Texas has a risk pool program, called the Texas Health Insurance Risk Pool that offers health coverage for persons who are HIPAA eligible and for people with expensive health conditions who are unable to buy individual coverage.

When can I get coverage from the Texas Health Insurace risk pool?

• If you are HIPAA eligible, you can buy health insurance from the Health Pool.

To be HIPAA eligible, you must meet certain criteria

No matter where you live in the U.S., if you are HIPAA eligible you are guaranteed the right to buy individual health insurance of some kind with no pre-existing condition exclusion periods. In Texas, you are guaranteed the right to buy coverage only from the Health Pool.  To be HIPAA eligible, you must meet all of the following:

• You must have had 18 months of continuous creditable coverage, at least the last day of which was under a group health plan.
• You also must have used up any COBRA or state continuation coverage for which you were eligible.
• You must not be eligible for Medicare, Medicaid or a group health plan.
• You must not have health insurance. (Note, however, if you know your group coverage is about to end, you can apply for coverage for which you will be HIPAA eligible.)
• You must apply for health insurance for which you are HIPAA eligible within 63 days of losing your prior coverage.

HIPAA eligibility ends when you enroll in an individual plan, because the last day of your continuous health coverage must have been in a group plan.  You can become HIPAA eligible again by maintaining continuous coverage and rejoining a group health plan.

• If you are not HIPAA eligible, there are many different ways to qualify for coverage through the Health Pool. You are eligible if:
• o You are eligible for the Health Coverage Tax Credit (HCTC) (see page 31).
• o You were turned down for coverage by an insurer or HMO because of your health;
• o You received a certificate from an agent saying that the agent would be unable to find coverage for you because of your health;
• o You were offered coverage by an insurer, but the health plan contained an elimination rider that would have reduced the benefits you would receive from the health plan;
• o You were offered coverage by an insurer or HMO, but it would have been more expensive than buying coverage from the Health Pool; or
• o You have been diagnosed with a serious health condition, for example, cancer, epilepsy, or AIDS.
• o You only need to show that you are eligible in one of these ways in order to get Health Pool coverage. The Texas Health Insurance Risk Pool requires that you not be eligible for other, similar employer-based coverage before you can get coverage from the Health Pool.
• You may not be eligible for the Health Pool if you were offered COBRA or state continuation coverage and didn’t elect the coverage or didn’t exhaust the coverage. The Health Pool can deny eligibility until the time that you would have otherwise exhausted COBRA or state continuation coverage had you elected it.
• The Health Pool offers family coverage, so if one person in your family qualifies, your family can get Health Pool coverage. Each person in your family will be assessed a separate premium.

What will the Texas Health Insurance Risk Pool cover?

• Coverage includes hospital and physician care, maternity services, prescription drugs, treatment for serious mental health illness, and other services. Four plan options are available with varying deductibles and coinsurance maximums. All plans are preferred provider organization (PPO) plans. This means that when you receive care from a health care provider within the network, the plan will pay more than if you get care from a provider outside the network.

What about coverage for my pre-existing condition?

• If you are HIPAA eligible or eligible for the HCTC, your health coverage will not be subject to a pre-existing condition exclusion when you enroll in the Health Pool.
• If you are not HIPAA or HCTC eligible, you may have a 12-month pre-existing condition exclusion period when you first enroll in the Health Pool. When you enroll, the Health Pool will look back 6 months to see if you had a condition for which you actually received a diagnosis, medical advice, or treatment. Pregnancy can be considered a pre-existing condition. Elimination riders are not permitted on the Health Pool plans.

If your break in coverage is less than 63 days and you had 12 months of prior coverage, no pre-existing condition exclusion will be imposed when you join the Health Pool.   Even if your break in coverage is 63 days or more, the Health Pool will give you credit for any coverage that was in effect in the 12 months prior to the effective date of your coverage.  The Health Pool considers creditable coverage to include most types of prior individual or group health plan that you may have had.

What can I be charged for Health Pool coverage?

• Premiums will vary based on the health plan you choose, your age and gender, the geographic area where you live, and whether you smoke. Health Pool rates are limited to twice the amount that a healthy person who bought a similar plan sold by a private insurer would pay.

For example, a 24-year-old man who was a non-smoker would pay $144 to $388 in monthly premiums, depending on which deductible option he chose and what part of the state he lived in.  On the other hand, a 64-year-old man who was a non-smoker would pay $445 to $1194 in monthly premiums, depending on the deductible option he chose and where he lived.  Please note that rates may have changed since this guide was written, so contact the Health Pool administrator for the most current information.

How long does Texas Health Insurance Risk Pool coverage last?

• Coverage under the Health Pool is renewable as long as you pay your premiums, continue to reside in Texas, and meet other eligibility requirements. If you cancel your Health Pool coverage, you will not be able to reapply for coverage under the Health Pool for 12 months, unless you are HIPAA eligible or you can show a good faith reason for canceling.