Category: General Info

Instructions

Important: Do Not file this form if your Provider of Service is submitting these charges to Blue Cross and Blue Shield of Texas. Please complete every item on claim form.

Insured’s/Subscriber’s Name, Address and Employment Status

Please show the insured’s/subscriber’s name exactly as it appears on the Blue Cross and Blue Shield of Texas identification card and specify the current address including the ZIP code. Check the appropriate box indicating the insured’s/subscriber’s employment status. If retired, give the date of retirement.

Patient Information

Make sure the group number and identification number are exactly as shown on the insured’s identification card. List the patient’s full name; no nicknames or initials please. Check the appropriate blocks for the patient’s sex and relationship to the insured. Ensure the patient’s correct date of birth is shown.

Type of Treatment Received

Check only one treatment type (injury, illness, pregnancy or preventive care) and specify the date of injury, date of first symptom, date of conception or date preventive care was received. You may attach multiple itemized statements if they are for one type of treatment (example: illness only, preventive care only).

Diagnosis or Symptoms of Illness or Injury

Give the diagnosis or a brief description of symptoms. If preventive care services were received, state the type of care (routine physical, hearing exam, vision exam or immunization diagnosis, etc.).

If Illness or Injury is in any way work related

Check the appropriate box and enter the name and address of the employer.

If Motor Vehicle Injury

Check the appropriate box.

Other Insurance

Please check the appropriate box. If “yes,” complete the required information.

Medicare Information

Please check the appropriate box concerning Medicare eligibility. If “yes,” show the effective date and give the Medicare identification number.

Medicare enrollees should include a copy(s) of the Medicare Explanation of Benefits Form(s) (EOB) with their itemized statements unless the patient is actively employed and requires group coverage to pay primary.

Insured’s Signature, Date and Daytime Phone

Please sign and date this form and attach your physician’s itemized letterhead statement(s).

Read more

Tape receipt for prescription 1 here.
Receipts must contain the following information:
• Date prescription filled
• Name and address of pharmacy
• Doctor name or ID number
• NDC number (drug number)
• Name of drug and strength
• Quantity and days’ supply
• Prescription number (Rx number)
• DAW (Dispense As Written)
• Amount paid
Tape receipt for prescription 2 here.
Receipts must contain the following information:
• Date prescription filled
• Name and address of pharmacy
• Doctor name or ID number
• NDC number (drug number)
• Name of drug and strength
• Quantity and days’ supply
• Prescription number (Rx number)
• DAW (Dispense As Written)
• Amount paid

Read more

AUSTIN – This is National Cover the Uninsured Week, and events across the country are highlighting the problem of the uninsured and proposing strategies to help more people find health coverage to protect themselves and their families from the high cost of medical care. Unfortunately, Texas leads the nation in the rate of uninsured. Approximately one in four Texans does not have health coverage. That’s about five and a half million men, women and children.

One factor cited as a reason why individuals, families and companies do not purchase health insurance is a lack of knowledge about how to shop for health care coverage or where to turn for a list of available resources. In Texas the answer is: www.TexasHealthOptions.com.

TexasHealthOptions.com is a comprehensive starting point for anyone seeking information about how to go about finding health care insurance, or in some cases, options for low-cost or free health care services. The website guides consumers through a series of questions designed to help them determine what type of coverage they need, and whether they may be eligible for various types of public coverage. Information and links are provided to a large number of public programs and informational resources.

The website can be accessed from the TDI homepage, www.tdi.state.tx.us, or directly at www.TexasHealthOptions.com. Both English and Spanish versions are available.

Business owners considering providing health benefits to their employees can visit TDI’s Business Resources page at: http://www.tdi.state.tx.us/commish/smbiz.html. There they can find information about options such as Consumer Choice Plans, Small Employer Health Coalitions and Health Group Cooperatives, tailored to meet their particular needs.

There are options for finding and obtaining health coverage in Texas. And doing so is critical to a person’s well being. Besides the health risks associated with not having access to regular medical care, a serious illness or injury can easily wipe out an uninsured family’s bank account. TDI encourages all consumers to be proactive and investigate the options available to them, by contacting a local insurance agent or visiting www.TexasHealthOptions.com. If you need more help getting started, call the TDI Consumer Help Line at 1-800-252-3439.

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.

Read more

This Policy is issued in consideration of the application and the payment of premium. We agree to provide the benefits of the Policy for Covered Expenses incurred by You. The effective date of coverage is shown in the Policy Schedule. A copy of Your application is attached.

SECTION 1. 10-DAY RIGHT TO EXAMINE POLICY

Please read Your Policy. If You are not satisfied, send it back to the Administrator within 10 days after You receive it. The Policy will be voided and any premium paid returned to You.

SECTION 2. PLEASE READ APPLICATION

Please read the copy of Your application. If anything is not correct, You should tell the Administrator. The Policy was issued on the basis that all information in the application is correct and complete. If not, Your Policy may not be valid.

SECTION 3. ELIGIBILITY FOR COVERAGE

You are eligible for coverage by the Pool if:

• You are and remain a legal resident of Texas.
• You provide evidence that You are a Federally Defined Eligible Individual who has not experienced a Significant Break in Coverage.

You are eligible for coverage by the Pool if:

• You are under age 65.
• You are and remain a legal resident of Texas.
• You provide evidence that You maintained Health Benefit Plan coverage under another state’s qualified HIPAA health program that ended because You no longer resided in that state.
• You submit an application for Pool coverage no later than the 63rd day after the prior coverage terminated.

You are eligible for coverage by the Pool if:

• You are under age 65 (or over age 65 and not enrolled in Medicare Part B).
• You remain a legal resident of Texas.
• You provide evidence that You are certified as eligible under Trade Adjustment Assistance or the Pension Benefit Guaranty Corporation (HCTC Program).

Note: Federal law does not permit You to have other first-dollar medical coverage if You intend to use this Policy as an HSA-qualified policy.

You are eligible for coverage by the Pool if:

• You are under age 65.
• You have been, for at least 30 days, and remain a legal resident of Texas.
• You are a United States citizen or permanent legal resident for at least three continuous years.
• You provide one of the following:
  1. A notice that an Insurance Company rejected or refused to issue substantially similar individual Health Benefit Plan coverage for health reasons.
  2. Certification from an insurance agent or representative stating they cannot obtain substantially similar individual coverage for You because of Your medical condition.
  3. An offer of substantially similar coverage that includes conditional riders excluding medical conditions.
  4. A diagnosis of one of the medical conditions designated by the Pool Board of Directors for automatic eligibility.

You are eligible for coverage by the Pool if:

• You are a Dependent of an eligible individual; or
• You are a Family Member living with an eligible child who enrolls for Pool coverage.

In either case, You must:

• Be under age 65.
• Have been, for at least 30 days, and remain a legal resident of Texas.
• Be a United States citizen or permanent legal resident for at least three continuous years.

---

You are not eligible for Pool coverage if any of the following apply:

1. You already have other Health Benefit Plan coverage in effect on the date Pool coverage would begin.

   Exception: does not apply to eligibility under the HCTC Program.

   Note: Federal law does not permit other first-dollar medical coverage if this Policy is used as an HSA-qualified policy.

2. You are eligible for or covered by a Group Health Plan, Church Plan, Governmental Plan, self-insured health plan, or continuation coverage under federal or state law, unless one of the following exceptions applies:

   • Your current coverage is maintained only long enough to satisfy a preexisting condition limitation or waiting period.
   • Your current plan excludes coverage for an individual or limits coverage through conditional riders.
   • You are a part-time employee (usually working fewer than 30 hours per week), and:
     • the employer’s plan is more limited than Pool coverage;
     • the employer pays none of the cost of coverage;
     • documentation proving both conditions is provided.

   • You were eligible for COBRA or comparable continuation coverage but:

     • did not elect continuation;
     • or Your continuation coverage lapsed or was canceled without reinstatement.

     In this case:

     • You are subject to at least a 180-day exclusion for any preexisting condition, regardless of prior creditable coverage.
     • The 180-day exclusion does not apply if You maintained federal continuation coverage for the maximum period allowed.

   Note: A dependent covered under the prior Group Health Plan is entitled to continuation coverage regardless of whether the employee elects continuation.

3. You are covered by an individual Health Benefit Plan unless You cancel that coverage before Pool coverage becomes effective.

   If the individual policy excludes certain medical conditions, it may remain in force. During that time, Pool coverage will be secondary.

   Note: Federal law does not permit other first-dollar medical coverage if this Policy is used as an HSA-qualified policy.

4. You terminated Pool coverage within the previous 12 months unless You demonstrate a good-faith reason for doing so.

   This does not apply to Federally Defined Eligible Individuals.

5. You are confined in a county jail or imprisoned in a state or federal prison.

6. Your premiums are paid or reimbursed by a government-sponsored program, government agency, or health care provider.

   Exception: does not apply to eligibility under the HCTC Program.

7. Your previous Pool coverage was terminated for nonpayment of premiums within the previous 12 months.
8. Your previous Pool coverage was terminated for fraud.
9. You have already received $2,000,000 in benefits from the Pool under this or any previous Pool policy.

Your Prescription
Drug Benefit
Handbook

How to get the most from your new benefit

Welcome!
We’re proud that the Texas Health Insurance Pool has chosen Medco to manage your prescription drug benefit for retail and mail-order services. You’re now with the industry leader. Medco has provided quality prescription drug benefit services to millions of Americans for over 30 years.
What’s inside:
Your prescription drug benefit at a glance . . . . . . . . . . . . . . . . . . . 3
Medications preferred by your plan . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Your pharmacy options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Online services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
General information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Other things you should know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Use Medco By Mail to get up to a 90-day supply of your medication, often for less than you would pay at a drugstore. See “Your pharmacy options” for details.

Read more

IMPORTANT NOTICE

YOUR TEXAS HEALTH INSURANCE POOL COVERAGE IS ENDING

With implementation of health insurance reform well under way, Texas Health Insurance Pool (THIP) members, like you, will soon have new options for coverage.

As of January 1, 2014, you can no longer be denied a health insurance policy because of your pre-existing health condition, and you are guaranteed coverage at the same premium rate as others your age.

As a result of these changes, the THIP program will no longer be needed and will soon cease operations. THIP health insurance coverage will end at midnight December 31, 2013.

Beginning October 1, 2013, you will be able to purchase a health insurance policy through a new online Marketplace at Healthcare.gov, or directly from an insurance company, for coverage starting January 1, 2014. Either way you shop for new coverage, you can get professional assistance from a licensed health insurance agent at no additional cost.

If you purchase a policy through Healthcare.gov, you may qualify for tax credits to help pay your premiums and subsidies to lower your out-of-pocket health care costs. These tax credits and subsidies are available only if you purchase coverage through the Marketplace. At Healthcare.gov, you will see multiple policies and prices from various insurance companies, making it easier to compare plans and select the one that best suits your needs. Your new coverage can begin as early as January 1, 2014, provided you enroll by December 15, 2013. If you enroll after December 15, you will have a gap in coverage.

Enhanced benefits, such as no lifetime maximum and 100% coverage for certain preventive care services, will be available to you through all new health insurance policies offered both on and outside the Marketplace. Also, all policies will cover a comprehensive range of benefits, including doctor visits, hospitalization, and prescriptions. It is very important that you prepare now for your new insurance coverage. Mark your calendar to start shopping for a new policy on October 1st. If you have any questions about this notice, please call THIP Customer Service at 1.888.398.3927, or email us at: [email protected]. To learn more about your new coverage options, visit www.healthcare.gov or call 1.800.318.2596 for more information.

Read more