The Texas Health Insurance Risk Pool was created by the Texas Legislature with the cooperation of participating health insurance companies and first became available on January 1, 1998. The Risk Pool was designed to offer access to health insurance coverage for Texas residents unable to obtain adequate coverage due to medical conditions or who are considered Federally Eligible Individuals as defined by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Eligibility guidelines are specific and only those individuals, their dependents and certain family members may obtain coverage through the Risk Pool.
Basic eligibility guidelines require that the applicant be under the age of 65, a legal resident of Texas and a United States Citizen, or a permanent resident of the United States for at least three continuous years. In addition, they must provide evidence of inability to obtain comparable coverage through a standard state-licensed insurance provider at a reasonable premium rate.
There is also a list of specific medical conditions which have been predetermined as a condition for automatic eligibility by the Risk Pool Board of Directors. Proof of diagnosis must be provided.
Even if an applicant meets the general eligibility guidelines, coverage may not be available if other coverage is in effect or if they are eligible to participate in other coverage. COBRA extension and other continuation benefits must be exhausted before an applicant becomes eligible for the Risk Pool.
Participants are no longer eligible after they have received $2,000,000 in benefits from the Risk Pool. Premiums for the participants are based on age, gender, zip code, and smoker status.
The Risk Pool has selected Blue Cross and Blue Shield of Texas, Inc. as the plan administrator. Although insured participants may choose any medical provider or hospital, they will save money and obtain better benefits by using the BlueChoice© Network.
The Risk Pool offers four basic plans of coverage and a Health Saving Account Option designed to cover major hospital, medical, and surgical expenses incurred as a result of a covered injury or sickness. Prescription drugs have a separate calendar year deductible and then are provided on a copay schedule.
As with any plan, there are exceptions and limitations too numerous to detail in the scope of this article. Coverage details, applications, and premium rates can be obtained from most insurance agents providing health insurance plans or by reviewing the Department of Insurance website at www.txhealthpool.com. In addition, the Texas Risk Pool can be contacted directly at 888-398-3927.
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