TEXAS HEALTH INSURANCE RISK POOL
SUMMARY OF COVERAGE
(Part 1 of 3)
By Patricia Barrett, CFP CDFA Mediator
The Texas Health Insurance Risk Pool was created by the Texas legislature to offer health insurance to residents of the state through participation of health insurance companies. This program is designed to provide health insurance to those Texans who are unable to obtain adequate health coverage due to their medical condition or who are considered “Federally Eligible” individuals as defined by the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
A federally defined eligible individual means you meet these requirements:
1) Prior coverage continued for 18 months or more as of the date you apply for the Pool.
2) The recent coverage was under a Group Health Plan.
3) You are not eligible for coverage under a Group Plan now.
4) Your last coverage wasn’t terminated for fraud or non-payment of premiums.
5) If offered, the individual elected and continued coverage under COBRA as long as offered.
Additionally, in order to qualify for coverage you must have applied and been rejected by an insurance company because of your health, or an insurance company denies coverage for your specific health condition. However, you are automatically eligible for coverage if you have many serious diseases, such as cancer, lupus, psychiatric disorders, and many more.
There is no preexisting condition limitation, so long as you qualify as a Federally Defined Eligible Individual as described above.
Coverage includes hospital, medical, and surgical expenses, as well as prescription drugs. Benefits are outlined in the table below, showing the payment percentages for medical expenses after satisfying the deductible. There are four different plans of coverage, depending on the amount of the deductible. While you can move to a higher deductible, you are not allow to change to a lower deductible amount after the policy is issued.
Similar to HMOs covered expenses are limited to an “allowable amount” determined by the administrator of the plan. BlueChoice, sets these benefits in a contract with the providers. If you choose a “non-preferred” provider, the allowable amount is based on the amount that would have been paid for the same covered service with a preferred provider. Note that the deductible is substantially higher out of network, as well.
Even if you consult a “preferred provider”, be sure that any of the others rendering care to you are also “preferred providers”. For example, if you are scheduled for surgery, ensure that the preferred provider surgeon is using a preferred facility and that you employ preferred anesthesiologist, radiology and pathology services.
You can find a list of Preferred Provider Facilities at this location.
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In the Custom Search box, click on the link at the “Important Note” to verify information for your facility.
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For a list of Preferred Provider medical professionals, you can call the preauthorization referral department at 1-888-398-3927 or visit their web site.
For more information, see Exclusions and Premiums and Policy Deductibles and Benefits.
