Thursday, August 19, 2010

About That PCIP Coverage . . .

[Welcome Kaiser Health News readers!]

A new site is up giving more information on PCIP, the Obamapool for those who cannot obtain health insurance and can prove it. This site has been established by the administrator of the taxpayer funded health insurance plan for those who are otherwise uninsurable in the private market.

To participate in PCIP, you must have a pre-existing medical condition that precludes you from obtaining medically underwritten health insurance. You must have a denial letter from a health insurance company that proves you are uninsurable and, you must not have had health insurance in the last 6 months. If you have health insurance, such as Medicaid or COBRA, and are losing those benefits you must go without coverage for 6 months before you can apply for PCIP.

So how good is this Obamapool plan any way?

The benefits summary details the following:

  • No benefits are payable until AFTER you have satisfied a $2500 deductible

  • Your annual physical exam is the exception and is not subject to the deductible

  • In network doctor visits are $25 (after the deductible)

  • Out of network doctor visits require you to pay 40% of the billed rate

  • Generic drugs are $4 after the $2500 deductible for the first 2 fills, afterward you pay 50%

  • Formulary brand drugs are $30 after the $2500 deductible for the first 2 fills, afterward you pay 50%

  • Non-formulary brand drugs are $50 after the $2500 deductible for the first 2 fills, afterward you pay 100%

More details are available in the 76 page plan document.

Let's say you want to find a participating provider in your area. The site provides this handy link to locate doctors, hospitals and other medical providers who participate in PCIP.

I live in a large, metro area (Atlanta) and can easily find 300+ doctors and over two dozen hospitals within 10 miles of my home. These are doctors that participate in networks for Aetna, Blue Cross, Cigna, Humana, etc. So how does PCIP compare?

A quick search on their site turned up 13 general practice doctors who are willing to treat PCIP patients. Interesting that there are 65 psychiatrists willing to treat PCIP patients but only 13 GP's. If my wife needed an obstetrician she can pick from Dr. Schaefer or Dr. Schaefer (he has 2 offices). Cardiologists? There are 100. Oncologists? You can pick from 26.

How about hospitals? Only 4 within 10 miles of my home who are willing to treat PCIP patients and none of them have a labor and delivery room.

To recap, if you want Obamapool coverage you must be uninsured for at least 6 months before you can apply, even if you were on Medicaid and lost that coverage. Once you are approved, you are responsible for the first $2500 of all medical charges before the plan pays anything. This includes prescription drugs.

If you are taking anything other than a generic drug you will be responsible for paying 50% or more of the cost of the drug if you get it filled more than twice after satisfying your deductible. Consider that some cancer drugs (most of which are not generic nor are they on a formulary) can run anywhere from $400 to $8,000 per month.

You also need to try and find a doctor that will treat you and heaven help you if you need to schedule a hospital stay.

Smaller cars, bigger health insurance headaches, Poppa Washington.

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