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:
- A notice that an Insurance Company rejected or refused to issue substantially similar individual Health Benefit Plan coverage for health reasons.
- Certification from an insurance agent or representative stating they cannot obtain substantially similar individual coverage for You because of Your medical condition.
- An offer of substantially similar coverage that includes conditional riders excluding medical conditions.
- 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:
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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.
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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.
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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.
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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.
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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.
- You are confined in a county jail or imprisoned in a state or federal prison.
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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.
- Your previous Pool coverage was terminated for nonpayment of premiums within the previous 12 months.
- Your previous Pool coverage was terminated for fraud.
- You have already received $2,000,000 in benefits from the Pool under this or any previous Pool policy.