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California Risk Pool - Health Insurance Provided for the Uninsurable

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Acronym or name of the risk pool: MRMIP or Major Risk Medical Insurance Program.

Regulation establishing risk pool: California Assembly under assembly bill no.1401. This provides an amendment to the original MRMIP legislation.

Funding: The funds operating the MRMIP are primarily from the premium payments made by members of the plan. The deficits incurred are made up for by the subsidy from the Cigarette and Tobacco Surtax Funds provided under proposition 99.

Plans offered: Under this pool, health insurance coverage is provided for a maximum of 36 months. Both HMO and PPO type plans are available. The PPO plan is the Blue Cross of California preferred PPO plan. It is managed by Blue Cross of California. Many companies offer the HMO type of plans including Blue Shield of California, Kaiser Permanente and Contra Costa Health Plan.

Plan Benefits: No deductible for the PPO plan from BlueCross of CA (BCCA) and for many covered medical expenses, get 15% coinsurance. Office visits are valued $25 co-pay and for prescription drugs, no deductible is available. The yearly co-pay is maximum of $2,500 for this plan. Two plans, "Access +" from Blue Shield of California and "HMO's" from Contra Costa Health Plan, offer $200 as a hospitalization co-pay and a $15 as a office visit co-pay on per day basis. The HMO Plan, offer through Kaiser Permanente has a office visit co-paymant of $20.

MRMIP brochure: http://www.mrmib.ca.gov/MRMIB/MRMIPBRO.pdf

Maximum benefit limits: Plans offered through the MRMIP have annual maximum benefit levels of $75000.

Eligibility: (1) The person must be a resident of California. (2) He cannot be eligible for Medicare plans A or B unless on the end stages of a renal disease and on Medicare. The concerned person cannot be eligible for coverage under COBRA or (CALCOBRA). (3) The person cannot obtain any other insurance. This has to be verified by a letter stating that the said person was terminated as a member of a plan on an involuntary basis. This has to be within period of 12 months preceding the application. Proof also has to be provided than the person was offered a similar insurance plan at higher premiums than the one offered by MRMIP.

Enrollment periods: It is one of the few states with a cap on enrollments in their risk pool. Previously, before the guaranteed issue pilot programme, there was a long waiting list to get on the programme.GIP reduced the maximum time for an enrolment to 36 months. In this way, the plan was made easier to enroll in as the current members had to leave before new members could be entered. The number of new members allowed is restricted. However, no limitations are placed on when the application can be made.

Premium payments: Your plan, age and county determine the premiums you have to pay. They are due on the first of every month and are paid in advance for the next month of coverage. A grace period of 31 days is allowed after which the covers are terminated because of non- payment of premiums.

Premium calculations: The board decides on the monthly premiums and it is usually restricted to 137.5% of the standard risk rate. This refers to other benefits that Californians can obtain from private health insurance providers. The minimum rate is 125% of the standard rates.

Pre existing condition waiting period: Members who enroll for a PPO type plan have to wait for 3 months as a pre existing condition clause. During this time, no benefits are paid for the treatments or medications associated with this condition. Under HMO plans, the post enrollment period is of 3 months. During this time, members are not allowed to receive any benefits. The waiting condition is waived under certain conditions. (a) If the person concerned was on the waitlist of the MRMIP for more than 180 days. (b) The person was enrolled in another plan within the preceding 63 days of application. (c) The person was a member of a group insurance policy and the covers were he enrolled for MRMIP within 180 days of termination of the last cover. (d) The person was a member of another similar risk pool group in another state within the last 12 months.

Contact information: Managed Risk Medical Insurance Board, 1000 G Street, Suite 450, Sacramento, CA 95814, Phone: 916-324-4695, Fax: 916-324-4878. MRMIP Website.

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