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Government Eases Eligibility Requirement for Children in PCIP

To address concerns that insurance companies were ceasing to offer child-only individual insurance plans, rather than be forced to guarantee issue to children with pre-existing conditions, the government issued a policy guidance on February 17 reaffirming that children under the age of 19 would be eligible for the government-sponsored Pre-existing Condition Insurance Plan (PCIP).  The PCIP program is similar to high-risk pools available in many states, but is designed to cost the same as the average private insurance plan.

In the past, to be eligible for the PCIP, typically a person had to prove that he or she was denied coverage by a private insurer, or was offered coverage at a price that was twice the standard market rate.  If an insurer stopped offering child-only individual plans, it was not considered denial of coverage, and the policy holder was not normally eligible for the PCIP.  Now, the Department of Health and Human Services (HHS), which oversees the PCIP, has changed its eligibility requirements for children.  Patients under 19 only need a signed statement from a healthcare provider affirming that they have been diagnosed with a pre-existing condition.

"In its role in the federally-administered PCIP, HHS is acting to make sure that the PCIP program remains a viable coverage option for children that may be unable to obtain a denial letter from an issuer," the guidance stated. The federal government is administering PCIP in 23 states and the District of Columbia; 27 other states are operating PCIP programs directly.  PCIP was created by the Patient Protection and Affordable Care Act (PPACA) to provide health insurance to uninsured people with medical conditions until 2014, when insurers must cover everyone without charging more for such conditions.  A total of $5 billion was appropriated under PPACA for the program.  Health insurance coverage for people with pre-existing conditions is available at the same monthly premium rate as that for an average person without health problems. 

The full guidance letter is available here:  Information on the Pre-existing Condition Insurance Plan is available at:



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