CMS-10334 CMS-10334.DRAFT Federal fallback enrollment form

Instructions for Completing Your Application for the Pre-Existing Condition Insurance Plan in
2011
What is the Pre-Existing Condition Insurance Plan?
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

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.
If I am eligible, when will my coverage start?
If we receive your complete application, including all supporting documents, on or before the
15th of the month, your coverage will start on the first day of the next month. If we receive
your complete application, including all supporting documents, after the 15th of the month and
before the last day of the month, your coverage will start the first day of the second month,
unless you choose to have your coverage start on the first day of the next month. For example,
if we receive your complete application on February 14 and we determine that you are eligible,
your coverage will start on March 1. If we receive your complete application on February 26
and we determine that you are eligible, your coverage will start on April 1, unless you elect to
have your coverage start on March 1. If we approve your application, we will let you know how
to choose an earlier effective date. Coverage always begins on the first day of the month.
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.

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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.
3. Please remember to print your full name on the line located at the top of pages 2, 3, and 4.
4. You must sign and date your application on page 4.
5. Review the Checklist for Submitting Your Application on page 5 to make sure that your
application is complete.
6. The Official Processing Center for the Pre-Existing 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 plan, 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 1-866-7175826 (TTY 1-866-561-1604), or visit www.pcip.gov.

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Application for Coverage in the Pre-Existing Condition Insurance Plan in 2011
Section 1. Information about the Person Applying for Coverage.
Last Name

First Name

Social Security Number
(if you have one)

Gender
Male

Middle
Initial

Female

Maiden Name (if
applicable)

Age

Telephone Number with
Area Code

Date of Birth
(MM/DD/YYYY)

Email Address (if you have
one)

Permanent Address
City

State

ZIP Code

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 PreExisting 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 5 of this form.
Section 4. Information about Your Medical Condition or Diagnosis.
Please check the box that applies to you:

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I have been denied health coverage. 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 have been offered individual health coverage with an exclusionary rider. 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.)
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. (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.)
I am under age 19 or I live in Massachusetts or Vermont and have been offered
individual health coverage for a high premium as described below. 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).)

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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.
1.
2.
3.
4.
5.
6.
7.

Individual or job-based health insurance, including COBRA?
Yes
No
Medicare (Part A and/or Part B)?
Yes
No
Medicaid?
Yes
No
Children’s Health Insurance Program (or CHIP)?
Yes
No
A state high risk pool?
Yes
No
TRICARE (military health insurance)?
Yes
No
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?
Yes
No
8. FEHBP (health insurance for Federal employees or retirees), including Temporary
Continuation of Coverage (TCC)?
Yes
No
9. Health benefit plan provided to Peace Corps workers?
Yes
No
10. Services provided by the Indian Health Service or by a Tribe or Tribal organization for
treating your medical condition?
Yes
No
We also want to know about any health coverage you had in the past year. If you had health
coverage from more than two insurance companies or providers in the past year, 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:
City:
State:
Insurance Company Telephone Number with Area Code:
Employer Name (if coverage was provided by the employer) :

ZIP Code:

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 your insurance company stopped covering dependents.
Because you or someone in your family stopped working full-time and were no longer eligible for benefits.
Because you moved out of the insurance company’s service area.
Other. State the reason your coverage ended:

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:

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City:
State:
Insurance Company Telephone Number with Area Code:
Employer Name (if coverage was provided by the employer) :

ZIP Code:

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 your insurance company stopped covering dependents.
Because you or someone in your family stopped working full-time and were no longer eligible for benefits.
Because you moved out of the insurance company’s service area.
Other. State the reason your coverage ended:

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-ofnetwork 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-ofnetwork 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.

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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

Your Relationship to the Person Applying for Coverage:
Parent
Legal Guardian

ZIP Code

Authorized Representative

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

Internet Article

Healthcare Provider

Coworker or Colleague

Radio

Insurance Company

Mail Solicitation

Television

Insurance Broker

Internet Search

Publication (newspaper, magazine or journal)

Public Event

Other

Section 9. Checklist for Submitting Your Application.

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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, or in a case of a child under
age 19, a copy of a letter from a physician, physician assistant, or nurse practitioner.
(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 I94 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,

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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 09381095. 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.