Form CMS-10334 PreExistingConditionPlan_EnrollmentForm_508

Instructions for Completing Your Application for

the Pre-Existing Condition Insurance Plan in 2011

What is the Pre-Existing Condition
Insurance Plan?

3. Please remember to print your full name on the
line located at the top of pages 2, 3, and 4.

The Pre-Existing Condition Insurance Plan provides
a new health coverage option to people who meet
these requirements:
• Have been without health coverage for at least
six months,
• Have a pre-existing condition or have been
denied health coverage because of their
health condition,
• Are U.S. citizens or are residing in the
U.S. legally.

4. You must sign and date your application on
page 4.

For a monthly premium, the Pre-Existing Condition
Insurance Plan covers a broad range of health
benefits, including primary and specialty care,
hospital care, and prescription drugs. The Plan
doesn’t charge you a higher premium just because
of your medical condition.
If you are eligible, you will have access to
preventive care (paid at 100%, with no deductible)
when you see an in-network doctor and your
doctor gives a preventive diagnosis. For all other
care, you will pay a separate deductible for
in-network care and out-of-network care, which
varies by your plan option.
Starting in 2011, the Plan offers you three choices:
the Standard Option, the Extended Option, and the
Health Savings Account Option. Be sure to choose
the option that best meets your current or expected
health care needs.

How do I apply?
To apply, you may print and complete a paper
application or apply online at www.pcip.gov/apply.
You can also get a paper application or apply by
calling 1-866-717-5826 (TTY 1-866-561-1604).
1. When filling out this application, print clearly in
blue or black ink.

5. Review the Checklist for Submitting Your
Application on page 6 to make sure that your
application is complete.
6. The Official Processing Center for the PreExisting Condition Insurance Plan is in New
Orleans, Louisiana.
Mail your application and all required

documents to:

National Finance Center
Pre-Existing Condition Insurance Plan
P.O. Box 60017

New Orleans, LA 70160-0017

7. If you are eligible, we will mail you a letter that
includes the amount of your monthly premium
and instructions for making your first premium
payment to complete your enrollment. Do not
send any payment with this application.
8. If you are eligible, you will pay a monthly
premium for a broad range of health benefits,
including primary and specialty care, hospital
care, and prescription drugs. Premiums vary by
state and age.
9. Section 6 asks you to choose one of three
plan options. Please do not rely solely on the
information in this application for benefits
information. More information about each of
these options, including premiums, benefits,
and cost-sharing, is available at
www.pciplan.com.
10. For help completing this application or if you
have any questions, please call 1-866-717-5826
(TTY 1-866-561-1604), or visit www.pcip.gov.

2. You must answer every question on this
application and include copies of any
documents that we require you to send us
with your application. We cannot process
your application unless it is complete. If you
are helping someone fill out this application,
remember to answer the questions about the
person applying for coverage.
Application for Coverage in the Pre-Existing Condition Insurance Plan—INSTRUCTIONS (01/11)

Form Approved
OMB No. 0938-1095

APPLICAtION FOr tHE PrE-ExIStINg CONdItION

INSUrANCE PLAN IN 2011

Section 1: Information about the Person Applying for Coverage.

Last Name

First Name

Middle Maiden Name
Initial
(if applicable)

Age

Social Security Number
(if you have one)

Gender

Telephone Number with
Area Code

Email Address
(if you have one)

State

Zip Code

Male

Female

Date of Birth
(mm/dd/yyyy)

Permanent Address

City

Mailing Address (only if your Mailing Address is different from your Permanent Address)

City

State

Zip Code

Section 2: Information about the State Where You Live.

To be eligible for this coverage, you must live in a state that is served by the Federally-run Pre-Existing
Condition Insurance Plan.
What state do you live in? ________________________________________

Section 3: Information about Your Citizenship or Immigration Status.
Please check one of the following boxes:
I am a citizen of the United States.
You must provide your Social Security Number in Section 1 because you are attesting that you are
a U.S. citizen. We will match your information, including your Social Security Number, with
information in Federal records.
I am a noncitizen national of the United States.
You must provide a copy of a document that confirms your status as a noncitizen national, such
as a copy of a U.S. passport that shows your national status.
I am a noncitizen who is lawfully present in the United States.
You must provide a copy of your immigration document, including a document that has your
Alien Registration Number or I-94 Number, to verify your current immigration status. A list of
acceptable documents is on page 6 of this form.

Application for Coverage in the Pre-Existing Condition Insurance Plan (01/11)

1

H NAmE
Section 4: Information about Your medical Condition or diagnosis.

Please check the box that applies to you:
Because I have a medical condition, I received either a denial letter from an insurance company for
individual insurance coverage (not health insurance offered through a job) in my state that is dated
within the past 12 months, or I received a letter dated within the past 12 months from an insurance
agent or broker licensed in my state that tells me that I am not eligible for individual insurance
coverage from one or more insurance companies because of my medical condition. (You must
provide a copy of the insurance company’s denial letter or a copy of the agent or broker’s letter.)
I received an offer of individual insurance coverage (not health insurance offered through a job)
that I did not accept from an insurance company in my state that is dated within the past
12 months. This offer of coverage has a rider that says my medical condition won’t be covered if I
accept the offer. (You must provide a copy of your offer of coverage with the rider that shows that
your medical condition won’t be covered. Please note that if you currently have insurance coverage
that doesn’t cover your medical condition, you are not eligible for the Pre-Existing Condition
Insurance Plan.)
(APPLICABLE ONLY FOr A CHILd UNdEr AgE 19 Or FOr A PErSON WHO LIvES IN mASSACHUSEttS
Or vErmONt) I have a medical condition, and I received an offer of individual insurance coverage
(not health insurance offered through a job) that I did not accept from an insurance company in
my state that is dated within the past 12 months. This offer of coverage shows a premium that is
at least twice as much as the Pre-Existing Condition Insurance Plan premium (the monthly payment
you make to an insurer to get and keep insurance) for the Standard Option in my state. (You must
provide a copy of the insurance company’s letter showing the premium for the individual coverage
you were offered, but did not accept. To find out if the premium you were offered is twice as much
as the premium in the Pre-Existing Condition Insurance Plan for the Standard Option in your state,
visit www.pcip.gov or call 1-866-717-5826 (ttY 1-866-561-1604.)

Section 5: Information about Your Other Coverage.
To be eligible for this coverage, you must have been without other health coverage for at least
6 months from the date of this application. At any point in the past 6 months, have you had any of
the following types of coverage? You must answer each question.
Yes No
Individual or job-based health plan, including COBRA?

Medicare (Part A and/or Part B)?

Medicaid?

Children’s Health Insurance Program (or CHIP)?

A state high risk pool?

TRICARE (military health insurance)?

Health coverage provided by a public health plan established by a state, the U.S. government

such as coverage provided to veterans enrolled in VA health care, or a foreign country?
FEHBP (health insurance for Federal employees or retirees), including Temporary
Continuation of Coverage (TCC)?
Health benefit plan provided to Peace Corps workers?
Services provided by the Indian Health Service or by a Tribe or Tribal organization for
treating your medical condition?
Application for Coverage in the Pre-Existing Condition Insurance Plan (01/11)

2

H NAmE
We also want to know about any health coverage you had in the past 12 months. If you had health
coverage from more than two insurance companies or providers in the past 12 months, you only need
to identify the two most recent ones. If you did not have coverage, you can leave this section blank.
Name of Insurance Company or Program that Provided Your Health Coverage:

Insurance Company Address:

Insurance Company Telephone Number with Area Code:

City:

State:

Zip Code:

Employer Name (if coverage was provided by the employer):

Coverage Start Date:

Coverage End Date:

Reason Your Health Coverage Ended (Check all that apply):

Because you or someone in your family

lost or left their job.

Because you moved out of the insurance
company’s service area.

Because your insurance company stopped

covering dependents.

Other. State the reason your coverage
ended: ___________________________________

Because you or someone in your family

stopped working full-time and were no

longer eligible for benefits.

__________________________________________

Information for any other health coverage in the past 12 months.
Name of Insurance Company or Program that Provided Your Health Coverage:

Insurance Company Address:

Insurance Company Telephone Number with Area Code:

City:

State:

Zip Code:

Employer Name (if coverage was provided by the employer):

Coverage Start Date:

Coverage End Date:

Reason Your Health Coverage Ended (Check all that apply):
Because you or someone in your family
lost or left their job.

Because you moved out of the insurance
company’s service area.

Because your insurance company stopped

covering dependents.

Other. State the reason your coverage
ended: ___________________________________

Because you or someone in your family

stopped working full-time and were no

longer eligible for benefits.

Application for Coverage in the Pre-Existing Condition Insurance Plan (01/11)

__________________________________________

3

H NAmE
Section 6: Choosing Your 2011 Plan Option.

Please check the box of the plan option you choose. more information about each of these options,
including premiums, benefits, and cost-sharing, is available at www.pciplan.com.
2011 Standard Option. The Standard Option has a $2,000 in-network/$3,000 out-of-network
deductible for medical care and a $500 formulary/$750 non-formulary deductible for prescription
drugs. (Higher Deductible, Lower Premiums)
2011 Extended Option. The Extended Option has a $1,000 in-network/$1,500 out-of-network
deductible for medical care and a $250 formulary/$375 non-formulary deductible for prescription
drugs. (Lowest Deductible, Higher Premiums)
2011 Health Savings Account Option. The Health Savings Account Option has a $2,500 in-network/
$3,000 out-of-network deductible combined for both medical care and prescription drugs. (Highest
Deductible, Lower Premiums)

Section 7: verifying Your Understanding of this Application and Signing It.
1. I understand that my coverage will not begin until (a) this completed application and all required
documents are received and approved, and (b) I am billed for the first month’s premium and my
payment is received and processed.
2. I understand that it is my responsibility to inform the Pre-Existing Condition Insurance Plan of any
changes that may affect my eligibility, including any health insurance coverage that I may get in
the future.
3. I understand that, if I move out of the area served by the Pre-Existing Condition Insurance Plan, I
must notify the Plan so that I can disenroll.
4. I understand that if I voluntarily disenroll from the Pre-Existing Condition Insurance Plan or if I am
disenrolled involuntarily (for example, for failure to pay my premium on time), I may not re-apply
for enrollment until at least 6 months after my coverage ends.
5. I understand and agree to the release of the information on this application to the United
States Department of Agriculture’s National Finance Center, other Federal agencies, and Federal
contractors to determine my eligibility and enroll me in the Pre-Existing Condition Insurance Plan.
6. I understand that, by signing below, I certify that all information and documents provided as part
of this application for coverage are complete, accurate, and true to the best of my knowledge. I
understand that, if this application has intentional material misstatements or omissions, the
Pre-Existing Condition Insurance Plan may, during the first 2 years of my enrollment, (a) cancel my
enrollment as though it were never effective and refund my premiums, less any claims that were
paid on my behalf, and/or (b) take any other action available by law.
Signature

Today’s Date

If you are a parent or legal guardian or an authorized representative of the person applying for
coverage, you must sign above and provide the following information:
Full Name

Telephone Number with Area Code

Mailing Address
City

State

Zip Code

Check Your relationship to the Person Applying for Coverage:
Parent

Authorized Representative

Application for Coverage in the Pre-Existing Condition Insurance Plan (01/11)

Legal Guardian
4

Section 8: How You Heard about the Pre-Existing Condition Insurance
Plan (Optional).
Please tell us how you heard about the Pre-Existing Condition Insurance Plan (Check all that apply).
Completing this section of the application is optional.
Family Member or Friend
Coworker or Colleague
Mail Solicitation
Internet Search
Internet Article
Radio
Television
Publication (newspaper, magazine or journal)
Healthcare Provider
Insurance Company
Insurance Broker
Public Event
Other

Application for Coverage in the Pre-Existing Condition Insurance Plan (01/11)

5

Section 9: Checklist for Submitting Your Application.

I have completed this entire application and have answered every question.
I have signed and dated this application.
I have included with this application a copy of an insurance company’s denial letter, a copy of an
insurance agent or broker’s letter, or a copy of an insurance company’s letter offering coverage
with a rider. Or, if applicable, I have included a copy of a letter from an insurance company
showing the premium quote I was offered for coverage.
(U.S. Citizens Only) I have provided my Social Security Number.
(U.S. Noncitizen Nationals Only) I have included a copy of a document that confirms my status as a
noncitizen national, such as a copy of a U.S. passport that shows my national status.
(Noncitizens Only) I have included a copy of my immigration documents, including at least one

that has my Alien Registration Number or I-94 Number that will be used to verify my status.

I have provided a copy of:

I-327 (Reentry Permit)

I-551 (Permanent Resident Card)

I-571 (Refugee Travel Document)

I-766 (Employment Authorization Document)

Machine Readable Immigrant Visa (with Temporary I-551 Language) affixed to

Unexpired Foreign Passport
Temporary I-551 Stamp (on passport or I-94) affixed to I-94 or Unexpired Foreign Passport
I-94 (Arrival/Departure Record) with Unexpired Foreign Passport
Unexpired Foreign Passport for Visa Waiver Program travelers
I-20 (Certificate of Eligibility for Nonimmigrant (F-1) Student Status) accompanied by I-94 and
an Unexpired Foreign Passport
DS2019 (Certificate of Eligibility for Exchange Visitor (J-1) Status) accompanied by I-94 and an
Unexpired Foreign Passport
Other Document with an I-94 or Alien Number

PrIvACY ACt ANd PAPErWOrK rEdUCtION NOtICE
Section 1101 of the Patient Protection and Affordable Care Act, Public Law 111-148, authorizes the collection of information
on this form. The information you provide will allow the United States Department of Health and Human Services through
the United States Department of Agriculture’s National Finance Center to determine if you are eligible for the Pre-Existing
Condition Insurance Plan. We are required to ask for your Social Security Number if you attest that you are a U.S. citizen.
We match your information, including your Social Security Number, against Federal records, such as those maintained by the
Social Security Administration. We perform this match by computer to confirm your information and verify whether you are
eligible for the Pre-Existing Condition Insurance Plan. Only individuals who are citizens or nationals of the United States or
are otherwise lawfully present in the United States are eligible for this program. If you do not provide this information, we
will not be able to make a decision on your application.
Paperwork reduction Act Statement. This information collection meets the requirements of 44 United States Code §3507,
as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we
display a valid Office of Management and Budget control number. The valid OMB control number for this information
collection is 0938- 1095. We estimate that it will take about 1 hour to read the instructions, gather the facts, and answer
the questions. You may send comments on our time estimate to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Send only comments relating to our time estimate to this
address, not your application form.
Application for Coverage in the Pre-Existing Condition Insurance Plan (01/11)

6