This is only a summary of information. This summary is NOT a legal document. Refer to the Health Pool’s Contract
(Policy) and application package for complete information.
On this page:
Qualifying Medical Conditions
An employer’s payment of employee’s individual health insurance policy premiums can create a small or large employer group plan, making those employees ineligible for the Pool. Please review the Insurance Commissioner Bulletin for more information by clicking on the link below:
Texas Department of Insurance Commissioner Bulletin B-0028-06
- You are eligible (for Health Pool coverage) if you are under age 65 and you have been for at least 30 days and remain a legal resident of Texas and a United States citizen, or a legal permanent resident of the United States for at least 3 continuous years, and if you provide the Health Pool’s administrator with one of the following:A. Notice of rejection or refusal by an insurance company to issue substantially similar individual health benefit plan coverage due to health reasons;B. A certification from an agent or salaried representative of an Insurance Company on the Pool’s Application form, that states the agent or representative is unable to obtain substantially similar individual health benefit plan coverage for you with any state-licensed Insurance Company, which the agent or representative represents, because you will be declined for coverage, as a result of your medical condition, under the underwriting guidelines of the Insurance Company.C. An offer by an Insurance Company to issue substantially similar individual health benefit plan coverage that excludes a medical condition or conditions; or
D. Doctor’s office letter stating you have been diagnosed with or treated for one of the Qualifying Medical/Health Conditions within the last 5 years.
- You are also eligible (for Health Pool coverage) if you are under age 65 (or over 64 and not eligible for Medicare), you are a legal resident of Texas, and if you have maintained health benefit plan coverage for at least 18 months preceding application for coverage to the Health Pool, with no gap in coverage greater than 63 days, and your last health benefit plan coverage was provided through employment, with a U.S. employer. (United States citizenship or 3-year legal permanent residency is not required for this HIPAA eligibility category.) See outline of Coverage for definition of Federally Defined Eligible Individual.
- You are also eligible (for Health Pool coverage) if you are under age 65, you are a legal resident of Texas, and if your last health benefit plan coverage was provided by another state’s qualified HIPAA program, such as a risk pool, that terminated because you no longer reside in that state. You must apply to the Texas Pool within 63 days of the loss of coverage in the other state plan. (U.S. citizenship or 3-year legal permanent residency is not required for this HIPAA eligibility category.)
- Dependents and Family Members, as defined in the Outline of Coverage, are also eligible if they are under age 65, and U.S. citizens or 3-year legal permanent residents.
You are NOT ELIGIBLE (for Health Pool coverage) IF:
- You have other health coverage in effect on the date Health Pool coverage would otherwise be effective, except as noted below:
(NOTE: In the case of coverage by Medicare, you are allowed to retain Medicare coverage if you otherwise qualify for the Pool. The Pool’s coverage will be secondary to coverage provided by Medicare, except for outpatient drug coverage, which is not a Pool benefit for Medicare beneficiaries.
In the case of an individual policy of health coverage, you will be required to terminate such individual
policy within 60 days after the effective date of a Pool policy. A Pool enrollee is allowed, however, to keep an existing individual policy with medical condition waivers, but the Pool will pay secondary to such coverage); or
- You are eligible for or covered by employer-sponsored health coverage, including a self-insured health benefit plan, or continuation of coverage under state or federal law, except as noted below:(NOTE: If you or your dependents were covered by prior group coverage, you and your dependents may be eligible for COBRA or state continuation of coverage. A dependent, covered under the terminating prior group coverage, is entitled to continuation, regardless of the continuation election of the employee.)(NOTE: You may apply to the Pool if you are a part-time employee, the group plan offered by your employer is more limited than the Pool’s coverage (as determined by the Pool), and your employer does not pay or reimburse any portion of the cost of the group coverage. You may also apply if you are still within your 9-month State Continuation period or 18-month COBRA period, but did not elect it, or it later lapsed. If you qualify under this exception, however, you will be subject to the Pool’s pre-existing condition exclusion period for at least 180 days.)
III. You have terminated Health Pool coverage within 12 months prior to application for Health Pool coverage, unless there’s a good faith reason for such termination; or
- You are confined to county jail or prison; or
- You had prior Health Pool coverage terminated for fraud; or
- You had prior coverage with the Health Pool that was terminated for nonpayment of premiums within 12 months
prior to application for subsequent coverage; or
VII. You have received $4,000,000 in benefits from the Health Pool; or
VIII. You will have premiums paid or reimbursed by or through a government sponsored program or government
agency, or by a health care provider.
- DefinitionPreexisting Conditionmeans a disease or condition for which the existence of symptoms would cause a prudent person to seek diagnosis, care or treatment during the 6 months before an Insured Person’s effective date of Pool coverage, or for which medical advice, care or treatment was recommended or received during the 6 months before an Insured Person’s Pool coverage date. Preexisting Condition includes a preexisting pregnancy or a complication of a preexisting pregnancy, whether the complication occurs before or after the effective date of Pool coverage. Preexisting Condition does not include genetic information in the absence of a diagnosis of the condition related to the genetic information.
- Preexisting Condition Exclusions/LimitationsUnless you have credit for prior coverage, during the first 12 months following the effective date of Health Pool coverage the policy does not pay benefits for any charges or expenses for any Preexisting Conditions (except as indicated below).A. The Preexisting Condition limitation does not apply if an individual was continuously covered for an aggregate period of at least 12 months under Creditable Coverage that was in effect up to a date not more than 63 days before the individual’s effective date of coverage through the Health Pool (excluding any waiting period under the prior health coverage) provided that the individual’s application for coverage through the Health Pool was made no later than 63 days following termination of the prior health coverage.B. The Preexisting Condition limitation will not apply to an Insured Person who has been continuously covered, since birth, adoption or Your suit for adoption of the Insured Person by Creditable Coverage which was in effect up to a date not more than 63 days before the Insured Person’s effective date under this Policy, excluding any waiting period, provided that application for coverage under this Policy for the Insured Person is made no later than 63 days following the termination of such Creditable Coverage.C. In determining whether a Preexisting Condition limitation applies, credit is given for the time an individual was covered under any prior Creditable Coverage (including any waiting period for such coverage) that was in effect at any time during the 12 months before the effective date of Health Pool coverage.
- NOTE: An individual who qualifies under the state continuation or COBRA exception will be subject to a minimum 6-month waiting period.
Qualifying Medical/Health Conditions