Texas Health Insurance Pool

Texas Health Insurance Risk Pool

Guaranteed Issue Health Insurance Texas

Now available to Texans that have A Pre-Existing Condition and have been declined. THIS IS NOT A DISCOUNT PLAN but the Government Guarantee Issue Health Insurance.



Premium rates for Texas

Here are the 2011 monthly PCIP premium rates for Texas by the age of an enrollee, effective July 1, 2011.

Age Standard Option Extended Option HSA Option
0 to 18 $133 $179 $138
19 to 34 $199 $268 $207
35 to 44 $239 $323 $248
45 to 54 $306 $412 $318
55+ $426 $572 $442

Texas High Risk Health Pool

History of the Pool

The Texas Health Insurance Pool was created by the Texas Legislature to provide health insurance to eligible Texas residents who, due to medical conditions, are unable to obtain coverage from individual commercial insurers. The Pool also serves as the Texas alternative mechanism for individual health insurance coverage, guaranteeing portability of coverage to qualified individuals who lose coverage under an employer group plan, church plan or state plan, as mandated by the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Program continues to serve the State of Texas as an important “safety net” for individuals who have been denied health insurance coverage because of pre-existing conditions, can afford the Pool’s premiums, and do not have other coverage options. Learn more about from these dentitox pro reviews.

The Texas Health Insurance Pool is the state’s HIPAA mechanism and the insurer of last resort for Texans unable to obtain individual health insurance due to their pre-existing medical conditions or other qualifying criteria. The Pool may assess “health benefit plan issuers” pursuant to Chapter 1506 of the Texas Insurance Code. The Pool has developed reporting forms that will be used to collect the 2009 data necessary to determine the 2009 Regular Assessment and the 2010 Interim Assessment. Both the Covered Lives Reporting Form and the HEALTH BENEFIT PLAN PREMIUMS REPORTING FORM must be completed and returned by the due date, and include all supporting documentation required.
* The Coinsurance Maximum for Non-PPO Providers for all plans is $10,000 in a Calendar Year.

* The Lifetime Maximum benefit for all plans is $3,000,000.

* Plans III, IV and V are not available to individuals eligible for Medicare. Plans I & II are available to supplement Medicare Disability. Plans I and II do not provide outpatient prescription drug benefits to Medicare-eligibles due to the availability of Medicare Part D.


The Calendar Year Deductible, the Emergency Care Deductible, Physician Office Visit Copayments, and Charges for Outpatient Prescription Drugs DO NOT COUNT toward the Coinsurance Maximums.

After the insured pays the medical deductible for the policy, the policy pays the amount of Covered Expenses in excess of the Coinsurance Amount subject to policy limits. For Covered Expenses from a Preferred Provider, once you have paid your Coinsurance Maximum, the policy pays 100% of Covered Expenses from Preferred Providers for the rest of the Calendar Year. In no event will the policy pay more than the Lifetime Maximum for each Insured Person.

The deductible amount selected may not be changed to a lower amount after the Policy is issued. You may request to change to a higher deductible, if offered, but only one such change will be allowed in a calendar year. The change will be effective on the first of the month following the date your written request is received, or a later date if requested. Read how revitaa pro works.

Summary-Health Pool Plan Benefits

[see Outline and Policy for specifics related to each benefit]
Hospital Average semi-private room rate. No more than one visit per physician per day
Intensive Care or Cardiac Care Unit No more than 3 times the average semi-private room rate
Assistant Surgeon or Surgical First Assistant One assistant, no more than 25% of the primary surgeon’s fee
Hospital or other facility for Emergency Care Subject to additional $100 deductible per visit (not credited toward coinsurance maximum). Does not apply to Plan V
Physician Office Visits-for covered illness or injury PPO Plan: $30 copayment per visit, for first 6 visits per calendar year. Thereafter, visits are subject to Calendar Year Deductible & Coinsurance. Non-PPO Plan: Subject to Calendar Year Deductible and/or Coinsurance
Home Health Care Lesser of 60 visits or $5,000 per calendar year
Skilled Nursing Facility 45 days per calendar year
Hospice Care Lesser of 180 days or $10,000 lifetime maximum
Named Transplants Subject to a lifetime combined maximum benefit for all transplants of $300,000. Transplants covered include: kidney, pancreas, heart, liver, lung and bone marrow. Includes preparation and transportation.
Physical, Speech, Occupational Therapy $5,000 per calendar year
Serious Mental Illness Calendar year maximum benefit of 30 inpatient days and 50 outpatient visits.
Preauthorization Provisions If a preauthorization requirement is not met, benefits for covered services and supplies will be reduced 50%.

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Preauthorization required for: inpatient admissions, skilled nursing facility admissions; home health care services, home infusion therapy, hospice care, transplants, and durable medical equipment over $2,000.
Outpatient Prescription Drugs
See Pharmacy Program page of website.

Summary – Other Health Pool Medical Plan Benefits

[See Outline and Policy for specifics related to each benefit]

* Acquired Brain Injury

* Ambulance

* Anesthesia

* Blood

* Breast Reconstruction in connection with mastectomy

* Diabetes

* Durable Medical Equipment

* Genetic Testing and Counseling

* Home infusion therapy

* Hospital/Surgical

* Miscellaneous Hospital Services and Supplies

* Outpatient Care

* Outpatient contraceptive services

* Oxygen

* Physical, Occupational, Speech, Language Therapy

* Preadmission Testing

* Complications of Pregnancy

* Preventive Care

* Prosthetic Devices

* Radiation Therapy, Inhalation Therapy, Chemotherapy

* Second Surgical Opinion

* Surgeons

* Surgical Services and Supplies from an Ambulatory Surgical Center and Hospital Outpatient Facility

* X-rays and Laboratory Tests

BlueChoice® Network

The Pool has selected the BlueChoice® Network as the Pool’s Preferred Provider Organization (PPO). Although you may choose any medical provider or hospital, you will save money by using providers from the BlueChoice® Network.

If you choose a BlueChoice provider, the Policy will pay a greater coinsurance rate and the BlueChoice provider’s rate will be based on the contract rate of the network. If you choose a Non- Preferred Provider, the Policy will pay a lower coinsurance rate and there is no coinsurance maximum. Also, Covered Expenses for a Non-Preferred Provider will be based on the Allowable Amount, which may be less than the provider’s billed rate and which could result in a greater expense to you.

If you choose not to use a BlueChoice® provider, it is still beneficial to use a “ParPlan” provider. While not a network preferred provider, a ParPlan provider will not bill you for the difference between covered expenses and the provider’s billed charges.

There are other advantages to using BlueChoice and ParPlan providers. They will handle the initial paperwork so you do not have to file claims. They may also precertify benefits for you, although it is ultimately your responsibility to ensure that your services have been authorized by the Pool. Prevent most dental conditions with dentitox pro.

If there are no BlueChoice providers available to you, you must contact the Administrator’s precertification referral department at its toll free number. Generally, a BlueChoice provider will be considered to be unavailable to you if you reside more than 30 miles from a BlueChoice provider. If there are no BlueChoice providers available to you and you contact the Administrator before obtaining services from a Non Preferred Provider, Covered Expenses for treatment or services by the Non Preferred Provider will be paid at the Preferred Provider coinsurance level.

If an Insured Person’s Preferred Provider’s arrangement with the Network, chosen by the Pool for this Policy, terminates and, at the time of such termination, the Insured Person has special circumstances, benefits for Covered Expenses received from that provider will be paid as if the Covered Expenses were received from a Preferred Provider until: in the case of an Insured Person who has been diagnosed with a terminal illness, the end of nine months after the effective date of termination; in the case of an Insured Person who, at the time of termination, is past the 24th week of pregnancy, delivery of the child, immediate post-partum care and the follow-up checkup within the first six weeks after the delivery; or in all other special circumstances, the end of 90 days after the date of termination.
BlueCard Program

The BlueCard Program provides access to Preferred Providers of other Blue Cross and  Blue Shield  Texas Plans outside Texas. If You incur expenses outside Texas through the BlueCard Program, You must pay the Preferred Provider Coinsurance amounts after satisfaction of the Deductible. Covered Expenses for a BlueCard program provider will be calculated using the lesser of the billed charges of the BlueCard provider or the negotiated rate the Administrator pays the local Blue Cross and/or Blue Shield Plan.

Preexisting Condition Limitation

During the first 12 months following the effective date of coverage, the Policy will not pay benefits for any charges or expenses for a preexisting condition.
This waiting period will be reduced by the number of months the Insured was covered by creditable coverage in place during the 12 months before the
Pool policy effective date.

Insureds who enroll under the COBRA exception and did not exhaust continuation are subject to a minimum 6-month preexisting condition waiting period.

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