California has a risk pool program called the Major Risk Medical Insurance Program (MRMIP). MRMIP offers health coverage for people with pre-existing health conditions who have trouble obtaining individual insurance coverage.

When can I get coverage from MRMIP?

· If you are “uninsurable” you can buy coverage from MRMIP. You are considered uninsurable if you were turned down for coverage within the last 12 months by an insurer or HMO because of your health. In addition, if you were offered individual health insurance that is considered by MRMIP to be inadequate to cover you medical needs, such as a policy that excludes or limits coverage for your pre-existing health condition, or if you were offered individual insurance that is more expensive than MRMIP, you are considered uninsurable.

In addition, you may be able to get MRMIP coverage if you have been involuntarily terminated from health insurance coverage within the 12 months for reasons other than nonpayment of premium or fraud.

· You can also buy coverage from MRMIP if you have moved to California from another state’s high risk pool as long as complete application is received within 62 days of losing the prior coverage.

· MRMIP offers both individual and family policies, so dependents are also eligible for coverage under the high risk pool.

· To be eligible for MRMIP, you must be a California resident and not be eligible for employer-sponsored group health plan, including COBRA and CalCOBRA, or Medicare (unless on Medicare solely because of end-stage renal disease).

What will MRMIP coverage cover?

· MRMIP coverage includes hospital and physician care, maternity services, prescription drugs, treatment for serious mental health illness, and other services. HMO and PPO plans are available from the different companies that participate in the program. For all plans, you must satisfy a $500 deductible. In addition, although co-payment requirements vary depending on the plan and service provided, all MRMIP plans have an out-of-pocket maximum of $2,500 for individuals and $4,000 for families. MRMIP plans will pay up to $75,000 in benefits per calendar year and $750,000 in a lifetime.

What about coverage for my pre-existing condition?

· When you first enroll, MRMIP will look back 6 months to see if you had a condition for which medical advice, diagnosis, care, or treatment, including use of prescription drugs, was recommended or received by a licensed health practitioner.

· For individuals enrolled in a PPO plan, there is a pre-existing condition exclusion period of 90 days. For individuals enrolled in an HMO plan, there is an affiliation period of 90 days. During this time you will not be eligible for health care services and you will not be charged any premium in addition to the premium you submitted with your MRMIP application. At the end of the 90 days, your pre-existing conditions will be covered.

· In some circumstances, your pre-existing condition exclusion period or your affiliation period may be waived if you had prior health insurance. Call MRMIP to see if you are eligible for a pre-existing condition exclusion period waiver.

What can I be charged for MRMIP coverage?

· Premiums will vary based on the health plan you choose, your age, your family size and where you live.

For example, a 24-year old single person in Sacramento would pay $695 per month for a Blue Shield HMO plan and $275 for the Kaiser plan. A 60-year old with one dependent in Sacramento would pay $3,486 per month for a Blue Shield HMO plan and $1,258 for the Kaiser plan.

Please note that premium may have changed since this guide was written, so contact MRMIP for the most current information.

How long does MRMIP coverage last?

· MRMIP policies are renewable as long as you pay your premiums, continue to reside in California and meet other eligibility requirements. If you commit fraud against MRMIP or become eligible for Medicare (unless eligible solely because of end-state renal disease), you will be allowed to continue in MRMIP.