Related Links Texas Health Insurance Pool 1-888-398-3927 TDD 1-800-735-2989 www.txhealthpool.org
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Frequently Asked Questions
Why are my premiums so high? Does the State of Texas contribute any funding for this program?
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 2009, for example, the Pool assessed health insurers $77,000,000.
Is Blue Cross and Blue Shield of Texas my insurance company? Who is Medco?
The Pool provides your health benefits coverage. Blue Cross and Blue Shield of Texas (BCBSTX) is the Pool’s third party administrator, handling enrollment, medical claims processing, and premium collection for the Pool. The Pool phone number for BCBSTX customer service is: 888-398-3927. Medco Health Solutions (Medco) is the Pool’s pharmacy benefits manager for all questions about outpatient retail and mail order prescriptions. The Pool phone number for Medco customer service is: 800-290-1708.
BCBSTX and Medco do not determine the benefits provided by the Pool or the premium rates charged by the Pool. Both companies are paid a flat monthly administrative fee, based on the number of Pool enrollees. Neither company receives any compensation based on the Pool’s premium rates or how claims are processed by the Pool.
Does my Pool policy cover preventive care?
The Pool has always covered various mandated preventive medical services, including immunizations for young children and certain routine cancer screening tests for adults. In 2009, the Pool Board of Directors added a $300 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.
My Pool Policy provides that the first 6 physician office visits each year are subject only to a $30 copayment.
What services does my $30 copayment cover?
The $30 copayment covers the doctor’s charge for examination or consultation associated with an illness or other
services provided in connection with that office visit, including lab work or x-rays, are subject to deductible and/or
coinsurance.
What is the Texas Health Insurance Pool?
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.
When was the Health Pool started?
The Health 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 Health 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 Health Pool.
Who manages the Health Pool?
The Health 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.
- Who can be a member of the Board?
The Statute requires that certain interests be represented on the Board of Directors. These are:health insurance
companies and persons who are eligible or who are parents of someone eligible for the Health 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.
Who are the current members of the Board?
Gary Cole, Chair- Public Representative
Rick Ott, CLU, Vice-Chair- Industry Representative
D. Greg Barbutti, Secretary/Treasurer - Insured Representative
Robert Emmick, M.D. - Professional Representative
Pati McCandless - Industry Representative
Vicky Paparelli, APRN, Professional Representative
William C. Rainey, M.D.- Insured Representative
Marinan Williams, Industry Representative
Vacant Position
- When did the Health Pool begin operations?
The first Health Pool policies were effective February 1, 1998
- What type of health insurance is provided by the Health Pool?
The policy issued by the Health Pool provides major medical expense coverage including coverage for prescription drugs. Benefits are provided up to a $2,000,000 lifetime maximum benefit. The coverage is subject to a calendar year deductible and coinsurance payments by the policyholder. For a more complete explanation, see the Outline of Coverage.
How are the operations of the Health Pool financed?
The Health Pool charges premiums for the policies that it issues. Since claims and expenses for the Health Pool's operation exceed collected premiums, the Health Pool collects additional funds from health insurance companies through assessments.
Who sets the premiums charged?
The Board of Directors recommends the premium rates to be charged and the Insurance Commissioner approves the rates.
- What is a standard premium rate?
The standard rate is the average rate charged by health insurance carriers in Texas for similar coverage. The Board of Directors engages an independent actuarial firm to set a standard rate for the commercial market. The Board uses this standard rate when setting the premium rates for the Health Pool policy.
- What premium is charged for the Health Pool policy?
Effective January 2004, the Pool's premium multiplier above the standard rate was raised to the 200%, the level required by state law. Rates will continue to be reviewed twice a year and adjusted, when necessary, to maintain this statutory level above the standard rate. For a more complete description of premiums, see the Premium Rate information page.
Who is eligible for the Health Pool Coverage?
How do I apply for coverage?
Interested persons may request a mailed application by contacting the Health Pool at (888) 398-3927
(e-mail address, texashealthpool@bcbstx.com). The application package will contain an Outline of Coverage, an Application for Coverage and a table of premium rates. You can also download the application package - See Application.
Can I be turned down for coverage?
Yes. See Health Pool Non-Eligibility.
- What about preexisting conditions?
Can I obtain or keep Pool coverage if I am under age 65 and I become eligible for Medicare
disability?
In the case of coverage by Medicare, you are allowed to retain Medicare coverage if you otherwise qualify for the Pool, but the Pool will provide medical coverage on a secondary basis, and there is no coverage for outpatient prescription drugs.
Can I go to any doctor or hospital?
The Health Pool Board of Directors selected the BlueChoice Network as its Preferred Provider Organization ("PPO"). An individual covered by the Health Pool may go to any medical provider or hospital he or she chooses. However, if the covered individual chooses a BlueChoice provider, the individual will pay a smaller coinsurance payment. If the person chooses a provider outside the network, the person will pay a higher coinsurance payment. In addition, PPO providers cannot charge the Pool member for amounts in excess of the PPO contract rate. A non-PPO provider, that is not a ParPlan provider, may charge the difference between the benefits allowed by the Pool and the provider's billed rate; therefore, the Pool member will be responsible for any charges over the allowed amount.
- What are the health care benefits provided by the Health Pool?
After the covered individual has satisfied the deductible each year, the Health 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 Health Pool will pay 100% of covered expenses for the remainder of the year, subject to the maximum lifetime benefit amount of $2,000,000. 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.
- What are the deductible amounts?
The Health Pool offers 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 $1,250 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.
- Does the Pool offer a High Deductible Health Plan that qualifies for a Health Savings Account?
Yes, Plan V is a high deductible health plan that can be paired with a Health Savings Account.
- What are the coinsurance amounts, after the annual deductible is satisfied?
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.
What are the policy exclusions?
See Health Pool Benefits and Exclusions.
When does the policy terminate?
The Health Pool may cancel coverage for non-payment of premiums within the 31-day grace period. The policy is renewed each time the required premium is timely paid, but coverage will terminate for each person insured under this Policy:
a) 31 days after the day on which a premium payment for the Policy becomes due if
payment is not made before that date;
b) the earlier of the premium due date or the first day of the month that follows the date
on which the Pool determines:
1) an Insured Person is no longer eligible for coverage under the Pool;
2) an Insured Person is no longer a resident of the state of Texas except for: a
child who is student under the age of 25 and financially dependent upon You
or Your spouse; a child for whom You and Your spouse is obligated to pay
child support; or a child of any age who is disabled and dependent on You or
Your spouse;
3) an Insured Person is 65 years old;
c) 30 days after the date We make inquiry concerning an Insured Person's place of
residence or any other eligibility criteria and You do not reply;
d) You request coverage to end;
e) on the date of death; or
f) state law requires cancellation of this Policy.
How are payments of premiums handled?
Premium may be paid monthly by automatic bank withdrawal or quarterly, semi-annually or annually by direct payment. Rates are based on age, gender, zip code and smoker status. Rates are subject to change with 30-days notice. An initial premium payment must be submitted with each application
Page Updated on: 07/02/2010
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