Risk Pool Denial of Coverage
MRMIP members enrolled in a PPO plan have a 3 month waiting period before they can receive benefits on pre-existing medical conditions. If you enrolled in an HMO plan, there is a post-enrollment waiting period of 3 months in which members will not be eligible for health care services. Basically, this means that you are not covered at all during this period. The exclusionary period may be waived if you were enrolled in another health insurance plan within 63 days of your enrollment in MRMIP and that previous coverage was in effect for at least 3 months. There are other instances in which you may qualify for a waiver of this pre-existing condition exclusion, but you probably would have been made aware of these during enrollment. This information is also available on the MRMIP website at http://www.mrmib.ca.gov/MRMIB/MRMIP.html. There is a very logical reason why state health insurance risk pools place exclusions or waiting periods on pre-existing medical conditions. These state sponsored plans provide insurance to the “uninsurable”, many of whom require medical treatment for severe conditions. The premiums that are collected from plan members are not sufficient to pay the claims of all members, so these state plans are funded by other means. However, funds are limited and if the state does not control the number of claims, these plans would not be available for those who need them. If any person, at anytime, could enroll in the plan and then have their pre-existing conditions immediately treated and paid for, these state plans would not last long. So, they need to place certain regulations that prevent uninsured people from enrolling in the plan only when they require costly medical treatment. No CommentsNo comments yet. Leave a comment |
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I applied for a Blue Cross plan in California and they declined me because I need to have knee replacement surgery. They referred me to MRMIP and I enrolled in that plan. Now, MRMIP is telling me that they aren’t going to cover my knee surgery. I am paying these high premiums, but they aren’t covering anything. Is this right?
During the enrollment process, and upon review of the MRMIP plan brochure, you should have read about how they cover pre-existing medical conditions. Most states that have a Health Insurance Risk Pool have a waiting period on pre-existing medical conditions. California is no exception, but their waiting period is actually less than other states. When your pre-authorization for the knee surgery was denied, you should also have received an explanation as to why, and also information as to when you would be eligible for this procedure.
