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Texas Health Insurance Pool


The Texas Health Insurance Pool is the state’s risk pool for individuals who have been turned down or charged more by private health insurers for medical reasons, or are HIPAA eligible. If you have lost your employer coverage, elected and exhausted COBRA or continuation coverage, and have not had a break in coverage of over 63 days, you likely qualify for the risk pool. Those who have been rejected coverage, rated up, or issued an exclusion period for having a preexisting condition also qualify for both the state and federal high risk pools. The federal temporary high risk pool that closed in 2013, PCIP, was not affiliated with the Texas Health Insurance Pool, though they did not have waiting periods for individuals with preexisting conditions.

The pool has about 24,000 members and has insured a total of 90,000 Texans since the program’s beginnings. While anyone can apply for coverage regardless of their health status under the Affordable Care Act, the risk pool remains available to those who want coverage and have an illness. Enrolling in the risk pool helps maintain balance in the insurance market so that premiums don’t get incredibly high for everyone insured through an individual health plan.

Eligibility

In order to qualify for the Texas Health Insurance Pool, you must fit one of the following groups and subsequent criteria.

Conditions

  • Under age 65
  • Legal resident (for at least 3 years) or U.S. citizen
  • Resident of Texas
  • Provide notice of rejection from insurer for similar coverage to the Pool or;
  • Notice of uninsurability from health insurance agent due to a medical condition or;
  • Health insurance plan offered by private insurer for similar coverage to Pool with exclusions for a condition or;
  • Physician’s letter acknowledging diagnosis and treatment (in the past 5 years) for a Qualifying Medical/Health Condition

 

HIPAA Eligible

  • Under age 65
  • Resident of Texas
  • Have had at least 18 months of continuous coverage (provided by a U.S. employer) prior to application with no break over 63 days

OR

  • Under age 65
  • Resident of Texas
  • Member of another state’s qualified HIPAA program, such as a high risk pool, and coverage ended due to relocation
  • Must apply within 63 days of losing coverage

 

Dependents & Family Members

  • Under age 65
  • Resident of Texas
  • Legal resident of 3 years or U.S. citizen

 

 

Premiums

The risk pool offers premium assistance to those who cannot afford the full cost of their coverage. If your income is less than or equal to 300 percent of the Federal Poverty Level, you may qualify for assistance. Click here to find out if you qualify for a subsidy to help pay your premiums.

 

 

Plans & Benefits

The risk pool in Texas offers five different plan types, with deductibles ranging from $1,000 to $7,500, including an HSA option. Each one, with the exception of the HSA-qualified plan, offers 80 percent coverage after deductible, and the $3,000 HSA plan covers 100 percent. Non-network care is covered at 60 percent after deductible.

All plans cover the same services, as medically necessary, ranging from preventive to hospital care. However, there are limits on most types of care either by dollar amount or number of visits. The following are some common examples of covered benefits, though others are included, as well. To find out more about specific services, call the Pool at Blue Cross and Blue Shield of Texas at 888 398 3927 or email texashealthpool@bcbstx.com.

  • Hospitalization
  • Intensive care or cardiac care unit
  • Emergency care
  • Physician office visits
  • Preventive care
  • Surgery
  • Hospice care
  • Home health care
  • Physical, occupational, and speech therapy
  • Mental health care
  • Prescription medications
  • Skilled nursing facility
  • Transplants
  • Ambulance
  • Contraceptives
  • Outpatient care
  • Diabetes supplies and management
  • Blood work
  • Durable Medical Equipment
  • Laboratory and X-ray
  • Brain injury treatment
  • Complications of pregnancy

 

 

How to Apply

Fill out the application form and provide all necessary documentation depending on your eligibility group. Send or fax your form to the Texas Health Insurance Pool when completed. View the full list of requirements and choose your plan after reviewing the outline of coverage here.

Texas Health Insurance Pool Application

 

Resources

 

Texas Health Insurance Pool

Contact Texas Health Insurance Pool:

888 398 3927 or 800 735 2989 TDD

 

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