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Pharmacy Program Medical Providers About the Pool
Frequently Asked Questions
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The Pool receives no state funding. The Pool's statute, Ch. 1506 of the Texas Insurance Code, requires Pool premium rates to be set at twice the rates charged in the commercial insurance market. Even with higher premium rates, the premiums paid by Pool members are not enough to cover the medical and pharmacy claims the Pool pays for its members. The additional funding is provided by health insurance companies in Texas who, by state law, are required to cover the Pool's net loss. This assessment on health insurers is allocated among the companies based on their share of the Texas health insurance market. In 2012, for example, the Pool assessed health insurers $165,000,000.
Blue Cross and Blue Shield of Texas (BCBSTX) is the Pool's third party administrator. The Pool phone number for BCBSTX customer service is: 888-398-3927. Express Scripts (formerly Medco) is the Pool's pharmacy benefits manager for all questions about outpatient retail pharmacy and mail order prescriptions. The Pool phone number for Express Script's customer service is: 800-290-1708.
The Pool has always covered various mandated preventive medical services, including immunizations for young children and certain routine cancer screening tests for adults. In 2012, the Pool Board of Directors added a $500 annual preventive care benefit to the Pool coverage. This benefit covers routine physical examinations, lab and x-ray charges, immunizations, and well care consultations. This new benefit is not subject to the annual deductible if services are provided by in-network medical providers.
The $30 copayment covers the
doctor's charge for examination or consultation associated with an illness or
The Texas Health Insurance Pool is an individual health insurance program created by the Texas Legislature to provide health insurance to Texas residents who either (i) cannot obtain adequate health insurance coverage as a result of their medical conditions, or (ii) are considered "Federally Eligible Individuals," as defined by the Health Insurance Portability and Accountability Act of 1996, commonly referred to as HIPAA.
The Pool was originally created by the Legislature in 1989 in a bill sponsored by Representative John Gavin. The Legislature, however, did not provide funding for the operation of the Pool. In 1997, the 75th Legislature amended the 1989 legislation in a bill sponsored by Senator David Sibley and Representative Kip Averitt, which, among other changes, provided funding mechanism. It also included $500,000 of state appropriated funds to cover the startup expenses of the Pool.
The Pool is managed by a nine member Board of Directors, appointed by the Commissioner of Insurance. The Executive Director's office oversees the day-to-day operation of the Pool.
Statute requires that certain interests be represented on the Pool Board of Directors. These are: health insurance companies and persons who are eligible or who are parents of someone eligible for the Pool coverage. Additionally, Board members may be physicians, hospital administrators, advanced nurse practitioners or members of the general public, not affiliated with the insurance and health care industries.
Gary Cole, Chair- Public Representative
The first Pool policies were effective February 1, 1998
After the covered individual has satisfied the deductible each year, the Pool will pay the amount of covered expenses in excess of the coinsurance amount required to be paid by the Insured until the Insured meets the coinsurance maximum for the year. After the individual meets the coinsurance maximum for the year for PPO covered expenses, the Pool will pay 100% of covered expenses for the remainder of the year, subject to the maximum lifetime benefit amount of $4,000,000. It should be noted that the calendar year deductible, the emergency care deductible and charges for outpatient prescription drugs do not count towards the annual coinsurance maximum.
The Pool offered five plans: Plan I has a $1,000 deductible, Plan II has a $2,500 deductible Plan III has a $5,000 deductible, and Plan IV has a $7,500 deductible. The HSA Qualified Plan V has a $3,000 medical deductible and a $1,450 prescription deductible. The deductible amount selected may not be changed to a lower amount after the Policy is issued. You may request to change to a higher deductible, if offered, but only one such change will be allowed in a calendar year.
Plans I- IV require a 20% coinsurance payment for PPO providers and 40% for non-PPO providers. The annual out-of-pocket coinsurance maximum for PPO providers is $3,000 Plans I-III, and $5,000 for Plan IV. Plan V does not carry a PPO coinsurance requirement. The annual out-of-pocket coinsurance maximum for non-PPO providers is $10,000 for all plans.
See Pool Benefits and Exclusions.