For a Sister with Cancer, “Pre-existing” No Longer Needs to Mean “Uninsurable”

Dear Cheasty-

My sister is 45 and had no insurance through her job (she is a Licensed Social Worker, has worked for MHMR for years) and was recently diagnosed with Stage IV Gastric Cancer. Her bills for diagnosis and surgery have probably topped $150K so far; she is on her 2nd round of chemo. She had enough leave time that she got her last paycheck this month; so she won’t qualify for Medicaid until she can show only her husband’s income. I have read about a high-risk insurance pool, but no one has been able to tell her about it. Would that be an option for her?

Thank you so much –
Hurting Sister

Dear Hurting Sister,

In the first place, let me just say how sorry I am that your sister and your whole family is going through such a difficult experience. As it stands, our current health insurance system is terrible at helping people who are actually sick, and often only adds stress and pain to any health crisis.

The good news is that your sister is likely an ideal candidate for the Pre-existing Condition Insurance Plan (PCIP), also known as a high risk pool.  Here’s how it works:

The PCIP accepts individuals who have fallen through the proverbial cracks (as long as they meet certain basic criteria). Those of us with pre-existing conditions who don’t have insurance through our employer are often “uninsurable” according to the insurance industry because of those conditions. And those conditions can range from cancer to depression to – check this one out – being an expectant parent, whether you’re the mother or the father!

In 2014 this will change, and all of us will be insurable, thanks to the Affordable Care Act. In the meanwhile, you are eligible for PCIP if you meet the following criteria:

  • You must be a citizen or national of the United States or reside in the U.S. legally.
  • You must have a pre-existing condition or have been denied coverage because of your health condition.
  • You must have been without health coverage for the last six months or more, prior to enrolling.
    • Please note: if you currently have insurance that does not cover your condition, or if you are currently enrolled in a state high risk pool, you are not immediately eligible for PCIP. To be eligible for PCIP you must be without health coverage for a period of six months prior to enrolling.

If you fit the above description, click here to enroll in the PCIP either online, by phone, or by mail.

Hurting, I assume your sister fits the first and second criteria, but I’m not sure about the third one. If she previously had insurance through her husband’s job, or if she used to purchase her own insurance but has recently been dropped from the plan, there may be a waiting period before she qualifies for the PCIP. I hope for her sake that she qualifies immediately.

If for some reason your sister does not qualify for PCIP, she can also try the state high risk pool. Unlike the PCIP, the state high risk pool has no 6-month uninsured requirement.  It can be prohibitively expensive for many as the monthly premiums are double the PCIP rates.  Nonetheless, expensive insurance is often better than no insurance at all.

To explore the state high risk pool as an option, you can visit www.texhealthpool.org for enrollment instructions.

Best wishes to your sister for a full recovery, HS, and please keep me posted on her insurance status.  Keep in mind, too, that with full implementation of the ACA in 2014, nobody will ever be in your sister’s position again, because no insurance company will ever be able to deny coverage (or even charge more for insurance!) based on pre-existing conditions.

To a well and healthy Texas,
Cheasty Anderson

Posted in The Texas Treatment|Tagged , , , , |

2 responses to “For a Sister with Cancer, “Pre-existing” No Longer Needs to Mean “Uninsurable””

  1. Rebecca says:

    thank you so much! Unfortunately, she had bought some kind of cheap policy last fall thinking she would go ahead to avoid the future penalty for not having any insurance. It pays total of $1500 on hospital, and doesn’t cover cancer! Looks like getting bad insurance has turned out worse than having no insurance in this case…
    thanks again for the information. Will follow this blog regularly now, people are so full of mis-information.

    • Cheasty says:

      Oh, that’s terrible news. Well, in 6 months from whenever your sister dropped the policy, she will qualify for PCIP. If she can’t afford to go 6 months with no insurance (though effectively she already is), then I advise she pursue the state high risk pool option described above. Best of luck to you all.

Leave a Reply

To reduce spam, please complete the equation. *