousendus.PCIPcannotreviewadecisionoverthetelephone.OncePCIPreceivesyourwrittenappealorAppealForm,PCIPwillsendyoualettertellingyoutheresultsofthereviewandanyrighttoadditionalappeals.

Please note:PCIPeligibilityappealsareavailableonlytodisputePCIP’s:1)enrollmentdecisions(decisionsaboutwhetherapersoniseligible)2)decisionsaboutaperson’seffectivedateofenrollment;or3)disenrollmentdecisions.

You can send your first level appeal to:

Pre-ExistingConditionInsurancePlanP.O.Box537032Sacramento,CA95853-7032Orfaxto:1-877-430-0843.(Thefaxnumberisfree.)

Ifthefirstlevelappealisdenied,youwillbenotifiedofyourrighttorequesta second level appealtotheExecutiveDirectoroftheManagedRiskMedicalInsuranceBoard(MRMIB).TheMRMIBisthestateagencythatadministersandoverseesthePCIP.Thesecondlevelappealmustbefiledinwritingwithinthirty(30)days

23


ofthefirstlevelappealdecision.Sendaletter,tellingusthefactualreasonwhyyouthinkthedecisioniswrong.Includeanyotherinformationyouthinkwillbehelpfulinthereview.WriteyourMemberNumberoneverydocumentyousendus.

You can send your second level appeal to:

ManagedRiskMedicalInsuranceBoardP.O.Box2769Sacramento,CA95812-2769Orfaxto:916-327-6560

Ifthesecondlevelappealisdenied,youhavetherighttosubmitawrittenrequestforanAdministrative Hearing.Attheadministrativehearing,thepriordecisionsandappealwillbereviewedbyanAdministrativeLawJudgefromtheOfficeofAdministrativeHearings.ThisisthefinalPCIPlevelofadministrativeappeal.Theadministrativehearingmustbefiledinwritingwithinthirty(30)daysfromthedateofthesecondleveldecision.Youwillneedtosendaletter,statingthefactualorlegalreasonsfortheappeal.Youwillbenotified,inwriting,ofthedate,time,andplaceoftheadministrativehearing,atleastten(10)dayspriortothedateofthehearing.Pleaseincludeanyotherinformationyouthinkwillbehelpfulinthefinallevelofappeal.WriteyourMemberNumberoneverydocumentyousendus.

You can send your request for an Administrative Hearing to:

ManagedRiskMedicalInsuranceBoardP.O.Box2769Sacramento,CA95812-2769Orfaxto:916-327-6560

How can I appeal a MRMIP decision?

TheMRMIPisaStateprogramandthesubscriber’srightsandobligationswillbedeterminedunderPart6.5,Division2,oftheCaliforniaInsuranceCodeandtheTitle10,CaliforniaCodeofRegulations,Chapter5.5,MRMIPRegulations.

ApplicantsorsubscribersmayfileanappealwiththeManagedRiskMedicalInsuranceBoard(MRMIB)onthefollowingissues:

n Anyactionorfailuretoactwhichhasoccurredinconnectionwithaparticipatinghealthplan’scoverage,

n Determinationofanapplicant’sordependent’seligibilityfortheMRMIP,

n Determinationtodisenrollasubscriberordependent,andn Determinationtodenyasubscriber’srequestortogranta

participatinghealthplan’srequesttotransferthesubscribertoadifferenthealthplan.

Anappealmustbefiledinwritingwithin60calendardaysoftheaction,failuretoact,orreceiptofnoticeofthedecisionbeingappealedto:

ManagedRiskMedicalInsuranceBoardBenefitsDivisionP.O.Box2769Sacramento,CA95812-2769

Orfaxto:916-327-6560

IncludeanyotherinformationyouthinkwillbehelpfulinMRMIB’sreview.WriteyourHealthCareIdentificationNumber(HCID)orSubscriberNumberoneverydocumentyousendus.

MRMIBcannotreviewadecisionoverthetelephone.OnceMRMIBreceivesyourwrittenappeal,MRMIBwillsendyoualettertellingyoutheresultsofthereviewandanyrighttoadditionalappeals.

Can I appeal health benefit decisions in the PCIP program?

Yes.Subscribershavetherighttoappealifahealthcareserviceisdelayed,denied,reduced,modified,orterminatedinfullorinpartbytheplan.ThefirstlevelofappealisaninternalappealwithPCIP.Ifyouareunhappywiththeresultsofyourappeal,youcanrequestadditionallevelsofappeal.Forexacttermsandconditions,refertotheSummaryPlanDescriptionbooklet.

How do I resolve a dispute with my MRMIP health plan?

Ifasubscriberisdissatisfiedwithanyaction(orinaction)ofthehealthplan,thesubscribershouldfirstattempttoresolvethedisputewiththeparticipatingplan.Thesubscribermustfollowtheplan’sestablishedpoliciesandproceduresinresolvingdispute.

Who can I call if I have more questions?

ForquestionsonthePCIP,youcangiveusacallat1-877-428-5060,MondaythroughFriday8:00AM–8:00PMor,onSaturdayfrom8:00AM–5:00PM.Thecallistollfree!Or,youcangotoourwebsiteatwww.pcip.ca.gov.AdditionalprograminformationandFrequentlyAskedQuestionsareavailableonourwebsite.

ForMRMIP,pleasecall1-800-289-6574,MondaythroughFriday8:30AM–7:00PM.Thecallistollfree!Or,youcangotoourwebsiteatwww.mrmib.ca.gov.AdditionalprograminformationandFrequentlyAskedQuestionsareavailableonourwebsite.

P.O.Box2769Sacramento,CA95812-27691-916-324-4695



pcip mrmib handbook

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