PART 152—PRE-EXISTING CONDITION INSURANCE PLAN PROGRAM Authority: Sec. 1101 of the Patient Protection and Affordable Care Act (Pub. L. 111-148). Source: 75 FR 45029, July 30, 2010, unless otherwise noted. Subpart A—General Provisions § 152.1 Statutory basis. (a) Basis. (b) Scope. § 152.2 Definitions. For purposes of this part the following definitions apply: Creditable coverage Enrollee Lawfully present Out-of-pocket costs Pre-Existing condition exclusion Pre-Existing Condition Insurance Plan (PCIP) Resident Service Area State [75 FR 45029, July 30, 2010, as amended at 77 FR 52616, Aug. 30, 2012; 89 FR 39436, May 8, 2024] Subpart B—PCIP Program Administration § 152.6 Program administration. (a) General rule. (b) Administration by State. (1) At the Secretary's discretion, a State may designate a nonprofit entity or entities to contract with HHS to administer a PCIP. (2) As part of its administrative approach, a State or designated entity may subcontract with either a for-profit or nonprofit entity. (c) Administration by HHS. (d) Transition in administration. § 152.7 PCIP proposal process. (a) General. (b) Special rules for transitions in administration. (2) A State's proposal to administer a PCIP must meet all the requirements of this section. (3) Transitions from State administration to HHS administration must comply with the termination procedures of the PCIP contract in effect with the State or its designated entity. (4) The Secretary may establish other requirements needed to ensure a seamless transition of coverage for all existing enrollees. Subpart C—Eligibility and Enrollment § 152.14 Eligibility. (a) General rule. (1) Is a citizen or national of the United States or lawfully present in the United States; (2) Subject to paragraph (b) of this section, has not been covered under creditable coverage for a continuous 6-month period of time prior to the date on which such individual is applying for PCIP; (3) Has a pre-existing condition as established under paragraph (c) of this section; and (4) Is a resident of one of the 50 States or the District of Columbia which constitutes or is within the service area of the PCIP. A PCIP may not establish any standards with regard to the duration of residency in the PCIP service area. (b) Satisfaction of 6-month creditable coverage requirement when an enrollee leaves the PCIP service area. (c) Pre-existing condition requirement. (1) Refusal of coverage. (2) Exclusion of coverage. (3) Medical or health condition. (4) Other. § 152.15 Enrollment and disenrollment process. (a) Enrollment process. (2) A PCIP must allow an individual to remain enrolled in the PCIP unless: (i) The individual is disenrolled under paragraph (b) of this section; (ii) The individual obtains other creditable coverage; (iii) The PCIP program terminates, or is terminated; or (iv) As specified by the PCIP program and approved by HHS. (3) A PCIP must verify that an individual is a United States citizen or national or lawfully present in the United States by: (i) Verifying the individual's citizenship, nationality, or lawful presence with the Commissioner of Security or Secretary of Homeland Security as applicable; or (ii) By requiring the individual to provide documentation which establishes the individual's citizenship, nationality, or lawful presence. (iii) The PCIP must provide an individual who is applying to enroll in the PCIP with a disclosure specifying if the information will be shared with the Department of Health and Human Services, Social Security Administration, and if necessary, Department of Homeland Security for purposes of establishing eligibility. (b) Disenrollment process. (2) A PCIP may disenroll an individual if the monthly premium is not paid on a timely basis, following notice and a reasonable grace period, not to exceed 61 days from when payment is due, as defined by the PCIP and approved by HHS. (3) A PCIP must disenroll an individual in any of the following circumstances: (i) The individual no longer resides in the PCIP service area. (ii) The individual obtains other creditable coverage. (iii) Death of the individual. (iv) Other exceptional circumstances established by HHS. (c) Effective dates. (d) Funding limitation. Subpart D—Benefits § 152.19 Covered benefits. (a) Required benefits. (1) Hospital inpatient services (2) Hospital outpatient services (3) Mental health and substance abuse services (4) Professional services for the diagnosis or treatment of injury, illness, or condition (5) Non-custodial skilled nursing services (6) Home health services (7) Durable medical equipment and supplies (8) Diagnostic x-rays and laboratory tests (9) Physical therapy services (occupational therapy, physical therapy, speech therapy) (10) Hospice (11) Emergency services, consistent with § 152.22(b), and ambulance services (12) Prescription drugs (13) Preventive care (14) Maternity care (b) Excluded services. (1) Cosmetic surgery or other treatment for cosmetic purposes except to restore bodily function or correct deformity resulting from disease. (2) Custodial care except for hospice care associated with the palliation of terminal illness. (3) In vitro fertilization, artificial insemination or any other artificial means used to cause pregnancy. (4) Abortion services except when the life of the woman would be endangered or when the pregnancy is the result of an act of rape or incest. (5) Experimental care except as part of an FDA-approved clinical trial. § 152.20 Prohibitions on pre-existing condition exclusions and waiting periods. (a) Pre-existing condition exclusions. (b) Waiting periods. § 152.21 Premiums and cost-sharing. (a) Limitation on enrollee premiums. (2) Premiums charged to enrollees in the PCIP may vary on the basis of age by a factor not greater than 4 to 1. (b) Limitation on enrollee costs. (2) The out-of-pocket limit of coverage for cost-sharing for covered services under the PCIP may not be greater than the applicable amount described in section 223(c)(2) of the Internal Revenue code of 1986 for the year involved. If the plan uses a network of providers, this limit may be applied only for in-network providers, consistent with the terms of PCIP benefit package. (c) Prohibition on balance billing in the PCIP administered by HHS. [75 FR 45029, July 30, 2010, as amended at 78 FR 30226, May 22, 2013] § 152.22 Access to services. (a) General rule. (b) Emergency services. (1) The enrollee had a reasonable concern that failure to obtain immediate treatment could present a serious risk to his or her life or health; and (2) The services were required to assess whether a condition requiring immediate treatment exists, or to provide such immediate treatment where warranted. Subpart E—Oversight § 152.26 Appeals procedures. (a) General. (b) Minimum requirements. (1) A potential enrollee with the right to a timely redetermination by the PCIP or its designee of a determination regarding PCIP eligibility, including a determination of whether the individual is a citizen or national of the United States, or is lawfully present in the United States. (2) An enrollee with the right to a timely redetermination by the PCIP or its designee of a determination regarding the coverage of a service or the amount paid by the PCIP for a service. (3) An enrollee with the right to a timely reconsideration of a redetermination made under paragraph (b)(2) of this section by an entity independent of the PCIP. § 152.27 Fraud, waste, and abuse. (a) Procedures. (b) Cooperation. § 152.28 Preventing insurer dumping. (a) General rule. (b) Procedures and criteria for a determination of dumping. (1) Situations where an enrollee or potential enrollee had prior coverage obtained through a group health plan or issuer, and the individual was provided financial consideration or other rewards for disenrolling from their coverage, or disincentives for remaining enrolled. (2) Situations where enrollees or potential enrollees had prior coverage obtained directly from an issuer or a group health plan and either of the following occurred: (i) The premium for the prior coverage was increased to an amount that exceeded the premium required by the PCIP (adjusted based on the age factors applied to the prior coverage), and this increase was not otherwise explained; (ii) The health plan, issuer or employer otherwise provided money or other financial consideration to disenroll from coverage, or disincentive to remain enrolled in such coverage. Such considerations include payment of the PCIP premium for an enrollee or potential enrollee. (c) Remedies. (d) Other. Subpart F—Funding § 152.32 Use of funds. (a) Limitation on use of funding. (b) Limitation on administrative expenses. § 152.33 Initial allocation of funds. HHS will establish an initial ceiling for the amount of the $5 billion in Federal funds allocated for PCIPs in each State using a methodology consistent with that used to established allocations under the Children's Health Insurance Program, as set forth under 42 CFR part 457, subpart F, Payment to States. § 152.34 Reallocation of funds. If HHS determines, based on actual and projected enrollment and claims experience, that the PCIP in a given State will not make use of the total estimated funding allocated to that State, HHS may reallocate unused funds to other States, as needed. § 152.35 Insufficient funds. (a) Adjustments by a PCIP to eliminate a deficit. (b) Adjustment by the Secretary. (c) Payment rates for covered services furnished beginning June 15, 2013 to enrollees in the PCIP administered by HHS. (2) With respect to all other covered services, the payment rates will be— (i) 100 percent of Medicare payment rates; or (ii) Where Medicare payment rates cannot be implemented by the federally-administered PCIP, 50 percent of billed charges or a rate using a relative value scale pricing methodology. [75 FR 45029, July 30, 2010, as amended at 78 FR 30226, May 22, 2013] Subpart G—Relationship to Existing Laws and Programs § 152.39 Maintenance of effort. (a) General. (b) Failure to maintain efforts. § 152.40 Relation to State laws. The standards established under this section shall supersede any State law or regulation, other than State licensing laws or State laws relating to plan solvency, with respect to PCIPs which are established in accordance with this section. Subpart H—Transition to Exchanges § 152.44 End of PCIP program coverage. Effective January 1, 2014, coverage under the PCIP program (45 CFR part 152) will end. § 152.45 Transition to the exchanges. Prior to termination of the PCIP program, HHS will develop procedures to transition PCIP enrollees to the Exchanges, established under sections 1311 or 1321 of the Affordable Care Act, to ensure that there are no lapses in health coverage for those individuals.