Insurance for Texans with Disabilities
(January 2012)
Fourteen percent of Texans have a mental or physical disability. People with disabilities often have trouble getting insurance and can have other insurance-related problems, such as claim denials, higher premiums, cancellations, and policy renewal refusals.
Overview
A disability is a physical or mental impairment that substantially limits a person’s ability to walk, breathe, hear, see, learn, work, or perform manual tasks.
Insurance companies consider your risk factors when deciding whether they want to sell you a policy. This is called underwriting. A company deciding whether to issue health care coverage will typically consider your age, occupation, medical history, and current health status, which includes your disability.
If your individual risk factors indicate that you are likely to have claims, the company may charge you more for your policy or refuse to cover you. For example, if you have a vision impairment that statistics show could increase the likelihood that you’ll have an accident, then a company may not want to sell you auto insurance.
Not all disabilities will prevent you from getting insurance. For example, if there’s no statistical evidence that people with vision impairment pose a higher risk for a health insurance claim than other people, then the company should give you the same consideration as anyone else.
Your Rights
The Texas Insurance Code prohibits insurance companies from denying, refusing to renew, limiting, or charging more for coverage because of a disability, unless the company can show that the disability statistically increases the chances that you’ll have a claim. The Texas Administrative Code has similar language to prohibit discrimination based solely on blindness or partial blindness.
The federal Americans with Disabilities Act (ADA) provides additional protections. For more information, call the ADA Technical Assistance Center or visit its website
1-800-514-0301
1-800-514-0383 (TTY)
www.ada.gov/taprog.htm
If a company won’t sell you a policy or cancels or refuses to renew your policy, ask why. Most auto and homeowners companies must give you their reasons in writing... The company must explain exactly what incident, circumstance, or risk factor violated the company’s underwriting guidelines. The company must also give you its sources of information.
Life and health insurance companies that issue individual policies are not required to give a written explanation of their decision.
How to Get Help
If you think an insurance company has treated you unfairly or won’t answer your questions, you have the right to file a complaint with the Texas Department of Insurance (TDI). For more information, call TDI’s Consumer Help Line or visit our website
1-800-252-3439
463-6515 in Austin
www.tdi.texas.gov
You can also file a complaint with the ADA Technical Assistance Center. For more information, call the ADA Technical Assistance Center.
Note: If you receive health insurance through your employer, you must file your ADA complaint with the Texas Workforce Commission’s Civil Rights Division. For more information, contact the division
1-888-452-4778
463-2642 in Austin
www.twc.state.tx.us
Get Legal Advice
You may find inexpensive or free legal assistance through local or government-sponsored assistance programs in your area.
The Texas Legal Services Center is a nonprofit organization that provides legal resources to Texans. Its TexasLawHelp.org website offers free information and helps people who can’t afford attorneys find free and low-cost legal aid. TLSC also operates the Legal Hotline for Texans for people who are over age 60 or on Medicare.
1-800-622-2520
www.tlsc.org
Check the phone book or Internet or call local bar associations and legal referral services for attorneys willing to help. Some attorneys may accept your case on a contingency basis, which means they will receive a percentage of any judgment you win.
Health Insurance Coverage Issues
Preexisting Conditions
If you are looking for health care coverage and you have a preexisting condition (a current or past health problem), you must tell the company about it when you apply for insurance. If you don’t tell the company, it could deny your claims or cancel your policy.
Some companies define a preexisting condition as any health condition that required you to seek medical advice, care, diagnosis, or treatment during a certain period. If you have questions about preexisting condition disclosures, contact the company before signing the application.
Federal law prohibits health plans from denying coverage or applying preexisting condition exclusions to coverage for children under age 19.
If a company offers you a policy, it may decide not to offer coverage for your preexisting conditions. They do this by attaching an exclusion rider to your policy. Employer group, Medicare supplement, and long-term care policies cannot have exclusion riders.
Waiting Periods
Some health plans have a standard waiting period before new members are eligible to receive any benefits, regardless of whether they have a preexisting condition. This means that your policy will not pay for any care you receive until the waiting period ends.
If you’re switching health plans or have recently had health coverage, you may have a shorter waiting period, as long as there is not a gap in coverage greater than 63 days. Prior coverage reduces your waiting period time on a month-for-month basis.
The following table summarizes how health plans handle preexisting conditions:
| Group Plan | Individual Plan | |
| Waiting period before a preexisting condition is covered | 12 months for plans offered by employers; up to 24 months for non-employer plans (from churches, unions, associations, etc.). Company may also impose a general waiting period for up to 90 days for all coverage. | Up to 18 months (12 months for those 65 or older). |
| Prior coverage |
Prior coverage is credited on a month-for-month basis. If previous coverage lasted 12 months, there is not waiting period for an employer group plan. However, coverage is only required at the level of the prior plan. Company may not include a rider specific to the employee that eliminates coverage for the preexisting condition. |
Prior coverage is credited on a month-for-month basis. Company may refuse to accept you because of a preexisting condition or may include a rider eliminating coverage for the condition. |
Appeals and IROs
Managed care plans will only pay for treatments it considers medically necessary. If your plan denies a treatment, it must send the denial to your doctor to determine whether the services are medically necessary. If the doctor agrees with the plan’s decision, the denial must include the medical reasons.
If you are not satisfied with the decision, you may file an appeal with the company or plan. Look at your plan documents for details on the appeal process.
Appealing a Denial
After you have exhausted your appeal rights, you can request that the denial be reviewed by an independent review organization (IRO), an independent third-party certified by TDI. The insurance company is required to accept the IRO’s decision and to pay for the review.
Insurance companies are required to give you an independent review request form when they deny a treatment and again if they deny your appeal. You can bypass the appeal process if you or your doctor believes your condition is life threatening.
You have a right to an independent review for denials of
- treatment that the plan considers not to be medically necessary
- treatment that is considered experimental or investigational
- medications that are not on the carrier’s formulary that your provider believes are medically necessary
An independent review is not available if the denied service or treatment is not covered by your plan or if your plan is not required to participate in the IRO review process. For more information about the IRO process, call TDI’s IRO Information Line
1-888-TDI-2IRO (834-2476)
322-3400 in Austin
Other Issues
Managed care plans provide health services to plan members through contracted networks of doctors and hospitals. Some managed care plans require members to use doctors and hospitals within the plan’s network for all routine care.
If a managed care plan stops including your doctor in its network, you can still go to your doctor for up to 90 days if you need treatment for a disability or life-threatening condition. If you are more than 24 weeks pregnant, you can continue to go to your doctor up to six weeks after your delivery. You can continue to go to your doctor for nine months if you are terminally ill.
Individual HMO and PPP plans and hospital medical-surgical insurance policies are guaranteed renewable. Your plan cannot be terminated as long as you pay your premiums.
HMOs and PPPs cannot adopt rules that prevent or discourage doctors from giving information or opinions to patients about
- medical conditions
- treatment options
- health care plan provisions
- status of a health care provider with the HMO
HMOs and insurance companies can be sued for medical malpractice. Companies that receive notice of a potential suit also may ask for an IRO to review the claim.
Health Care Coverage Options
Medicare
Medicare is a federal health insurance program for people 65 or older, some people under 65 with certain disabilities, and people with end-stage renal disease or Lou Gehrig’s disease. If you are on Medicare, it will pay for much – but not all – of your health care needs. Medicare eligibility is determined by the Social Security Administration.
Medicare benefits include
- Medicare Part A hospital or inpatient care
- Medicare Part B medical services and supplies
- Medicare Part D prescription coverage
Medicare Advantage Plans
Medicare Advantage plans are alternatives to original Medicare. If you join a Medicare Advantage plan, the plan will provide your Medicare parts A and B benefits, but you will still be in the Medicare program. Medicare Part D (prescription drug coverage) is only available through approved Medicare drug plans.
Medicare Advantage plans may include managed care plans such as HMOs and PPPs, Medicare special needs plans (SNP), private fee-for-service (PFFS) plans, and Medicare savings account plans (MSA). The special needs plans serve special populations, including people with Medicare and Medicaid, people living in certain institutions, and people with certain chronic illnesses. To be eligible to join a Medicare Advantage plan, you must live in a plan’s service area, be enrolled in Medicare Part A and Part B and, in certain plans, not have end-stage renal (kidney) disease.
For more information about Medicare health plan options, call Medicare or visit its website
1-800-Medicare (1-800-633-4227)
1-877-486-2048 (TDD)
www.medicare.gov
Medicare Supplement Plans
You may buy Medicare supplement insurance to help pay some health care costs that Medicare doesn’t pay. Because it helps cover some of the “gaps” in Medicare coverage, Medicare supplement insurance is often called Medigap insurance. Medicaid, an employer group plan (including TRICARE for Life), or a Medicare Advantage plan might also cover these gaps in Medicare. The 10 Medicare supplement plans (plans A, B, C, D, F, G, K, L, M, and N) offer a different combination of benefits, but they all offer at least these benefits:
- Hospitalization:
- Pays your daily copayments for hospitalization expenses from the 61st through the 90th day of the Medicare benefit period.
- Pays the Medicare Part A copayments for any hospital confinement beyond the 90th day in a benefit period, up to an additional 60 days during your lifetime. (These are your inpatient reserve days. You may use these days when you require more than 90 days in the hospital during a benefit period. When you use a reserve day, it is subtracted from your lifetime total and cannot be used again.)
- Pays the Medicare Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
- Medical expenses: Pays your portion of the 20 percent Part B coinsurance for Medicare-eligible expenses for medical services -- including doctor bills, hospital or home health care, and specified higher payments for certain services under the prospective payment system -- after you have met your Part B deductible. Plans K, L, and N require you to share in the payment of coinsurance.
- Hospice: Pays the coinsurance for out-patient drugs and inpatient respite care. Plans K and L cover this cost at a different rate. You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
- Blood: Pays the reasonable cost of the first three pints of blood each year under Medicare parts A and B.
People under age 65 who receive Medicare due to disabilities may buy a Medicare supplement policy during the six-month open enrollment period beginning the day they enroll in Medicare Part B. You may have a guaranteed issue right to buy a Medicare supplement policy outside of your open enrollment period if you lose certain types of health coverage.
You must have Medicare Part A and Part B to by a Medicare supplement policy. Companies that sell Medicare supplement plans in Texas may not deny you a Plan A policy because you have preexisting conditions. Companies may offer the other plans to Texans with disabilities, but they are not required.
The wait time before a Medicare supplement policy will cover preexisting conditions may not be longer than six months, but will be shorter if you have creditable coverage.
For more information about Medicare supplement insurance, read TDI’s Medicare Supplement Handbook and Rate Guide.
For more information about Medicare eligibility requirements, contact Medicare.
Medicaid Buy-In Program for Employees with Disabilities
Medicaid, a health insurance program for low-income Texans, has a buy-in program for employed people of any age with disabilities. The program allows Texans with disabilities to keep their Medicaid benefits, even if they earn more than the traditional Medicaid income eligibility limits. To be eligible for the program, you cannot earn more than $2,257 per month. People in the buy-in program pay monthly premiums based on income and other factors for Medicaid benefits. They will receive the same services as other people with Medicaid, including office visits, hospital stays, X-rays, vision and hearing services, and prescriptions.
For information about Medicaid and eligibility, call the Texas Health and Human Services Commission or visit its website
2-1-1 (for free access to health and human services information in your community)
1-800-252-8263 (Texas Medicaid Client Hotline)
www.yourtexasbenefits.com/
Other Health Care Coverage Options
If you are unable to find health insurance because of a pre-existing condition, you may be able to obtain coverage for you or your family through one of the following:
The Texas Health Insurance Pool (Health Pool) is for people who are unable to obtain health care coverage, their dependents or family members, and certain individuals who lose their employer-sponsored health coverage. The premiums may be up to twice the standard rate in the individual health insurance market. For more information, call the Health Pool or visit its website
1-888-398-3927
1-800-735-2989 (TDD)
www.txhealthpool.org
The Pre-Existing Condition Insurance Plan (PCIP) (the federal high-risk pool) is another option for Texans who have been without coverage for at least six months and who have a preexisting condition. PCIP is temporary until exchanges become effective in 2014. Premium costs for participants will be comparable to what an individual without preexisting conditions would pay to purchase insurance.
For more information, call PCIP or visit its website
1-866-717-5826
www.pcip.gov
The Children’s Health Insurance Program (CHIP) provides health care to children of many low-income Texas families who are not eligible for Medicaid. For more information, call CHIP or visit its website
1-877-KIDS-NOW (543-7669)
www.chipmedicaid.org
State and Federal Agencies for Texans with Disabilities
The following state and federal agencies may have information helpful to Texans with disabilities:
The Office of Public Insurance Counsel (OPIC) advocates for consumers and represents them at rule hearings, legislative hearings, and court proceedings. OPIC also promotes policyholder interests and rights in matters concerning insurance rates and coverage. OPIC cannot represent individual consumers or resolve individual consumer complaints, but it can provide tools to help you understand insurance products.
1-877-611-6742
322-4143 in Austin
www.opic.state.tx.us
Social Security’s Supplemental Security Income (basic needs assistance for certain people with little or no income)
1-800-772-1213
1-800-325-0778 (TDD)
www.socialsecurity.gov/ssi/
Texas Department of Aging and Disability Services
512-438-3011
www.dads.state.tx.us
Texas Department of Assistive & Rehabilitative Services, including Blind Services, Early Childhood Intervention Services, and Disability Determination Services
1-800-628-5115
www.dars.state.tx.us
Texas Governor’s Committee on People with Disabilities
512-463-5739
512-463-5746 (TDD)
www.governor.state.tx.us/disabilities
Texas Department of State Health Services
1-888-963-7111
458-7111 in Austin
1-800-735-2989 (TDD)
458-7708 (TDD in Austin)
www.dshs.state.tx.us
Texas Health and Human Services Commission
2-1-1 is the national abbreviated dialing code for free access to health and human services information. The alternative number is 1-877-541-7905.
1-877-787-8999
1-888-425-6889 (TDD)
www.hhsc.state.tx.us
U.S. Department of Justice Americans with Disabilities Act
1-800-514-0301
1-800-514-0383 (TTY)
www.ada.gov
U.S. Equal Employment Opportunity Commission
1-800-669-4000
1-800-669-6820 (TTY)
www.eeoc.gov
U.S. Department of Veterans Affairs
1-800-827-1000
1-800-829-4833 (TDD)
www.va.gov
For More Information or Assistance
For answers to general insurance questions or for information on filing an insurance-related complaint, call the Consumer Help Line between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website
1-800-252-3439
463-6515 in Austin
www.tdi.texas.gov
You can also visit HelpInsure.com to help you shop for automobile, homeowners, condo, and renters insurance, and TexasHealthOptions.com to learn more about health care coverage and your options.
For printed copies of consumer publications, call the 24-hour Publications Order Line
1-800-599-SHOP (7467)
305-7211 in Austin
Help us prevent insurance fraud. To report suspected fraud, call our toll-free Fraud Hot Line
1-888-327-8818
To report suspected arson or suspicious activity involving fires, call the State Fire Marshal’s 24-hour Arson Hot Line
1-877-4FIRE45 (434-7345)
The information in this publication is current as of the revision date. Changes in laws and agency administrative rules made after the revision date may affect the content. View current information on our website. TDI distributes this publication for educational purposes only. This publication is not an endorsement by TDI of any service, product, or company.
For more information contact:
