California Major Risk Medical Insurance Program Overview and Requirements

The California Major Risk Medical Insurance Program is a vital resource for individuals and families who need medical coverage but have been declined by other insurance companies. This program is designed to provide affordable health insurance to those who are considered high-risk due to pre-existing medical conditions.

To be eligible for the program, applicants must first be declined by at least two other insurance companies. This ensures that only those who truly need the program's benefits will be accepted.

The California Major Risk Medical Insurance Program (MRMIP) was originally developed to provide health insurance for Californians who were unable to obtain coverage in the individual market.

This program delivers its services through contracts with health insurance plans, which means you'll be working with a plan that's been vetted and approved by the state.

MRMIP subscribers participate in the payment for cost of their coverage by paying subscriber contributions, an annual deductible, and copayments.

These costs are essential to making the program work, as they help to ensure that everyone contributes to the overall cost of care.

MRMIP supplements subscriber contributions to cover the cost of care, providing an added layer of financial support when you need it most.

The program is funded annually by tobacco tax funds, which helps to keep costs low and accessible for those who need it most.

To be eligible for the PCIP, you must be a U.S. citizen, U.S. national, or lawfully present, with a Social Security Number and California residency. You also cannot have had health insurance in the last six months prior to application.

No health insurance coverage in the last six months prior to application is a key requirement, and you must not be enrolled in Medicare Part A & Part B, or COBRA or Cal-COBRA benefits.

To apply for the PCIP, you must provide evidence of a rejection letter from a health insurance company in the last 12 months, or that the premium cost of available insurance is higher than the cost of the MRMIP PPO in your geographic region.

Here are the specific requirements for eligibility and application:

You will need to provide proof of pre-existing condition, proof of US Citizenship, and other required documents with your application. You can find the handbooks, instructions, and required forms on California’s PCIP website.

To be eligible for the Pre-existing Condition Insurance Plan (PCIP) in California, you must satisfy several requirements. You must be a U.S. Citizen, U.S. National, or lawfully present, and have a Social Security Number. You also need to be a resident of California.

You cannot have had health insurance coverage in the last six months prior to application. Additionally, you cannot be enrolled in Medicare Part A & Part B, or COBRA or Cal-COBRA benefits.

To provide evidence of a pre-existing condition, you must have a rejection letter from a health insurance company in the last 12 months, or the premium cost of available insurance must be higher than the cost of the MRMIP preferred provider organization (PPO) in your geographic region.

Medi-Cal is a medical coverage program that provides benefits to people who meet specific disability standards and financial guidelines. It's based on the same standards as Social Security recipients.

To be eligible for Medi-Cal, you may qualify through Supplemental Security Income (SSI), which provides automatic medical coverage once you receive $1 or more of SSI income.

Aged and Disabled Medi-Cal is another option, which requires you to apply and have a disability income above SSI limits but not greater than $966 for a single person, or $1,298 for a couple.

Medically Needy Medi-Cal is also available, which requires a monthly co-payment called "Share of Cost" if your disability income is above $966 for a single person or $1,298 for a couple. The "Share of Cost" is your disability income in excess of $620 for a single person or $954 for a couple.

To apply for Aged and Disabled or Medically Needy Medi-Cal, you'll need to contact your local County Medical Office, listed under the county Department of Human or Social Services.

You're allowed to have up to $2,000 in assets, excluding a home if you live in it and a car valued at no greater than $4,500, unless used for medical appointments.

Cal-COBRA is a state law that requires employers with more than two and less than 20 employees to allow employees the right to continue health insurance benefits for 18 months after their employment ends for any reason, excluding gross misconduct.

You're responsible for paying 110 percent of the total health insurance premium for the first 18 months.

If you have a Social Security approved disability, you can extend coverage for an additional 11 months, but you'll need to pay 150 percent of the total premium.

If you're denied coverage under the California Major Risk Medical Insurance Program, don't worry, there's a process to appeal the decision.

You have 30 days from the date on your eligibility decision letter to submit your appeal in writing. The PCIP cannot review a decision over the phone.

You can submit your appeal by sending a letter to the PCIP explaining the factual reason why you think their decision is wrong. This must be done in writing, with your Member Number on every document.

To make the process smoother, you can also download the Appeals Form from the PCIP website. This will give you a clear format to include any additional information that might be helpful in their review.

Remember to include your Member Number on every document you send to the PCIP.