Tel.: 1-800-234-8732 (Toll Free)
Tel.: 1-408-234-4394
Fax.: 1-408-988-5952
E-mail: Info@SedonaBenefits.com

www.SedonaBenefits.com
About UsBusiness SolutionsIndividual SolutionsInsurance ProductsOther BenefitsCarriersGlossaryContact Us

MAJOR RISK MEDICAL INSURANCE PROGRAM (MRMIP)

The California Major Risk Medical Insurance Program (MRMIP) is a 36-month program developed to provide health insurance for Californians who are unable to obtain coverage in the individual insurance market. The MRMIP is administered by a five-member Board, which has established a comprehensive benefit package. Services in the MRMIP are

delivered through contracts with health insurance providers. Californians qualifying for the MRMIP participate in the payment for the cost of their coverage by paying premiums on their own behalf. The MRMIP supplements those premiums to cover the cost of care. The MRMIP is funded annually by $40 million from tobacco tax funds.

After 36 consecutive months of enrollment in MRMIP, individuals will be disenrolled and offered guaranteed coverage in the individual insurance market. All health plans currently offered in MRMIP, with the exception of Contra Costa Health Plan, will be available for guaranteed coverage.

To be eligible for the MRMIP:
  • You must be a resident of the state of California. A resident is a person who is present in California with intent to remain in California except when absent for transitory or temporary purposes. However, a person who was absent from the state for a period of greater than 210 consecutive days shall not be considered a resident.
  • You cannot be eligible for both Part A and Part B of Medicare, unless eligible solely because of end-stage renal disease.
  • You cannot be eligible to purchase any health insurance for continuation of benefits under COBRA or CalCOBRA. If you have COBRA or CalCOBRA you may apply for deferred enrollment.
  • You must be unable to secure adequate coverage elsewhere. This can be demonstrated in any of three ways:
    • If you have been denied individual coverage within the previous 12 months.
    • If you have been involuntarily terminated from health insurance coverage within the previous 12 months for reasons other than nonpayment of premium or fraud.
    • If you have been offered, in the previous 12 months, an individual, not a group, health insurance premium in excess of your Major Risk Medical Insurance Program subscriber rate.

If you are not currently eligible for the MRMIP, but anticipate becoming eligible, you may also apply. Examples of this are: if you are currently enrolled in COBRA or CalCOBRA coverage or if your employer has informed you that you will be involuntarily terminated from insurance coverage sometime in the future. To apply for a deferred enrollment, indicate when you will become eligible and include acceptable documentation. Enrollment in temporary policies does not qualify for deferred status.

If the MRMIP is not at maximum enrollment and all other eligibility criteria are met, you will be enrolled in the MRMIP on the date that eligibility will occur. If the MRMIP is at maximum enrollment at the time you become eligible you will be placed on a waiting list. Your place on the waiting list is determined by the date on which your complete application was received, not the date that you became eligible for the MRMIP.

While Medi-Cal beneficiaries are not prohibited from enrolling in the Major Risk Medical Insurance Program, a Medi-Cal beneficiary should carefully consider the cost before signing up for MRMIP coverage. MRMIP subscribers are responsible for their monthly subscriber contributions and a co-payment for services, which could be more than $5,000 per year. Medi-Cal BIC cards cannot be used for MRMIP co-payments.

The out-of-pocket maximum per calendar year for all MRMIP plans is $2,500 for individuals and $4,000 for an entire household covered by the MRMIP. This maximum does not apply to services rendered by providers that do not participate in the subscriber's chosen health plans provider network, or to services not covered by the MRMIP. There are MRMIP benefit limits of $75,000 per calendar year and $750,000 in a lifetime.