California Risk Pool - Health Insurance for the Uninsurable
Risk Pool Name / Acronym
Major Risk Medical Insurance Program/ MRMIP
Insurance Regulation Establishing Risk Pool
California Assembly
Assembly Bill No. 1401; Amends Original MRMIP Legislation
Major Risk Medical Insurance Program (MRMIP)
The state of California offers a high-risk pool program, MRMIP, for residents with pre-existing conditions who are unable to find health insurance through a private insurance company.
A California resident would be eligible for this risk pool provided he is not eligible for COBRA, CalCOBRA, HIPAA, or Medicaid/Medicare, his most recent coverage was not terminated due to nonpayment of premiums or fraud and he does not have other health insurance coverage. However, it is important to note that the California MRMIP does not provide coverage to the residents who are eligible under the Health Coverage Tax Credit federal program as well as HIPAA-eligible individuals who have exhausted their coverage options in the group market.
Funding
Funds to operate MRMIP come partially from premium payments made by plan members. The deficit incurred by the pool is subsidized through the Cigarette and Tobacco Surtax Fund established under Proposition 99.
Plans Offered
Health insurance coverage under the MRMIP is available for a maximum of 36 months. There is an HMO plan option available, as well as a PPO plan. The Anthem Blue Cross of California Preferred PPO plan and is administered by Anthem Blue Cross of California. The HMO plan is available through various insurance companies, including Blue Shield of California, Contra Costa Health Plan, and Kaiser Permanente. After the 36 months of MRMIP enrollment, guaranteed issue coverage is available through these same insurance companies at a slightly higher monthly premium.
Plan Benefits
The Anthem Blue Cross of California PPO plan has a $500 annual deductible and a 15% coinsurance for many covered medical expenses. Office visits are provided at a $25 co-payment and there is no deductible for prescription drugs. Once you reach your annual maximum coinsurance/copayment limit, Anthem Blue Cross pays 100% of the cost for in-network, covered services for the rest of the year. Blue Shieldâs Access+ HMO Plan is available to MRMIP subscribers in select counties only.The Blue Shield of California Access + HMO and the Contra Costa Health Plan HMO both offer a $15 office visit co-payment and a $200 per day hospitalization co-payment. The HMO Plan offered through Kaiser Permanente has a $20 office visit co-pay and $200 per day hospitalization co-payment.
The maximum out-of-pocket costs per calendar year for all MRMIP plans are $2,500 for individuals and $4,000 for an entire household covered by the MRMIP. This maximum amount does not apply to services offered outside the subscriber's plan or services not covered by the MRMIP.
Maximum Benefit Limits
All plans offered through MRMIP plan have an annual maximum benefit of $75,000 and a lifetime benefit of $750,000.
Eligibility
- Must be a resident of California
- Cannot be eligible for Medicare Part A and Part B unless you are on Medicare for end-stage renal disease
- You must be ineligible to purchase health insurance under COBRA or CalCOBRA
- You must not be able to obtain other adequate health insurance within the previous 12 months , which must be verified by; a) a letter of denial from an insurance company within the past 12 months, b) a letter proving that you were involuntarily terminated from another health plan within the past 12 months, or c) proof that you have been offered other individual health insurance at a higher premium than those available to you through MRMIP
Enrollment Periods
California is one of the few states that place a cap on enrollment in their health insurance risk pool due to funding limitations. If the MRMIP reaches maximum enrollment, applicants and dependents will be placed on a waiting list. Prior to the implementation of the Guaranteed Issue Pilot Program, there was a lengthy waiting list to get on to the MRMIP program. GIP reduced the maximum length of enrollment to 36 months, thus opening the plan to new members by requiring current members to leave the plan and enroll in any private health insurance company. A limited number of new members are permitted on the plan, but there are no restrictions on when you can apply for coverage.
While on the waiting list, applicants may purchase coverage through a MRMIP look-alike plan from the Anthem Blue Cross of California or Blue Shield of California, two of the health plans participating in MRMIP. However, since the two insurers provide unsubsidized MRMIP look-alike plans, the premium are quite higher than the regular MRMIP plans.
Premium Payments
Premiums are based on your plan selection, your age and your county of residence. Premium payments are made in advance of the month of coverage and are due on the first of the month. There is a 31-day grace period for payment before your policy can be cancelled for non-payment of premium.
Premium Calculations
Monthly premiums are determined by looking at the standard risk premiums available for plans of similar benefit levels available to healthy individuals in California. MRMIP plan premiums may not be higher than 137.5% of the standard risk, and no lower than 125% of this same standard rate.
Pre-Existing Condition Waiting Periods
MRMIP members enrolled in a PPO plan have a 3 month pre-existing condition exclusionary period. During this period, no benefits are paid toward any medical treatments or medications associated with this pre-existing condition. If you enroll on a HMO plan, there is a post-enrollment waiting period of 3 months in which members will not be eligible for health care services. The exclusionary period for the pre-existing condition may be waived if, a) you were on the MRMIP waiting list for longer than 180 days, b) 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, c) you lost your group health insurance policy and enrolled in MRMIP within 180 days of losing coverage, or d) you were on a similar high risk pool health insurance plan in another state within the past 12 months.
California Major Risk Medical Insurance Program Contact Information
Managed Major Risk Medical Insurance Board
PO Box 2769
Sacramento, CA 95812
Phone: 916-324-4695, 800-289-6574
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