Pre-existing Condition Insurance Program (PCIP)

The Patient Protection and Affordability Care Act, was enacted on March 23, 2010.

The Health Care and Education Reconciliation Act Public Law 111-152, was enacted on March 30, 2010.

Collectively, these laws are known as the "Affordable Care Act." Section 1101 of the Affordable
Care Act requires that the Secretary of the Department of Health and Human Services (HHS) establish, either directly or through contracts with States or nonprofit private entities, a temporary high risk health insurance program to provide access to coverage for uninsured Americans with pre-existing conditions.

(Hereafter, we generally refer to this program as the Pre-Existing Condition Insurance Plan program, or PCIP program, to avoid confusion with the existing State high risk pool programs, which will continue to operate separately.)

The PCIP program is intended to remain in place from the time of its establishment until the Exchanges established under sections 1311 or 1321 of the Act go into effect on January 1, 2014.

Agency - Department of Health and Human Services

The Department of Health and Human Services is the Federal government's principal agency for protecting the health of all Americans and providing essential human services, especially to those who are least able to help themselves.

Program Accomplishments

Not Applicable.

Uses and Use Restrictions

Please see State PCIP Model Contract.

Please see State PCIP Model Contract
Under the state-run PCIP contracts, HHS shall exercise each of the option years described in paragraph A.2 according to the model contract by giving a preliminary notice of its intent at least 90 days prior to the end of each performance period and a written notice of exercise at least 60 days prior to the end of each performance period to the Contractor.

The 90-day notice will state HHS"s intent to exercise the option, but does not commit HHS to exercising the option.

Eligibility Requirements

Applicant Eligibility

The applicants must meet the terms and conditions outlined in the model contract.

See the State PCIP Model contract at

Beneficiary Eligibility

Eligibility and enrollment rules for the Federal and state-operated PCIP programs can be found at or below as set forth in text from our Interim Final Regulation (IFR).

B. Eligibility and Enrollment (Subpart C, Sec. 152.14 Through Sec.
152.15 of the PCIP IFR (45 CFR Part 152).

Section 1101(d) of the Affordable Care Act provides the basic eligibility criteria for the PCIP program, which are set forth under Sec. 152.14. In addition, consistent with the Secretary"s general authority under section 1101(c)(2)(D) of the Act to establish requirements for a PCIP, we set forth enrollment and disenrollment requirements in Sec. 152.15.

In general, under section 1101(d) of the Affordable Care Act and subparagraphs (1), (2) and (3) of Sec. 152.14(a) of this interim final rule, an individual is eligible to enroll in a PCIP if he or she: (1) Is a citizen or national of the United States or is lawfully present in the United States as determined in accordance with section 1411 of the
Affordable Care Act; (2) has not been covered under creditable coverage, as defined in section 2701(c)(1) of the Public Health Service Act as of the date of enactment, during the 6-month period prior to the date on which he or she is applying for coverage through the PCIP; and (3) has a pre-existing condition, as determined in a manner consistent
with guidance issued by the Secretary. We further provide in Sec. 152.14(a)(4) that an individual must be a resident of a State that falls within the service area of a PCIP. Additional detail found in the IFR.


Applicants should review the OCIIO state model contract issued under this CFDA program for any required proof or certifications which must be submitted prior to or simultaneous with submission of an application package. OMB Circular No. A-87 applies to this program.

Aplication and Award Process

Preapplication Coordination

Preapplication coordination is not applicable.

Environmental impact information is not required for this program.

This program is excluded from coverage under E.O.


Application Procedures

This program is excluded from coverage under OMB Circular No. A-102. This program is excluded from coverage under OMB Circular No. A-110.

Award Procedures

In order to be awarded a state contract to run the Pre-existing Condition Program in an individual state, a state must have submitted a notice of intent to apply, a proposal and model contract criteria approved by HHS.


Jul 01, 2010


Patient Protection and Affordability Care Act, Section 1101.

Range of Approval/Disapproval Time

From 30 to 60 days.


Other - Not Specified.


Other - Not Specified.

Assistance Considerations

Formula and Matching Requirements

Statutory formulas are not applicable to this program.
Matching requirements are not applicable to this program.
This program has MOE requirements, see funding agency for further details. Yes, see State Solicitation at

Length and Time Phasing of Assistance

States have options years through 2013. The funding is proposed to carry the program to 2014, with the last option year of the contract exercised in 2013. See State Model Contract for details. See the following for information on how assistance is awarded/released: Funding is distributed through the Payment Management System to pay for administrative costs and medical claims, monitored by monthly cost-reporting. Please see the State Model Contract for more detail.

Post Assistance Requirements


Please see State Model Contract

Please see State Model Contract

Please see State Model Contract

Please see State Model Contract

Please see State Model Contract


This program is excluded from coverage under OMB Circular No. A-133. .



Financial Information

Account Identification



(Direct Payments for Specified Use) FY 10 $123,266,088; FY 11 $419,148,758; FY 12 Estimate Not Available

Range and Average of Financial Assistance

No Data Available.

Regulations, Guidelines, and Literature

Regulations can be found at: 45 CFR Part 152, Pre-Existing Condition Insurance Plan, Program; Interim Final Rule.

Information Contacts

Regional or Local Office


Headquarters Office

Michelle T. Feagins, 200 Indepence Ave., SW , Washington, District of Columbia 20201 Email: Phone: 301-492-4312

Criteria for Selecting Proposals

See state model contract requirements.

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