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California Office of AIDS Expands Its Insurance Premium Assistance

Autumn 2011

For several years, the California Office of AIDS has been paying health insurance premiums for qualified beneficiaries under the CARE/HIPP Plan. That program was greatly expanded effective July 1, 2011. It increases the financial requirement so that more will be eligible. It also increases the amount of monthly premiums it will pay and the program is no longer time limited. For the first time, it will also pay partial premiums for plans whose premium exceeds their new limit of $1,339 per month for non-ADAP clients and $1,938 per month for ADAP clients.

Since Medicare Drug Coverage was started in 2006, it has also had a program under AIDS Drug Assistance Program (ADAP) to pay the premiums for Medicare Part D beneficiaries on ADAP.

Now it is adding a new program for people who have not been able to get health insurance. It will begin paying premiums for the new Pre-Existing Conditions Insurance Plan (ADAP) created under the new Affordable Healthcare Act (ACA).

For more information on obtaining assistance in enrolling in these plans, contact your local Aids service organization or see the Office of AIDS Web site at

Enrollers are currently being trained to not only enroll you in the premium assistance plans under the new rules, but for those that are eligible for the PCIP health coverage, they will be able to enroll you in the health plan itself as well as set up the premium payment program.

PCIP is a health insurance plan available now to "uninsurable" individuals. Since the federal ACA does not require health insurance companies to accept anyone for coverage regardless of their health until 2014.

Waiting until 2014 to get health insurance is a very long wait for someone with a pre-existing condition and no health insurance. To solve that dilemma, the Act provides for temporary programs called Pre-Existing Conditions (health) Insurance Plan (PCIP). The Plan is temporary and will last only until insurance companies are required to cover anyone who requests coverage in 2014.

There is a PCIP plan in each state, and California has set up one of the first programs. However, there are strict limitations on who can purchase this insurance.

These programs were designed not just to help people who cannot purchase health insurance, but they were also planned as a method to help move some of the "uninsurable" people not having current coverage into the market to ease the pressure of everyone applying for coverage at once when 2014 arrives. Because these plans have not been well advertised, however, enrollments have been much lower than expected.

The plans:

  • Cover a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs. All covered benefits are available, even to treat a pre-existing condition.
  • Don't charge a higher premium just because of the medical condition.
  • Don't base eligibility on income.

To be eligible for these PCIP plans:

  • You must be a citizen or national of the United States or reside in the US legally.
  • You must have been without health coverage for at least the last six months. Please note that if you currently have insurance coverage that doesn't cover your medical condition or are enrolled in a state high risk pool, you are not eligible for the Pre-Existing Condition Insurance Plan. Also, people on full Medi-Cal are not eligible for PCIP, while people with Share-of-Cost Medi-Cal may be eligible for coverage.
  • You must have a pre-existing condition or have been denied health coverage because of your health condition.

Obviously, the requirement of having been without health insurance at least six months severely limits who can enroll in these plans, but the purpose of the program was to start making coverage available to people without insurance, not draw people from the current health insurance market.

In order to qualify for coverage, you will need to provide one of the following documents:

  • A letter from a doctor, physician assistant, or nurse practitioner dated within the past twelve months stating that you have or had a medical condition, disability, or illness. This letter must include your name and medical condition, disability, or illness and the name, license number, state of licensure, and signature of the doctor, physician assistant, or nurse practitioner.
  • -OR-

  • A denial letter from an insurance company licensed in your state for individual insurance coverage (not health insurance offered through a job) that is dated within the past twelve months. Or, you may provide a letter dated in the past twelve months from an insurance agent or broker licensed in your state that shows you aren't eligible for individual insurance coverage from one or more insurance companies because of your medical condition.
  • -OR-

  • An offer of individual insurance coverage (not health insurance offered through a job) that you did not accept from an insurance company licensed in your state that is dated within the past twelve months. This offer of coverage has a rider that says your medical condition won't be covered if you accept the offer.
  • -OR-

  • If you are under age 19 an offer of individual insurance coverage (not health insurance offered through a job) that you did not accept from an insurance company licensed in California that is dated within the past twelve months. This offer of coverage must show a premium that is at least twice as much as the Pre-Existing Condition Plan premium (the monthly payment you make to an insurer to get and keep insurance) for the Standard Option in your state.

The plan provides preventive care (paid at 100%, with no deductible) when you see an in-network doctor and the doctor indicates a preventive diagnosis. For other care, there is a deductible before PCIP pays for your health care and prescriptions. After you pay the deductible, you will pay 20% of medical costs in-network for coverage in and out of the hospital, in doctor's offices, x-rays and lab tests, and coverage for prescription drugs. The maximum you will pay out-of-pocket for covered services in a calendar year is $5,950 in-network/$7,000 out-of-network. There is no lifetime maximum or cap on the amount the plan pays for your care.

More information on the PCIP program can be found at

Jacques Chambers, C.L.U., is a Benefits Counselor in private practice with over 35 years experience in health, life and disability insurance and Social Security disability benefits. He can be reached by phone at 323.665.2595, by e-mail at, or through his Web site at

This article was provided by Being Alive. Visit Being Alive's website to find out more about their activities, publications and services.
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