CMS-10334.Justification of Non-material Change

The Pre-existing Condition Insurance Program (PCIP) wishes to update its enrollment application effective July 1, 2011 with a non-material change that expands current Section 4 of the enrollment application, which provides 4 options one may chose to prove eligibility for PCIP.  Currently, anyone under age 19 may submit a letter from a physician to document they have a pre-existing condition.  In the interest of increasing program enrollment, Senior Leadership has requested that this requirement be broadened to permit anyone (not just children under 19) to utilize this mechanism to demonstrate the existence of a pre-existing condition. 

This change has been requested by Senior Leadership to make it easier for all individuals to enroll in the PCIP program by simply providing a letter from a doctor, physician assistant, or nurse practitioner dated within the past 12 months stating that they have or, at any time in the past, had a medical condition, disability, or illness.  Applicants will no longer have to wait on an insurance company to send them a denial letter.  This option became available to children under age 19 in February, and this pathway is being extended to all applicants regardless of age.  Applicants will still need to meet other eligibility criteria, including that they are U.S. citizens or residing in the U.S. legally and that they have been without health coverage for six months.

This change does not impact our current burden estimates for completing a PCIP enrollment application because we are not requiring additional proof of a pre-existing condition.  Instead, we are simply allowing all applicants to now take advantage of this option, instead of limiting to applicants under age 19.  Furthermore, given our enrollment numbers are significantly lower than projected we believe this will not impact our original enrollment estimates either. 

Currently Says =

I am under age 19 and my provider has information about my current or prior condition.

I have a letter dated within the past 12 months from a physician (a doctor of medicine or a doctor of osteopathy), physician assistant, or nurse practitioner who is licensed to practice that says that I used to have or presently have a condition.

NOTE: You must provide a copy of a letter signed by the physician, physician assistant, or nurse practitioner that is dated within the past 12 months. This letter must include your name and condition and the name, license number, and state where the license is held of the physician, physician assistant, or nurse practitioner.

Proposed July 1, 2011 Language =

I have a medical condition, disability, or illness, or I had a medical condition, disability, or illness in the past.

NOTE: You must provide a copy of a letter from a doctor, physician assistant, or nurse practitioner dated within the past 12 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.