The Texas Health Insurance Pool (the Pool) was created by the Texas legislature to offer health insurance to Texas residents who are unable to obtain adequate health coverage due to medical conditions or who qualify as Federally Eligible Individuals under HIPAA (1996).
I. READ YOUR POLICY CAREFULLY.
This outline of coverage provides a brief description of the important features of your policy. It is not the insurance policy itself. Only the actual policy provisions control your rights and obligations. Your application and acceptance of the policy constitute your agreement to its terms and limitations.
II. This Policy provides coverage for major hospital, medical, and surgical expenses resulting from a covered injury or sickness.
Only eligible individuals, their Dependents, and Family Members are eligible for coverage. A separate policy is issued to each qualifying individual.
A. Eligibility for Coverage
1. You are eligible if you:
– Are a legal resident of Texas.
– Are a Federally Eligible Individual.
– Have not experienced a Significant Break in Coverage.
2. You are eligible if you:
– Are under age 65.
– Are a legal resident of Texas.
– Previously had HIPAA-qualified coverage in another state that ended because you moved from that state.
– Apply within 63 days after that coverage ends.
3. You are eligible if you:
– Are under age 65 (or over 65 and not enrolled in Medicare Part B).
– Are a legal resident of Texas.
– Qualify under the Trade Adjustment Assistance or Pension Benefit Guaranty Corporation (HCTC Program).
4. You are eligible if you:
– Are under age 65.
– Have been a legal resident of Texas for at least 30 days.
– Are a U.S. citizen or permanent legal resident for at least three continuous years.
– Provide one of the following:
– A rejection or refusal from an insurance company due to health reasons.
– Certification from an insurance agent that substantially similar coverage cannot be obtained because of your medical condition.
– An offer of coverage only with riders excluding medical conditions.
– A diagnosis or treatment within the past 5 years for one of these conditions:
– Addison’s Disease
– AIDS/HIV
– Amyotrophic Lateral Sclerosis (ALS)
– Angina Pectoris
– Artificial Heart Valve
– Brain Tumor
– Cardiomyopathy
– Cerebral Palsy
– Chronic Liver Failure
– Cirrhosis (non-alcoholic)
– Congestive Heart Failure
– Coronary Artery Disease
– Crohn’s Disease
– Cystic Fibrosis
– Dementia (including Alzheimer’s)
– Dermatomyositis
– Diabetes Mellitus
– Down’s Syndrome
– Epilepsy
– Friedreich’s Ataxia
– Guillain-Barré Syndrome
– Heart Attack
– Hemophilia
– Hepatitis
– Hodgkin’s Disease
– Huntington’s Chorea
– Hydrocephalus
– Intermittent Claudication
– Lead Poisoning with Cerebral Involvement
– Leukemia
– Lupus
– Metastatic Cancer
– Muscular Atrophy or Dystrophy
– Myasthenia Gravis
– Myotonia
– Organ Transplants (except corneal)
– Paraplegia or Quadriplegia
– Parkinson’s Disease
– Peripheral Vascular Disease
– Polycystic Kidney
– Polymyositis
– Psychotic Disorders
– Rheumatoid Arthritis
– Scleroderma
– Multiple Sclerosis
– Sickle Cell Anemia
– Silicosis (Black Lung)
– Stroke
– Syringomyelia
– Tabes Dorsalis (Locomotor Ataxia)
– Malignant Tumor
– Ulcerative Colitis
– Wilson’s Disease
5. Dependents
Your Dependents are also eligible for coverage. If the eligible individual is a child, a Family Member living with the child is also eligible.
Dependents and eligible Family Members must:
– Be under age 65.
– Have been legal residents of Texas for at least 30 days.
– Remain legal residents of Texas.
– Be U.S. citizens or permanent legal residents for at least three continuous years.