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1. What is the Texas Health Insurance Risk Pool? The Texas Health Insurance Risk Pool is an individual  health insurance program created by the Texas Legislature to provide health insurance to Texas residents who either (i) cannot obtain adequate health insurance coverage as a result of their medical conditions, or (ii) are considered “Federally Eligible Individuals,” as defined by the Health Insurance Portability and Accountability Act of 1996, commonly referred to as HIPAA.
2. When was the Health Pool started? The Health Pool was originally created by the Legislature in 1989 in a bill sponsored by Representative John Gavin. The Legislature, however, did not provide funding for the operation of the Health Pool. In 1997, the 75th Legislature amended the 1989 legislation in a bill sponsored by Senator David Sibley and Representative Kip Averitt, which, among other changes, provided a funding mechanism. It also included $500,000 of state appropriated funds to cover the start up expenses of the Health Pool.
3. Who manages the Health Pool? The Health Pool is managed by a nine member Board of Directors, appointed by the Commissioner of Insurance. The Executive Director’s office oversees the day-to-day operation of the Pool.
4. Who can be a member of the Board?The statute requires that certain interests be represented on the Board of Directors. These are: health insurance companies and persons who are eligible or who are parents of someone eligible for the Health Pool coverage. Additionally, Board members may be physicians, hospital administrators, advanced nurse practitioners or members of the general public, not affiliated with the insurance and health care industries.
5. Who are the current members of the Board?
   • Gary C. Cole, Chair - Public Representative
   • Phyllis Gordon, APRN, Vice Chair - Professional Representative.
   • D. Greg Barbutti, Secretary/Treasurer -  Insured Representative
   • Ed Baxter,  Public Representative
   • Robert Emmick, M.D. - Professional Representative.
   • Pati McCandless - Industry Representative
   • Rick Ott, CLU, LUTCF - Industry Representative.
   • William C. Rainey, M.D.- Insured Representative
   • Vacant
6. When did the Health Pool begin operations? The first Health Pool policies were effective February 1, 1998.
7. What type of health insurance is provided by the Health Pool? The policy issued by the Health Pool provides major medical expense coverage including coverage for prescription drugs. Benefits are provided up to a $1,500,000  lifetime maximum benefit. The coverage is subject to a calendar year deductible and coinsurance payments by the policyholder. For a more complete explanation, see the outline of coverage.
8. How are the operations of the Health Pool financed?The Health Pool charges premiums for the policies that it issues. When claims and expenses for the Health Pool’s operation exceed collected premium, the Health Pool  collects additional funds from the health benefit issuers through assessments.
9. Who sets the premiums charged? The Board of Directors recommends the premium rates to be charged and the Insurance Commissioner approves the rates.  Rates shall not exceed 200% of the standard premium rate.
10. What is a standard premium rate? A standard premium rate is a rate typically charged by commercial carriers for similar coverage. The Board of Directors engages an independent actuarial firm to set a standard rate for the commercial market. The Board uses this standard rate when setting the premium rates for the Health Pool policy.
11. What premium is charged for the Health Pool policy?Effective January 2004, the multiplier above the standard premium rate was raised to the 200% statutory limit. Rates will continue to be reviewed twice a year and raised, when necessary, to maintain this level above the standard rate.
    For a more complete description of premiums, see the Rate Information page.
12. Who is eligible for the Health Pool Coverage? See Health Pool Eligibility
13. How do I apply for coverage? Interested persons may request an application by contacting the Health Pool at (888) 398-3927 (e-mail address, texasriskpool@bcbstx.com). The application package will contain an Outline of Coverage, an Application for Coverage and a table of premium rates. You can also download the application package - See Application. Anyone interested in applying must return the completed application with the appropriate amount of premium. If the applicant is accepted, coverage becomes effective on the first day of the month following approval of the application by the Health Pool administrator.
14. Can I be turned down for coverage? Yes.  See Health Pool Non-Eligibility.
15. What about preexisting conditions? See Health Pool Eligibility - Preexisting Conditions
    

   16.  Can I obtain or keep Pool coverage if I am under
age 65 and I become eligible for Medicare
disability?

          In the case of coverage by Medicare, you are allowed to retain
Medicare coverage if you otherwise qualify for the Pool, but the
Pool will provide medical coverage on a secondary basis, and
no coverage for outpatient prescription drugs.

   17.   Can I go to any doctor or hospital?

             The Health Pool Board of Directors selected the BlueChoice
Network as its Preferred Provider Organization (”PPO”).  An
individual covered by the Health Pool may go to any medical
provider or hospital he or she chooses.  However, if the covered
individual chooses a BlueChoice provider, the individual will pay
a smaller coinsurance payment.  If the person chooses a provider
outside the network, the person will pay a higher coinsurance
payment.  In addition, PPO providers do not charge the covered
person for charges in excess of the PPO contract rate.  A
non-PPO provider, that is not a ParPlan provider, may charge the
difference between the benefits paid by the Pool and the
provider’s billed rate; therefore, the Pool member will be
responsible for any charges over the allowed amount.

18.  What are the health care benefits provided by the Health Pool?

         After the covered individual has satisfied the deductible each
year,   the Health Pool will pay the amount of covered expenses in
excess of the required coinsurance amount, payable by the
individual, until the individual meets the  coinsurance maximum for
the year.  After the individual meets the coinsurance maximum for
the year for PPO covered expenses, the Health Pool will pay
100% of covered expenses for the remainder of the year, subject
to the maximum lifetime benefit amount of $1,500,000. It should
be noted that the calendar year deductible, the emergency care
deductible and charges for outpatient prescription drugs do not
count towards the annual coinsurance maximum.

  19. What are the deductible amounts?

        The Health Pool offers three plans. Plan I has a $1,000 deductible,
Plan II has a $2,500 deductible, and Plan III has a $5,000
deductible.  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.

20. What are the coinsurance amounts? In addition, the policy requires a 20% coinsurance payment for PPO providers and 40% for non-PPO providers. The annual out-of-pocket coinsurance maximum is $3,000 for PPO providers.  There is no coinsurance maximum for covered expenses from non-PPO providers.
21. What are the policy exclusions? See Health Pool Benefits and Exclusions.
22. When does the policy terminate? The Health Pool may cancel coverage for non-payment of premiums within the 31-day grace period.

    The policy is renewed each time the required premium is timely paid, but coverage will terminate for each person insured under this Policy:

    a) 31 days after the day on which a premium payment for the Policy becomes due if payment is not made before that date;

    b) the earlier of the premium due date or the first day of the month that follows the date on which the Pool determines:
    1) an Insured Person is no
    longer eligible for coverage
    under the Pool;
    2) an Insured Person is no longer
    a resident of the state of
    Texas except for: a child who
    is student under the age of 25
    and financially dependent upon
    You or Your spouse; a child
    for whom You and Your
    spouse is obligated to pay child
    support; or a child of any age
    who is disabled and
    dependent on You or Your
    spouse;
    3) an Insured Person is 65 years
    old;

    c) 30 days after the date We make inquiry concerning an Insured Person’s place of residence or any other eligibility criteria and You do not reply;

    d) You request coverage to end;

    e) on the date of death; or

    f) state law requires cancellation of this Policy.

23. How are payments of premiums handled? Premium may be paid monthly by automatic bank withdrawal or quarterly, semi-annually or annually by direct payment. Rates are based on age, gender, zip code and smoker status. Rates are subject to change with 30-days notice. An initial premium payment must be submitted with each application.