Texas Risk Pool – Health Insurance Questions
Are you a residence of Texas?
The Texas Health Insurance Pool was created by the Texas Legislature to provide health insurance to eligible Texas residents who, due to medical conditions, are unable to obtain coverage from individual commercial insurers. The Pool also serves as the Texas alternative mechanism for individual health insurance coverage, guaranteeing portability of coverage to qualified individuals who lose coverage under an employer group plan, church plan or state plan, as mandated by the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA).
What is Continuation of coverage?
Prior or recent coverage from you prior or Current Insurance plan ensures that your new Insurance plan grants you credit for your prior Coverage and waives the pre-existing exclusion period for your pre-existing conditions. Prior or Current coverage does NOT guarantee Coverage to your new policy, you will still have to be medically underwritten, you can be declined coverage, Rated Up, or have exclusions applied to your new policy.
Applicants with Certain Medical Conditions, who are NOT eligible to enroll in any Medically Underwritten Plans, may be eligible for coverage under the Texas Health Insurance Risk Pool. The Texas Health Insurance Risk Pool is an individual Health Insurance program created by the Texas Legislature to provide Health Insurance to Texas Residents who cannot obtain adequate Health Insurance Coverage as a result of the their Medical Conditions. Interested persons may contact the Texas Health Insurance Pool at 1-888-398-3927 or visit their website at www.txhealthpool.org or Contact me and I will help you with this Process, we have helped over 12 people this year get signed up with the TX Risk Pool.
Have you heard of the Federal Risk Pool (PCIP) it ran out of funds and on 02/16/13 it is no longer issuing any new policies? The Federal Government had estimated that 400,000 people would sign up for this coverage, but only 100,000 selected this plan, and they were NOT able to fund it any longer. The Affordable Healthcare Act does not start until 01/1/14 with the Guarantee Issued Policy. If you are interested we can help you shop for insurance coverage during the OPEN ENROLLMENT Period starting October 2013 for policies effective 01/01/2014.
The TX Risk Pool Program continues to serve the State of Texas as an important “safety net” for individuals who have been denied health insurance coverage because of pre-existing conditions. Can you afford the Pool’s premiums, and if you do not have other coverage options you could qualify for Assistance.
- POOL ENROLLMENT AS OF APRIL 2013: 23,179
- TOTAL TEXANS ENROLLED SINCE INCEPTION: 91,220
Are you currently on the TX Risk Pool? As you may know, implementation of the federal Affordable Care Act (the ACA) is moving ahead.
- Effective January 1, 2014, Texans will be able to buy guaranteed health insurance coverage, with no medical underwriting and no preexisting condition exclusions or waiting periods. Coverage will be available from any insurance company offering individual health insurance products— either directly, or through a federal insurance exchange website. Premium assistance will be available through the exchange for individuals who qualify based on income.
- Under the current federal timetable, early enrollment through the new health insurance exchange is scheduled to begin 10/01/2013, with coverage to be effective 1/1/2014.
- We can provide updates to Pool members when the Texas Legislature makes a decision about the Pool’s future. Whatever happens, we can assure you that Pool coverage will remain in place until at least January 1, 2014. Let us help you find a plan that fits your needs and your budget. We can help you decide if you will qualify for assistance with the Federal Government (the Federal Government has projected that 19% of the people in the United States will qualify).
- As we learn more details about the exchange and new marketplace enrollment opportunities we will be happy to send you all available information so that you can make the best possible choice about your new insurance coverage.
- In the meantime, you can get more information about the ACA and the insurance exchange marketplace at: www.healthcare.gov or contact me and we can add you to our Mailing list.
You can click here for the TX Risk Pool application (see attached PDF file).
The Texas Risk Pool provides premium assistance to qualified lower income enrollees. See the Premium Rates page of this website for more information.
- You are eligible (for Health Pool coverage) if you are under age 65 and you have been for at least 30 days and remain a legal resident of Texas and a United States citizen, or a legal permanent resident of the United States for at least 3 continuous years, and if you provide the Health Pool’s administrator with one of the following:
A. Notice of rejection or refusal by an insurance company to issue substantially similar individual health benefit plan coverage due to health reasons;
B. A certification from an agent or salaried representative of an Insurance Company on the Pool’s Application form, that states the agent or representative is unable to obtain substantially similar individual health benefit plan coverage for you with any state-licensed Insurance Company, which the agent or representative represents, because you will be declined for coverage, as a result of your medical condition, under the underwriting guidelines of the Insurance Company.
C. An offer by an Insurance Company to issue substantially similar individual health benefit plan coverage that excludes a medical condition or conditions; or
D. Doctor’s office letter stating you have been diagnosed with or treated for one of the Qualifying Medical/Health Conditions within the last 5 years.
- You are also eligible (for Health Pool coverage) if you are under age 65 (or over 64 and not eligible for Medicare), you are a legal resident of Texas, and if you have maintained health benefit plan coverage for at least 18 months preceding application for coverage to the Health Pool, with no gap in coverage greater than 63 days, and your last health benefit plan coverage was provided through employment, with a U.S. employer. (United States citizenship or 3-year legal permanent residency is not required for this HIPAA eligibility category.) See outline of Coverage for definition of Federally Defined Eligible Individual.
- You are also eligible (for Health Pool coverage) if you are under age 65, you are a legal resident of Texas, and if your last health benefit plan coverage was provided by another state’s qualified HIPAA program, such as a risk pool, that terminated because you no longer reside in that state. You must apply to the Texas Pool within 63 days of the loss of coverage in the other state plan. (U.S. citizenship or 3-year legal permanent residency is not required for this HIPAA eligibility category.)
- Dependents and Family Members, as defined in the Outline of Coverage, are also eligible if they are under age 65, and U.S. citizens or 3-year legal permanent residents.
You are NOT ELIGIBLE (for Health Pool coverage) IF:
I. You have other health coverage in effect on the date Health Pool coverage would otherwise be effective. (NOTE: In the case of coverage by Medicare, you are allowed to retain Medicare coverage if you otherwise qualify for the Pool. The Pool’s coverage will be secondary to coverage provided by Medicare, except for outpatient drug coverage, which is not a Pool benefit for Medicare beneficiaries. In the case of an individual policy of health coverage, you will be required to terminate such individual policy within 60 days after the effective date of a Pool policy. A Pool enrollee is allowed, however, to keep an existing individual policy with medical condition waivers, but the Pool will pay secondary to such coverage); or
II. You are eligible for or covered by employer-sponsored health coverage, including a self-insured health benefit plan, or continuation of coverage under state or federal law. (NOTE: If you or your dependents were covered by prior group coverage, you and your dependents may be eligible for COBRA or state continuation of coverage. A dependent, covered under the terminating prior group coverage, is entitled to continuation, regardless of the continuation election of the employee.) (NOTE: You may apply to the Pool if you are a part-time employee, the group plan offered by your employer is more limited than the Pool’s coverage (as determined by the Pool), and your employer does not pay or reimburse any portion of the cost of the group coverage. You may also apply if you are still within your 9-month State Continuation period or 18-month COBRA period, but did not elect it, or it later lapsed. If you qualify under this exception, however, you will be subject to the Pool’s pre-existing condition exclusion period for at least 180 days.)
III. You have terminated Health Pool coverage within 12 months prior to application for Health Pool coverage, unless there’s a good faith reason for such termination; or
IV. You are confined to county jail or prison; or
V. You had prior Health Pool coverage terminated for fraud; or
VI. You had prior coverage with the Health Pool that was terminated for nonpayment of premiums within 12 months prior to application for subsequent coverage; or
VII. You have received $3,000,000 in benefits from the Health Pool; or
VIII. You will have premiums paid or reimbursed by or through a government sponsored program or government agency, or by a health care provider.
- Definition – Preexisting Condition means a disease or condition for which the existence of symptoms would cause a prudent person to seek diagnosis, care or treatment during the 6 months before an Insured Person’s effective date of Pool coverage, or for which medical advice, care or treatment was recommended or received during the 6 months before an Insured Person’s Pool coverage date. Preexisting Condition includes a preexisting pregnancy or a complication of a preexisting pregnancy, whether the complication occurs before or after the effective date of Pool coverage. Preexisting Condition does not include genetic information in the absence of a diagnosis of the condition related to the genetic information.
- Preexisting Condition Exclusions/Limitations
Unless you have credit for prior coverage, during the first 12 months following the effective date of Health Pool coverage the policy does not pay benefits for any charges or expenses for any Preexisting Conditions (except as indicated below).
A. The Preexisting Condition limitation does not apply if an individual was continuously covered for an aggregate period of at least 12 months under Creditable Coverage that was in effect up to a date not more than 63 days before the individual’s effective date of coverage through the Health Pool (excluding any waiting period under the prior health coverage) provided that the individual’s application for coverage through the Health Pool was made no later than 63 days following termination of the prior health coverage.
B. The Preexisting Condition limitation will not apply to an Insured Person who has been continuously covered, since birth, adoption or Your suit for adoption of the Insured Person by Creditable Coverage which was in effect up to a date not more than 63 days before the Insured Person’s effective date under this Policy, excluding any waiting period, provided that application for coverage under this Policy for the Insured Person is made no later than 63 days following the termination of such Creditable Coverage.
C. In determining whether a Preexisting Condition limitation applies, credit is given for the time an individual was covered under any prior Creditable Coverage (including any waiting period for such coverage) that was in effect at any time during the 12 months before the effective date of Health Pool coverage.
- NOTE: An individual who qualifies under the state continuation or COBRA exception will be subject to a minimum 6-month waiting period.
Qualifying Medical/Health Conditions
|§ Addisons Disease
§ Amyotrophic Lateral Sclerosis (ALS)
§ Angina Pectoris
§ Artificial Heart Valve
§ Brain Tumor
§ Bronchopulmonary Dysplasia
§ Cerebral Palsy
§ Childhood Asthma
§ Chronic Liver Failure
§ Cirrhosis (non-alcoholic)
§ Congenital Heart Disease
§ Congestive Heart Failure
§ Coronary Artery Disease
§ Crohns Disease
§ Cystic Fibrosis
§ Dementia (including Alzheimers)
§ Diabetes Mellitus
§ Down¡¯s Syndrome
§ Fredrichs Ataxia
§ Guillian-Barre Syndrome
§ Heart Attack
§ Hodgkins Disease
§ Huntingtons Chorea
|§ Inborn Errors of Metabolism
§ Intermittent Claudication
§ Lead Poisoning with Cerebral Involvement
§ Metastatic Cancer
§ Muscular Atrophy or Dystrophy
§ Myasthenia Gravis
§ Organ Transplants (except Corneal)
§ Paraplegia or Quadriplegia
§ Parkinson¡¯s Disease
§ Pediatric Carniofacial Abnormalities
§ Peripheral Vascular Disease
§ Polycystic Kidney
§ Psychotic Disorders
§ Rheumatoid Arthritis
§ Sclerosis, Multiple, Disseminated or Posterolateral
§ Short Bowel Syndrome
§ Sickle Cell Anemia
§ Silicosis (Black Lung)
§ Spina Bifida
§ Tabes Dorsalis (Locomotor Ataxia)
§ Tumor, Malignant
§ Ulcerative Colitis
§ Wilson’s Disease
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