---
kind: "section"
citation: "45 C.F.R. § 152.14"
title: "45"
number: "152.14"
heading: "Eligibility."
url: "https://uscodex.org/cfr/45/152.14"
---

# §152.14. Eligibility.

- (a) **General 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 lawfully present in the United States;
  - (2) Subject to [paragraph (b)](#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)](#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.** An individual who becomes ineligible for a PCIP on the basis of no longer residing in the PCIP's service area as described in [paragraph (a)(4)](#a-4) of this section is deemed to have satisfied the requirement in [paragraph (a)(2)](#a-2) of this section for purposes of applying to enroll in a PCIP in the new service area.
- (c) **Pre-existing condition requirement.** For purposes of establishing a process for determining eligibility, and subject to HHS approval, a PCIP may elect to apply any one or more of the following criteria in determining whether an individual has a pre-existing condition for purposes of this section:
  - (1) **Refusal of coverage.** Documented evidence that an insurer has refused, or a clear indication that the insurer would refuse, to issue coverage to an individual on grounds related to the individual's health.
  - (2) **Exclusion of coverage.** Documented evidence that such individual has been offered coverage but only with a rider that excludes coverage of benefits associated with an individuals' identified pre-existing condition.
  - (3) **Medical or health condition.** Documented evidence of the existence or history of certain medical or health condition, as approved or specified by the Secretary.
  - (4) **Other.** Other criteria, as defined by a PCIP and approved by HHS.

## Notes

### Authority

Authority: Sec. 1101 of the Patient Protection and Affordable Care Act (Pub. L. 111-148).

### Source

Source: 75 FR 45029, July 30, 2010, unless otherwise noted.