Texas has a risk pool program, called the Texas Health Insurance Pool, to provide insurance for residents of Texas who are unable to buy private health insurance due to their health conditions, and for people who are HIPAA eligible.

When can I buy coverage from the Texas Health Insurance Pool?

· If you are HIPAA eligible, you can buy health insurance from the Texas Health Insurance Pool.

· If you are not HIPAA eligible, there are many different ways to qualify for coverage through the Texas Health Insurance Pool. You are eligible if:

o You are eligible for the Health Coverage Tax Credit (HCTC). (see Financial Assistance)

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 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 Pool coverage. The Texas Health Insurance Pool requires that you not be eligible for other, similar employer-based coverage before you can get coverage from the Pool.

· Your eligibility for Texas Health Insurance Pool coverage will be delayed under certain circumstances. If prior to applying you had been covered under a small group health plan, you lost that coverage, you were then eligible for state continuation coverage, and you did not elect that state continuation coverage, then you are not eligible to apply for the Texas Health Insurance Pool until your state continuation coverage would have run out. Usually, this is nine months from the date you lost your small group coverage. This delay in eligibility for the pool does not apply to people who had been eligible for COBRA coverage.

· The Pool offers family coverage, so if one person in your family qualifies, your family can get Pool coverage. Each person in your family will be assessed a separate premium.

What will the Texas Health Insurance Pool cover?

· Coverage includes hospital and physician care, maternity services, prescription drugs, treatment for serious mental health illness, and other services. Five plan options are available with varying deductibles and coinsurance maximums, including one HSA qualified plan. 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 Texas Health Insurance 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 Texas Health Insurance Pool. When you enroll, the 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 Pool plans.

Generally, 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 Pool. Even if your break in coverage is 63 days or more, the 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 Pool considers creditable coverage to include most types of prior individual or group health plan that you may have had.

However, if before you applied to the Pool you were covered under a group health plan, and you were eligible for COBRA when you left that plan, and you didn’t elect COBRA, then when you join the Pool you will have a six-month pre-existing condition exclusion no matter how much prior coverage you had.

What can I be charged for Texas Health Insurance 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. 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 $156 to $449 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 $481 to $1,380 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 Texas Health Insurance Pool administrator for the most current information.

How long does Texas Health Insurance Pool coverage last?

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